Board papers November 2015 by Surrey and Sussex Healthcare NHS Trust

Surrey and Sussex Healthcare NHS Trust Board papers

November 2015

Trust Board Meeting – IN PUBLIC Thursday 26th November 2015 - 11:00 to 13:30 AD77, Trust Headquarters, East Surrey Hospital, Canada Avenue, Redhill, RH1 5RH

AGENDA 1

11:00

11:30

12:15

GENERAL BUSINESS 1.1

Welcome and apologies for absence

A McCarthy

Verbal

1.2

Declarations of Interests

A McCarthy

Verbal

1.3

Minutes of the last meeting held on 29th October 2015 - For approval

A McCarthy

Paper

1.4

Action tracker

A McCarthy

Paper

1.5

Chairman’s Report For assurance

A McCarthy

Verbal

1.6

Chief Executive’s Report For assurance

M Wilson

Paper

1.7

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

G FrancisMusanu

Paper

SAFETY, QUALITY AND PATIENT EXPERIENCE 2.1

Patient Story For assurance

D Holden

Paper

2.2

Chief Nurse & Medical Director’s Report For assurance

D Holden/ F Allsop

Paper

2.3

Safety & Quality Committee Update For assurance

R Shaw

Paper

OPERATIONAL PERFORMANCE 3.1

3.2

3.3

Integrated Performance Report (M07) 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

3.4

13:05

13:25

Charitable Funds Committee Update For assurance

A Hall

Paper

RISK, REGULATORY AND STRATEGY ITEMS 4.1

Update from the Shadow Council of Governors For assurance

G FrancisMusanu

Paper

4.2

Rules of Procedure â&#x20AC;&#x201C; Annual Update & Review For approval and assurance

G FrancisMusanu

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

5.1.3

Charitable Funds Committee

5.2

ANY OTHER BUSINESS

5.3

QUESTIONS FROM THE PUBLIC

All

A McCarthy

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 17th December 2015 at 11.00am

A McCarthy

Minutes of Trust Board meeting held in Public Thursday 29Th October 2015 from 11:00 to 13:30 Room AD77, PGEC East Surrey Hospital Present (AM) Alan McCarthy (MW) Michael Wilson (PS) Paul Simpson (FA) Fiona Allsop* (DH) Des Holden (AS) Angela Stevenson (PBi) Paul Biddle (RD) Richard Durban (PL) Pauline Lambert (RS) Richard Shaw (AH) Alan Hall

Chairman Chief Executive Chief Finance Officer / Deputy Chief Executive Chief Nurse (left the meeting during item 3.3) Medical Director Chief Operating Officer Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director

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

Director of Corporate Affairs Head of Corporate Governance (Notes) Deputy Director of Human Resources

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. No apologies for absence were noted.

1.2

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

1.3

Minutes of the last meeting – 24th September 2015 The minutes of the meeting held on 24th September were discussed. PS noted that minutes should state ‘current base case’ (P6). The Board noted some minor typographical errors that did not represent material changes. With these amendments noted the minutes were approved as a true and accurate record.

1.4

Action Tracker The following actions were updated and closed. TBPU-01: FA agreed to provide an update to the Trust Board in relation to the Temporary Staffing Contract in the coming months. An update on the Agency Contract variations will also be reported to the Finance and Workforce Committee (FWC) in advance. Page 1 of 9

TBPU-03: The Board asked the Safety and Quality Committee (SQC) to focus on the management of FFT and patient feedback. – This action is moved to the SQC action tracker - closed TBPU-04: DH to provide an update on recent trends in E-Coli numbers. DH reported that from his review there are no specific concerns in this area. This will be kept under review by the Infection Control Committee and any further concerns will be reported to the SQC. - closed TBPU-05: FA to provide a verbal commentary on the time period involved in reporting the August SI which had occurred in 2008. FA indicated that the investigation is currently on-going and an update will be provided on conclusion. TBPU-07: To sign the Trust statement confirming compliance with The Medical Profession (Responsible Officers) regulations 2010 – closed. 1.5

Chairman’s Report for Assurance The Chairman highlighted that the Trust’s Board had been shortlisted by Kent Surrey and Sussex (KSS) Leadership Awards for the governing body of year award recognising the significant work and focus on developing clinical leadership and local clinical services. The Chairman went on to announce that the first meeting of the Shadow Council of Governors had been both valuable and thought provoking. In particular the newly appointed governors had provided a different perspective and challenge on the development of the Trust’s strategic goals. The Chairman noted the work had commenced on the Trust’s Virginia Mason Institute (VMI) development programme and that interestingly no initial changes or challenges to the Trust’s corporate governance have been identified. Finally the Chairman highlighted the strengthening relationships between East Surrey CCG and the Trust, following meetings with Dr Elango Vijaykumar, The CCG Clinical Chair. The Board noted the report.

1.6

Chief Executives report for Assurance The Board received and noted the Chief Executive’s report in advance of the meeting. MW introduced the report bringing specific elements of interest to the Board’s attention. Notably the relaxation of rules that dictate employment of staff from non EU countries, the national agency cap and the appointment of a Chief Executive for the new strategic governing body, NHS Improvement. MW highlighted the local success of the Trust’s ‘Mouth Matters’ programme which is being scoped for national implementation and shortlisting for the KSS leadership award that had been given to the Trust’s Dental team. MW echoed the Chairman’s comments on the Trust’s VMI development programme noting that the focus would be on thinking, tools and systems. PL highlighted the recent Dental ‘hot topic’ which had been both interesting and Page 2 of 9

had provided a great deal of assurance. The Board then discussed the issues surrounding nurse recruitment and gap in newly qualified nurses within the local health economy, noting that the local deanery is commissioning more places but the effect will not be felt for around four years. As such the Trust is in regular contact with Health Education England and has recently shown interest in joining a pilot for Band 4 Nurses. FA highlighted how the dependency of patients was changing and there is a strong need for Band 4 skilled staff. FA went on to assure the Board that the Trust had successfully been allocated 25 student nurses from Brighton, that the Trust had increased the number of Practice Development Nurses and a review of systems to support revalidation of Nurses aged between 45 and 55 had been commissioned. The Chairman noted that it was interesting to see how concerns relating to recruitment for organisations in special measures had been taken into account by national bodies. 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. Stating that the BAF had received its normal review and update of actions and assurances by the Executive Committee. GFM went on to highlight that the significant risk relating to management of adolescents with mental health conditions had been reviewed and downgraded. The Board discussed The Trustâ&#x20AC;&#x2122;s recent performance relating to cancer pathway targets which had been considered by the Trustâ&#x20AC;&#x2122;s Access and Responsiveness committee, who following discussion at the Executive Committee had agreed to recommend that this issue be added to the significant risk register. The Board noted that the risk associated with the ability to provide appropriate care and supervision of adolescent mental health patients was still on the Trustâ&#x20AC;&#x2122;s risk register but that the likelihood of extreme outcome had been reviewed and reduced. The Board noted and agreed the content of the Board Assurance Framework. The Board duly approved and took assurance from the report.

Safety, Quality and Patient Experience 2.1 Patient Story for Assurance The Board received and noted the report in advance of the meeting. FA introduced the patient story relating to a patient who was unaware that they had a basal cell carcinoma of the eye. The consultant who saw the patient in 2009 did not follow best practice with regard to the care pathway. The patient had not been informed of the abnormal result and therefore was not able to monitor her own condition effectively. The case had not been discussed at MultiDisciplinary Team (MDT) as it was not a commonly discussed issue. It was not reported as an incident and went unknown to the Trust until receipt of the Page 3 of 9

patient’s complaint. The Board took assurance that once the incident was visible appropriate actions had been taken including open conversations with the patient, offering of legal support and a retrospective audit of patients to ensure that other patients have received the correct follow up. As such the Board agreed that efforts to rebuild loss of confidence in the Trust’s services are underway. Action: The Board asked for feedback on the outcome of the retrospective audit of patients to ensure that patients have received the correct follow up. The Board noted that failing to inform the patients GP had been a significant issue in this case and took reassurance that GP communication systems had greatly improved since the incident occurred. The Board discussed the lack of involvement form the Patient’s GP in the review of the incident and took assurance that processes are in place to escalate issues if deemed necessary. FA and DH highlighted how the Trust was interpreting ‘Duty of Candour’ such that each patient’s feedback was unique and relevant to their case. The Board 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 Chief Nurse’s report highlighting the safer staffing profile and in particular the Birthing Unit. The Birthing Unit has experienced staffing pressures this month with 27 shifts working at 50% of the planned staffing level FA went onto highlight how this unit is staffed by two midwives and as such a single absence has significant impact on the ratio. No incidents had occurred during the period which had been managed appropriately by the Women And Child Health (WACH) Matrons. FA highlighted that the National Quality Board paper regarding nursing safer staffing, requires that Boards’ receive staffing capacity and capability at a public Board meeting, at least every six months. The last six monthly nursing establishment review was presented in June 2015 with plans to recommence in September 2015 using the Safer Nursing Care Tool. FA asked for Board agreement to defer receipt of report on the grounds that; the ward configuration and function has not changed since the last audit was undertaken in March 2015, no areas of clinical concern in relation to ward nursing staffing levels have been raised and that the Trust would have to revert to the manual tool to carry out the assessment. The Board agreed with the deferment of the 6 monthly assessments until it could be achieved appropriately. The Board noted the recent ‘NHS Improvement’ letter which highlights issues of efficiency and ‘safer staffing’, acknowledging the variation of implementation of the initial instructions and supporting guidance. The Board accepted the Trust’s interpretation and plan of action detailed in the paper. DH provided a verbal report highlighting the initial implementation of the ‘Ideas to Innovation Factory’ which had seen nearly 100 ideas put forward in the first month. DH discussed how the national pay and conditions conversation is impacting on morale. At present the Trust’s junior doctors are very concerned and as such we Page 4 of 9

have invited the BMA to talk to our Junior Doctor’s to give a rounded view. The Board took assurance that should Junior Doctors decide to take industrial action every effort would be taken to ensure patient safety. The Board duly noted and took assurance from the report. 2.3

Children’s Safeguarding Annual Report for Approval The Board received and noted the report in advance of the meeting. The Board noted that the report had been reviewed and agreed by the SQC and took assurance from its members that it had been discussed in detail. The Board went on to discuss the number of a safeguarding alerts that the Trust raised externally with little formal feedback. FA stated that the Trust was in conversation with the local safeguarding board with a view to putting in place robust feedback loops. The Board went on to discuss the large number of low risk alert forms issued by the Trust. Noting that despite the volume, each was valuable, as it helped to raise concerns in cases of multiple provider involvement. PL asked specifically whether the safeguarding issues raised in Cambridge recently could impact on the Trust and took reassurance that this issue was timetabled for review. The Board duly approved the report.

2.4

Adult Safeguarding Annual Report for approval The Board received and noted the report in advance of the meeting. RS highlighted that similarly the report had been presented to the SQC prior to submission to Board for approval. The report had been well received by the SQC and the main detail is highlighted concisely in the executive summary. No questions or issues were raised. The Board duly approved the report.

2.5

Safety & Quality Committee Update for assurance RS presented the report form the Safety and Quality Committee, highlighting the work to implement the Trust’s ‘End of Life’ care pathway, the development of a focus on quality themes and the gastroenteritis risk that now impacts on the Trust throughout the year. The Board noted that the Trust was working in collaboration with GPs and local healthcare providers to both manage and share the burden of the risk. The SQC had noted that some care homes did not have the appropriate insurance cover to administer intravenous fluid and could not therefore manage clinically dehydrated patients. The Board duly noted and took assurance from the report.

Page 5 of 9

Operational Performance 3. 3.1

Integrated Performance Report (M6) for Assurance The Board received the Integrated Performance report in advance of the meeting.

3.1.1

AS introduced the section of the report that related to performance management. Highlighting the Trust’s cancer access performance and continuing growth in overall activity. The Board noted the Trust’s emergency department performance and thanked all staff involved for their hard work. AS spoke about the issues inherent in the Trust’s 2 week rule performance as the standard had not been met for the quarter. This target is being significantly impacted by patient choice and as such the teams are looking to change the support that individual patient’s get. The Board discussed the national cancer situation noting the impact on referrals that linked with effective awareness campaigns. The Board noted the overall Trust position for RTT incomplete and took assurance that the Trust was reviewing and acting to improve compliance. AS highlighted that the Trust was carrying out its highest levels of elective activity on record. Highlighting that the longest length of stay patients list was reducing which is clinically the most appropriate way to manage this issue. FA discussed elements of the report which focussed on patient safety highlighting improvements in safety thermometer metrics and the down grading of the safety risk relating to the management of adolescent patients. The Board noted the number of recent serious incidents and cases of Clostridium difficile. DH discussed the Trust’s mortality rates highlighting that overall mortality is better than expected. As such the Effectiveness Committee is focussing on Chronic Obstructive Pulmonary Disease (COPD) as mortality is higher than other specialities, but still within the expected range.

3.1.2

RD introduced the workforce element of the report which had been discussed at the FWC committee. Highlighting the development of plans to increase delivery of annual training, the Trust’s audit of management of long term sickness and achievement review compliance. RD highlighted that the corporate team is reviewing and developing an enhanced suite of KPIs.

3.1.3

PS introduced the finance element of the report stating that the Trust’s deficit was £3 million which is £800 thousand adverse to the revised planned deficit. However the Trust was still forecasting delivery of end of year targets and the Board had reviewed the level of risk to the Trust which remained high The underlying issues continue to be higher than planned emergency activity driving agency usage, escalation and reduced elective activity. PS indicated that elective activity was increasing which is a positive indicator. PS reminded the Board that due to the 70% emergency activity tariff, readmissions and commissioning specialist services the Trust had not been paid £2 million pounds of income. The Private Board had discussed the forecast at the end of Q1, which recorded a base case of £4.2 million deficit. The Q2 forecast Page 6 of 9

shows a base case of a £1.5 million deficit, which is better, but risk had increased to delivery of the £1.6 million surplus. The Trust is reviewing all divisional activity and challenging recovering plans in order to ensure the Trust achieves its planned £1.6 million surplus plan. The Trust’s capital loan application had been successful and the pause on capital rescinded. As noted by the Board and FWC the Trust’s liquidity concerns remains and a strengthening on restrictions to cash nationally has been noted. This provides an increased level of risk which will be reviewed monthly. PS went on to highlight risks to forecast indicating that emergency activity over winter, elective income and potential pay disputes are the most significant issues. RD highlighted that FWC had agreed to maintain the agreed forecast and noted assurances and challenges. The Board duly noted and took assurance from the report. 3.2

Breaking the Cycle & Winter Planning for Assurance AS provided feedback on the recent ‘breaking the cycle’ week highlighting that it focused on care of the elderly and patients which were medically fit for discharge. The week had been considered a success with key factors including the setup of MDT with community health and social care partners, changes in the ways Matron’s worked and the establishment of a ‘silver command’ to resolve problems. The week saw improvements in discharges for patients in the hospital admitted longer than 3 days evidenced by a range of metrics and the closing of all escalation areas by the close of play Thursday. The plan is to carry out a ‘breaking the cycle’ week for the 4 winter months. The Board discussed why this could not become business as usual. AS highlighted the strength of using it as an initiative to support periods of unusually high activity. Naturally any improvements that could be embedded daily would be considered. MW highlighted the importance of shared development and ownership of systems rather than central enforcement. The Board noted comments on ambulance attendances, handovers and pathways. MW assured the Board that discussions with senior leaders in the ambulance Trust are underway to increase local awareness of pathways such that unnecessary attendances at the emergency department are reduced. The Board duly noted and took assurance from the report.

3.3

Finance & Workforce Committee Update for Assurance The Board received and noted the update in advance of the meeting. RD introduced the report from the FWC, highlighting the review of implementation of ‘digital dictate’, the importance of clinical leadership and improvements in quality and speed of reporting. The Board noted that the FWC had agreed the approach to budget setting which would commence using assumptions for the next national tariff. The Board went on to discuss the savings and efficiency targets identified by Lord Carter. Meetings between the Trust’s Executive team and NHS England had taken place Page 7 of 9

and agreement that emphasis was on efficiency rather than performance management. The Board duly noted the report for assurance. 4.

Risk, Regulatory and Strategy Items 4.1

Q2 Annual Plan Update for assurance The Board received and noted the update in advance of the meeting. The Board noted that elements of strategic importance such as Outpatients services where not progressing at the expected rate. AS highlighted that a deep dive was being orgainsed and confident that the level of focus was appropriate. The Board noted that elements of the plan appeared green on the action tracker for long term delivery aligned with elements of performance that appeared red or amber in other reports. Action: 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. The Board duly noted and took assurance from the report.

4.2

Virginia Mason – Progress Update for assurance MW provided a verbal update on the Trust’s progress to date. Providing feedback from the first team visit to the Virginia Mason Institute and the comparisons between the services provided by the Trust and the Virginia Mason Hospital. The development programme will look to develop the Trust’s tools and techniques for continuous improvement. The focus is on waste reduction, minimising variation, avoidable defects with the aim to improve each patient’s experience and outcome. MW highlighted the development of ‘compacts’ between the National team (TDA) and the Trust which define expectations and behaviors of both parties to ensure that everyone has an agreed common understanding and expectation.

The Board duly noted progress and took assurance from the plan. Other Items 5.1 5.1.1

Minutes of Board Committees to receive and note 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 No further business was discussed by the Board.

5.3

Questions from the Public

5.3.1

One formal question from the public was received in writing advance of the meeting. Page 8 of 9

Mr. W asked why his wife had been told that one person who can book a cancer detecting hysteroscopy was on leave for a week and thus one else was capable for booking an appointment during that period. AS replied on behalf of the Board. That in this incident this was not hospital policy and the wrong information had been given to Mrs. W. Suitable cover had been arranged and was in place. Issues relating to communicating cover to all appropriate staff had been resolved. The matter is being handled as a formal compliant and the Consultant has spoken to the patient involved. Mrs. W had now received an appointment. 5.3.2

Jo Josh, Nominated Governor spoke, of her recent experiences of the NHS and her confidence in the Trustâ&#x20AC;&#x2122;s direction of travel.

5.3.3

Caroline Vaughn, Elected Governor, asked how the delays in receipt of pay for activity could be allowed to happen. PS explained how this situation arises within the NHS contractual system which is significantly based on planned activity. As such it takes time to resolve pay for unplanned levels of activity which is an ongoing element of financial management for an Acute Trust.

5.3.4 5.4

There were no other questions. Date of the next meeting Thursday 26th November 2015 at 11.00am in Room AD77, Trust Headquarters, East Surrey Hospital

Note: This is a public document and therefore will be placed into the public domain via the Trustâ&#x20AC;&#x2122;s website in the interests of openness and transparency under Freedom of Information Act 2000 legislation. These minutes were approved as a true and accurate record. Alan McCarthy Chairman:

Date:

Page 9 of 9

TRUST BOARD ACTION TRACKER Action Ref

Forum

Subject

Action

Date Open

Date Due

Date Closed

Status

ACTIONS FROM PUBLIC BOARD MEETINGs

TBPU-01

TB Public

Patient story

TBPU-02

TB Public

Patient story

The Board requested that Dr Julian Webb update the Board on findings and actions of the sample group. DH The Board asked for feedback on the outcome of the retrospective audit to ensure that patients have received the correct follow up. FA

Q2 Annual Plan Update

The Executive team is asked to consider the scoring of elements to ensure consistency across reports for the SJ / Executive next quarterly update with particular focus on elements already RAG rated as red. Team

TBPU-03

TB Public

28/08/2015

30/11/2015

OPEN

29/11/2015

31/01/2015

OPEN

29/11/2015

31/01/2015

OPEN

TRUST BOARD IN PUBLIC

Date: 26th November 2015 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: • New ambition to halve rate of stillbirths and infant deaths • Measures for greater patient power • Requirement for Doctors and Nurses to report FGM to the police • Right place, Right Time: Better Transfers of Care – call to action Local: • Winner of KSS Leadership Award for Innovation • SaSH Cancer Health and Well Being Day • Junior Doctors Industrial Action 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 November 2015 CHIEF EXECUTIVE’S REPORT 1.

National Issues

1.1

New ambition to halve rate of stillbirths and infant deaths

The Health Secretary, Jeremy Hunt, recently announced a new ambition to reduce the rate of stillbirths, neonatal and maternal deaths in England by 50% by 2030. The number of brain injuries occurring during or soon after birth will also be targeted as part of a new commitment by the government, in partnership with consultants, midwives and other experts across the country to make England one of the safest places to have a baby. The government will work with national and international experts to ensure that best practice is applied consistently across the NHS and that staff can review and learn from every stillbirth and neonatal death. Maternity services will be asked to come up with initiatives that can be more widely adopted across the country as part of a national approach – such as appointing maternity safety champions to report to the board and ensuring that all staff have the right training to enable them to identify the risks and symptoms of perinatal mental health. Trusts will receive a share of over £4 million of government investment to buy high-tech digital equipment and to provide training for staff already working to improve outcomes for mums and babies. This includes a £2.24 million fund to help trusts to buy monitoring or training equipment to improve safety, such as cardiotocography (CTG) equipment to monitor babies’ heartbeat and quickly detect problems, or training mannequins that staff can practise emergency procedures on. A further £500,000 will be invested in developing a new system for staff to review and learn from every stillbirth and neonatal death. The new safety investigation unit will also be asked, once established, to consider a particular focus on maternity cases for its first year. Over £1 million will be invested in rolling out training packages developed in agreement with the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists, to make sure staff have the skills and confidence they need to deliver world-leading safe care. This builds on previous government commitments to invest £75 million in improving perinatal mental health services and ensuring all maternity care is considered as part of ‘Ofsted style’ ratings for commissioners. Over time this initiative will allow the money spent on caring for injured children or paid as compensation to be re-invested in improved front line services. 1.2

Health Secretary outlines measures for greater patient power

The Health Secretary has outlined plans for the most patient-focused NHS culture ever. This will mean that from 2016 new ‘Ofsted style’ ratings will show patients how their local area’s health service is performing in crucial areas, including: • cancer • dementia • diabetes • mental health • learning disabilities • maternity care

The new ratings, broken down by Clinical Commissioning Group (CCG), will not only be based on local data but will also be verified by experts in each field, including: • •

the Chief Executive of Cancer Research UK will verify cancer ratings the government’s Mental Health Taskforce Chairman will lead on mental health ratings

Initial ratings, based on the current CCG assessments, will be published in June 2016. As part of the government’s transparency agenda, this will both spread best practice and help bring about improvement where services are underperforming. This will create a complete picture of care quality in the NHS. By giving patients access to performance data, healthcare services in local towns and cities will be much more accountable to their local population than previously. Patients and clinicians will also benefit from a range of new measures to cut bureaucracy across the health system, saving valuable time and money. Up to 27% of GP appointments could potentially be avoided if there was more co-ordinated working between GPs and hospitals, wider use of primary care staff and better use of technology. New measures will include immediately stopping pointless referrals from hospitals back to GPs which accounts for around 2.5% of appointments. Other measures to save valuable resources which can be given over to patient care include: • •

1.3

introducing a single payment system that covers all transactions to stop GP practices chasing different organisations for payment making surgeries paperless by 2018, ending the use of fax machine communications between hospitals and surgeries

Doctors and nurses required to report FGM to police

From 31 October, healthcare professionals must alert the police if they treat a girl under 18 who has had female genital mutilation (FGM). To coincide with the duty coming into effect, the Department of Health has introduced a range of resources to help ensure that healthcare staff are equipped and confident to deal with cases of FGM. Developed with the support of the NHS, the Royal Colleges and survivors of FGM, the package of support includes: • • • • •

quick guidance for professionals, including a flow-chart that sets out what action health professionals should take a poster for NHS organisations to publicise the duty to their staff training slides video interviews with health professionals a leaflet for staff to give to patients to explain the new duty

These resources will make sure that healthcare professionals are aware of their responsibilities towards girls who come into their care that have had FGM. 1.4

Right Place, Right Time: Better Transfers of Care – A Call to Action

Over four months in 2015, NHS Providers' Right place, right time commission captured evidence and good practice in transfers of care in all settings across acute, community, mental health and ambulance services.

Led by the former care minister and Chair of the Tavistock and Portman NHS Foundation Trust, the Rt Hon Paul Burstow, the commission’s report offers practical approaches, drawing on good practice in health, local government, social care and housing, and supports members and their partners to tackle the causes of delayed transfers of care in all settings. The report was formally launched at NHS Providers’ annual conference and exhibition at the ICC in Birmingham on 11th November. Latest statistics highlighted in the report state that delayed transfer of care in August 2015 were caused by a range of complex challenges within the patient journey from health settings back into the community or social care. Workforce capacity, skill mix, and flow within and between organisations are also key issues the report makes a link with the Carter efficiency review, which states that improving work flow could save £2bn for the NHS. The report gives evidence that delays in the discharge of mental health service users are also a key challenge. People in crisis or at suicide risk may face care in inappropriate settings or have to remain as an inpatient when there is no suitable housing or community support package in place. The report includes a call to action, calling on providers, local authorities, clinical commissioning groups and health and wellbeing boards to test their assumptions about the causes of delayed transfers of care. National bodies are called on to consider what support they can offer to the sector in terms of definitions, analytical capacity and guidance. The sector is also urged to listen more, to patients, service users, carers and staff. A copy of the report is available at: https://www.nhsproviders.org/resource-library/reports/right-place-right-timebetter-transfers-of-care-a-call-to-action

Local Issues

2.1

Winner of Kent Surrey & Sussex (KSS) Leadership Award for Innovation

I was pleased to attend the recent KSS awards ceremony, held at Sandown Park on 12th November to present the award to this year’s winner and particularly thrilled that Mili Doshi our Special Needs Dental Consultant, was announced as winner of the NHS Innovator of the Year award for her fantastic Mouth Care Matters initiative that has seen the introduction of our specialist Mouth Care Matters team and a real improvement in the oral health care of patients being cared for at East Surrey Hospital. As a board we are delighted that Mili’s hard work and dedication has been recognised by this well-deserved award and thrilled that the project is being rolled-out across all hospitals in Kent, Surrey and Sussex and excited that we have been given to understand that a national roll-out will follow. Our Board, led by Alan McCarthy, chair, was a finalist in the NHS Board of the Year category for their role in providing strategic support and enabling our clinical leaders to provide high quality care and to continue to develop SASH. 2.2

SaSH Cancer Health and Well Being Day

On 11th November Wednesday around 100 people who are living with and beyond cancer came along to our first, and very successful, SaSH cancer health and wellbeing day. A

very well done to the cancer team, led by Jane Penny, lead cancer nurse, who organised and hosted the day. 2.3

Junior Doctors Industrial Action

The British Medical Association has formally informed the Trust that industrial action by junior doctors will take place on Tuesday 1st December (24 hours) â&#x20AC;&#x201C; emergency care only and on Wednesday 8th December and Wednesday 16th December (9 hours on each day) will form a full withdrawal of labour. The Trust has plans in place to ensure the least disruption to services and to maintain patient safety.

Recommendation

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

Michael Wilson Chief Executive November 2015

Date: 26th November 2015

TRUST BOARD IN PUBLIC

Agenda Item: 1.7 Board Assurance Framework & Significant Risk Register Gillian Francis-Musanu Director of Corporate Affairs Colin Pink Head of Corporate Governance

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

Executive Committee 18/11/2015

Action Required: Approval (√)

Discussion (√)

Assurance (√)

Purpose of Report: The 2015/16 BAF highlights potential risks to the Trust’s strategic objectives and mitigating actions and the implementation of its programme of objectives for year two of the five year plan. The Significant Risk Register (SRR) details all risks on the Trust risk register system that are recorded as significant and the links to the Board Assurance Framework. Summary of key issues The BAF details 13 risks to the trusts strategic objectives, 7 of which are recorded as key strategic risks and red rated. There are 13 significant risks recorded on the Trust risk register, including 1 reworded risk relating to Referral to Treatment access standards. Recommendation: The Board is asked to discuss and approve the report and consider the following: • Review the BAF and its alignment to strategic objectives • Does the Board agree with the recorded controls and assurances • 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

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: November 2015 BAF and the current SRR

An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT – 26th November 2015 BOARD ASSURANCE FRAMEWORK and SIGNIFICANT RISK REGISTER 1.

Board Assurance Framework

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

Current status

The 15/16 BAF (attached) details a total of 13 risks to the 5 Trust strategic objectives which are scored as follows: Objective Red Amber Green (15-25) (8-12) (1-6) 1.Deliver safe services and be in the top 20% 0 2 0 against our peers 2.Deliver effective and sustainable clinical 1 0 1 services within the local health economy 3.Ensure patients are cared for and feel cared 1 0 0 about 4.Responsive - Become the secondary care provider and employer of choice for the 1 0 0 catchment populations of Surrey & Sussex 5. Well Led - become an employer of choice and deliver financial and clinical sustainability around 4 3 0 a clinical leadership model Total

7 3

An Associated University Hospital of Brighton and Sussex Medical School

One of the purposes of the BAF is to ensure that all risks are mitigated to an appropriate or acceptable level. It is expected that not all risks will be able to have mitigating controls that reduce the risk to green (low impact, low likelihood). 2.1 Updates since last Board Review Since the last board meeting the Audit and Assurance Committee and the Executive Committee have reviewed and updated the BAF to reflect current as detailed in descriptions. 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 –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.

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

S3 x L4 = 12

Target Risk Score

S4 x L3 = 12

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.

Current Risk Rating: Severity x Likelihood

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

Target Risk Score

S3 x L2 = 6

An Associated University Hospital of Brighton and Sussex Medical School

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

Objective 5 – Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model 5.1 Failure to deliver income plan 5. 2 Failure to stop divisional overspending against budget 5. 3 Unable to deliver realistic medium term financial plan 5. 4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position 5.5 There is a risk we will fail to realize the strategic benefits of having an Achievement Review Process that effectively monitors and influences behaviour and performance. 5.6 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

2.3.

Initial Risk Rating: Severity x Likelihood

Current Risk Rating: Severity x Likelihood

Target Risk Score

S4 x L4 = 16

S4 x L2 = 8

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

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

Target Risk Score

S5 x L3 = 15

S3 x L2 = 6

S5 x L3 = 15

S4 x L2 = 8

S5 x L3 = 15

S4 x L3 = 12

S3 x L3 = 9

S3 x L2 = 6

S4 x L2 = 8

S4 x L1 = 4

S5 x L3 = 15

S4 x L3 = 12

S3 x L3 = 9

S4 x L2 = 8

Key risks Strategic risks Identified

The BAF highlights the following 7 key red risks to the Trust objectives that have been identified at time of updating the framework. These are: Risk description 2.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the capacity to deliver the activity income that underpins the LTFM. 3.1 The continuing challenge to recruit and retain clinical staff is impacting on the Trust’s ability to maximize financial and quality benefits. 4.1 Failure to maintain Emergency Department performance because of lack of capacity in health system to manage pressures has a significant impact on the Trust's ability to deliver high quality care 5.1 Failure to deliver income plan 5. 2 Failure to stop divisional overspending against budget

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 S3 x L2 = 6

An Associated University Hospital of Brighton and Sussex Medical School

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

S5 x L3 = 15

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 13 risks on the Trust significant risk register. Risk 1678 has been reworded to reflect delivery of RTT Access Standards, this used to focus on generic cancelled or delayed elective operations. 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 1491 1501 1603

1604

1663

1672

1678 1688 1689

Title Risk of outbreak of viral gastroenteritis Failure to maintain Emergency Department performance Patient admitted to the right bed first time Unable to deliver realistic medium term financial plan Liquidity: Inability to pay creditors/staff resulting from insufficient cash due to poor liquid position Risk of not achieving Cost Improvement Plan Increasing Sickness Absence Levels with impact on day to day management and expenditure RTT Access Standards Risk of potential overspending from operational pressures Risk of Contract income below plan

Initial Rating

Current Rating

Residual Rating

Next Review

30/10/2015

31/12/2015

30/11/2015

11/02/2016

31/12/2015

An Associated University Hospital of Brighton and Sussex Medical School

Title

1696

1697

1724

Risk from agency overspending Financial risks linked to National Quality Board Paper, 7 day working and Carter productivity report Failure to maintain cancer access standards.

Initial Rating

Current Rating

Residual Rating

Next Review

31/12/2015

30/11/2015

4. Discussion/Action This report brings together the BAF for the Trusts strategic objectives and the Significant Risk Register into one report. The Board is asked to discuss and approve the report and consider the following: • Review the BAF and its alignment to strategic objectives • Does the Board agree with the recorded controls and assurances • Note the updated risks included in the Significant Risk Register

Gillian Francis-Musanu Director of Corporate Affairs November 2015

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

Health & Safety

• Avoidable death

• Minor harm event involving >5 patients

• Moderate harm event involving >5 patients

• Major harm incident involving >5 patients

• Minor unsatisfactory patient experience related to treatment / care given

• Unacceptable patient experience related to poor treatment / care

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

• Informal complaints raised / PALS contacted

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

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

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

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

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

• No harm injury

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

• Medical treatment required

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

• Death (RIDDOR reportable)

• Minor loss £2K to £100k

• Moderate loss, £100k - £1M

• Major loss, £1M-£10M

• Loss > £10M

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

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

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

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

• Adverse Monitor continuity of service rating <1 month

• Adverse Monitor continuity of service rating > 1 month

• A breach of Monitor Terms of authorisation

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

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

Financial Management • Small loss <£1K Governance Arrangements

Quality of Service

Extreme

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

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

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

Major

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

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

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

An Associated University Hospital of Brighton and Sussex Medical School

Page 1

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

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

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

Director responsible

Chief Nurse

Initial Risk Current rating

S4 x L3 = 12 S4 x L2 = 8

Target risk score

S4 x L1 = 4

Linked to Risk

1009,1055

Controls in place (to manage the risk)

Gaps in Control

1. Clinical teams to implement patient safety plans in the Trust (falls, pressure ulcers and infection control) 2. Regular review of patient safety data including the Safety Thermometer at divisional, executive and board level 3. Groups/Committee established including SQC, ECQR and its subcommittees, N & M and Divisional Governance. 4. Policies, procedures and guidelines provide the framework by which risks and incidents are managed. 5. 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) 6. Matron on site 7 days a week 7. Clinical Site Matron established 24/7 with enhanced team (2xB7 and 1x B8a) 8. Nursing staffing levels with daily real-time escalation 9. Incident reporting policy in place and monitored 10. Ward safety boards 11. Serious incident review group established to monitor and evaluate investigation progress and progress against actions 12. Training undertaken for clinical staff in the assessment and management of patients at risk of falls 13. Patient falls strategic group meet monthly and report KPIs to the patient safety committee. 14. System developed to split Trust and Community acquired VTE events which are reviewed at Clinical Effectiveness, Patient Safety and ECQR.

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

Potential Sources of Assurance (documented evidence of controls effectiveness)

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

Positive (+) CQC Chief Inspector of Hospitals Report (+) CQC risk rating, lowest possible (+) CNST level 2 Maternity (+) Numbers of Hospital Acquired Pressure Ulcers reduced and sustained (+) MUST 100% (+) QGAF assessment and action plan (+) New EWS trialed and audited (+) 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 VHI 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 low (2) (-) 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 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 10/11/15

Date discussed at board

1) 2)

Ongoing Ongoing action plan

To be discussed at November 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 (+)0 MRSA BSI so far in 2015/16 (+)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

Page 4

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

Mitigating actions underway 1) Roll out of Urinary catheter Passport 2) Full list of actions in IPCAS Annual Programme of work (2015/16) 3) Ongoing discussion with commissioners about penalties applying only to cases with poor/inadequate care. This conversation is nationally mandated 4) Considering implementation of two low risk C. diff Antibiotics (Fidoxamicin and Chloramphenicol IV) Update by Date discussed at Board DH 12/11/15

Page 5

Assurance Level gained: RAG

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Embedding 2) 2015/16 3) Ongoing 4) Under review To be discussed at November 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 12/11/15

Date discussed at Board

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Start date 01/04/2015 To be discussed at November 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 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 SECNational 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 3) Integrated Discharge Unit being built

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) End of quarter 3 2) Ongoing 3) January 2016

Update by

To be discussed at November Board

Page 7

AS 20/11/2015

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 Workforce subcommittee, Exec Committee and the Board 2. Monitoring of Safety Thermometer, patient experience and staff turnover, sickness at ward level 3. Planned versus actual staffing levels monitored on a shift by shift basis, reported daily by Matrons and issues escalated to DCNs with evidence actions taken 4. PMO in place to monitor agency use and progress of the five related work streams a. E-roster- migration to v10 approved 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. Nursing temporary staffing utilization (hours/costs) monitoring using Base Usage Value reports monthly 5. SNCT/Birthrate Plus tool utilized to monitor patient acuity and dependency presented to relevant committees including Board to determine future staffing demand 6. 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 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

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 10/11/2015 and DH 12/11/2015

Page 9

Assurance Level gained: RAG

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

Gaps in assurance Winter plans and local health economy position going into winter months 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 and Sept 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 and July 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) Assurance Level gained: RAG

Mitigating actions underway 1) 2) 3) 4) 5) 6)

Integrated Discharge Unit being built 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 20/11/15

Date discussed at Board

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) January 2016 2) Complete 3) Oct 2015 4) Complete 5) Complete 6) March 2016 To be discussed at November Board

Objective 5 – Well Led Priority ID and reference

5.A Live within our means to remain financially sustainable

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

5.1 Failure to deliver income plan

Director responsible

Chief Finance Officer

Initial Risk Current rating

S5 x L3 = 15 S5 x L3 = 15

Target risk score Linked to Risk

S4 x L2 = 8 1689

Controls in place (to manage the risk) 1) Business Plans and budgets (activity and financial) savings / transformation plans. 2) Agreed contracts in place with main sets of commissioners (NHSE and CCGs) – all 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) 1) Financial performance and contractual reporting to Exec Committee, Finance & Workforce Committee and Trust Board (including CQUIN reporting process). 2) Performance Review (PMO) and Exec Quality and Risk process with Divisions, monthly contract cycle with CCGs. Service line reporting process 3) Outputs and reporting from contract and information teams 4) Output and reporting from health system management (e.g.: System Resilience Groups and Chief Officer Meetings) 5) Output of Contract Management Process .

Gaps in assurance

Gaps in Control 1) Original risk share agreement (for emergency activity) with Sussex CCGs and Sussex Community Trust could not be agreed – ongoing discussions over MRET are now contractual. 2) There are also issues with Sussex over the under commissioning of activity and contractual action has also started to correct activity plans. 3) The Trust is also concerned over the robustness of plans for winter, noting delayed decision on investment in community schemes. 4) The strategic management of activity is not currently effective, but the Trust is doing all it can to support making it so. 5) Some actions long stopped to resolve – this includes ambulatory attendance pricing and payment for hospital @ home services – Surrey CCG is initiated escalation in respect of these items.

Actual Assurances: Positive (+) or Negative (-) Positive (+) 2014/15 activity and income met the Plan (noting that individual elements (e.g.: elective activity) did not) (+) Reconciliation process working with CCGs in 2014/15 and year end settlement achieved with all commissioners in 2014/15 with no outstanding disputes. (+) Contracts include clauses to allow inclusion of growth in indicative activity plans, and (vice versa) for any emergency activity reductions Negative (-) Risk over income growth assumptions. (-) Adverse income variance at M07 (although forecast remains on track) (-) Monitor response to MRET complaint provided no useful application in 2015/16 (-) No agreement with Sussex over risk share – now in a contractual process (-) Too much non elective activity, not enough elective – risk over emergency demand in 2015/16. Neither positive or adverse: no serious contractual disputes yet, although Surrey are intimating that these are coming. 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 starts this week); 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 some improvement in these areas) 5) Action around integrated discharge/social care unit is now at the next stage with Surrey County Council and East Surrey CCG. 6) Robust contractual processes being operated. Update by Date discussed at Board PS 19/11/15

Page 13

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

To be discussed at November 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 S5 x L3 = 15

Target risk score S3 x L2 = 6 Linked to Risk 1663,1688 Gaps in Control 1) Management of increased levels of emergency activity subject to review; 2) Investment in incremental changes to meet additional activity demand subject to review (at M04 budget changes were made – this is less of a gap) 3) At M07 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. 4) There is overspending (but now in just one Division) against agreed forecast control totals at M07 Actual Assurances: Positive (+) or Negative (-) Positive (+) Budget changes made to match activity to Q1, and recovery plan actions largely complete in Medicine; (+) New agency reduction plan now agreed, with realistic basis [needs to be delivered] (+) All bar one Division meeting YTD forecast spend Negative (-) Emergency activity pressures have continued to be greater than expected (-) Overall agency costs remain very high, with escalation still in use and significant. (-) Agency costs are high in Nursing still, with adverse increase noted in Medical Division. (-) The forecast describes significant risk to delivery of the Plan.

Gaps in assurance Assurance Level gained: RAG Overspending is the main area of risk and the ability of the Trust to reduce the rate of spend while maintaining services adequately. Mitigating actions underway Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) PMO/Performance structure continues - Divisions have been required to produce recovery plans Actions proceeding to timetable and PMO meetings have become weekly, now, for all Divisions. Weekly 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 19/11/15 To be discussed at November 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. 3) Reliance on centrally determined rules for PbR, Better Care Fund and the wider completed (submitted to Monitor in April 2015) 3) TDA Plan submitted in April 2015 NHS finance regime. 4) Board to Board held with the TDA in November 2014, Monitor 4) Risk over capacity from other operational pressures 5) Overall health system financial view (Chief Officer’s Finance Sub-Group) assessment now in train culminating in Monitor Board to Board in describes significant loss of resource to BCF funding – this reduces resource June 2015. 5) Cost improvement plan process in place (including PMO structure) available for health and social care overall. 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 (-) alignment with CCG plans is not complete with significant variances between actual performance on model and integrated business plan documentation, and activity and CCG plans [CCGs are paying over performance] delivery against them (-) 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 have 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 19/11/15 To be discussed at November 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. 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, but has not been actioned. 2) Contractual over-performance may see delay means delay in receiving cash payments to match accrued income from CCGs 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 (this will likely be discussed at Board) Actual Assurances: Positive (+) or Negative (-) Positive (+) Cash targets met in 2014/15 (+) Liquid ratio has followed expectations (+) Cash has been managed well in 2015/16 to date, largely as a follow on from income agreements with CCGs at end of 2014/15, capital slippage and now use of an agreed working capital facility and the successful receipt of a capital loan. Negative (-) no confirmed additional cash to resolve underlying liquidity problem – can only be resolved in FT application process (through a working capital loan) and which is now paused (-) cash flow dependent on financial outturn described in 5.A.1 and 5.A.2 above.

Overall rating “red” noting risk to forecast I&E. Assurance RAG "amber" - no current cash problem but underlying problem unresolved. Gaps in assurance Assurance Level gained: RAG In terms of cash flow management to end year, no material gaps in assurance. In terms of resolving the actual risk (liquidity), there is no confirmation of additional cash to resolve SoFP weakness. Mitigating actions underway Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Day to day cash control is main action currently, coupled with actions to maintain service income and Actions proceeding to timetable manage spend 2) Long term financial model, and TDA plan now provides additional validation of the level of cash injection required and the interaction from an improving financial position within the model 3) Discussion will continue with the TDA as the FT timeline progresses. Update by Date discussed at Board PS 19/11/15 To be discussed at November Board Page 16

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

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

3) 4) 5) 6)

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

Director responsible

Director of Human Resources

Initial Risk Current rating

S3 x L3 = 9 S3 x L3 = 9

Target risk score

S3 x L2 = 6

Linked to Risk 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

13/11/2015 JM

Date discussed at Board

1) 31 December 2015 2) 31 March 2016 3) Underway initial meetings postitive 4) Complete and ongoing 5) February 2016

To be discussed at November Board

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

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

5.G.2 We are a well governed organisation

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 7) Elections to Shadow Council of Governors 8) HDD to be completed as part of Monitor phase 9) Submission of Monitor information requests

Gaps in assurance Completion of Historical Due Diligence

Director responsible

Director of Corporate Affairs

Initial Risk Current rating

S4 x L2 = 8 S4 x L2 = 8

Target risk score

S4 x L1 = 4

Linked to Risk

1531

Gaps in Control No significant gaps in control identified

Actual Assurances: Positive (+) or Negative (-) Positive (+) Completion of Monitor pre-assessment phase (+) Monitor formal assessment underway (+) Election to the Council of Governors complete (+) 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 has confirmed timescales & remainder milestones (+) Monitor confirmed QGAF score as 3.5 â&#x20AC;&#x201C; Further actions being implemented (+) Shadow Council of Governors in place (+/-) Awaiting national guidance on future FT model (NHS Improvement) Assurance Level gained: RAG

Mitigating actions underway 1) Elections to the Council of Governors completed in July 2015 and Shadow Council in place 2) Monitor formal assessment in progress Update by Update by GFM 06/11/15 Page 18

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Ongoing 2) Plans are on track To be discussed at November 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 (+) 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 20/11/15

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 November Board

Appendix 1

Page 20

Abridged consequence table taken from Trust guidance

Risk Type Patient Safety

Insignificant • No obvious injury / harm

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

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

Health & Safety

• Minor harm event involving >5 patients

• Moderate harm event involving >5 patients

• Major harm incident involving >5 patients

• Minor unsatisfactory patient experience related to treatment / care given

• Unacceptable patient experience related to poor treatment / care

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

• Informal complaints raised / PALS contacted

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

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

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

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

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

• No harm injury

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

• Medical treatment required

• Death (RIDDOR reportable)

• Minor loss £2K to £100k

• Moderate loss, £100k - £1M

• Major loss, £1M-£10M

• Loss > £10M

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

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

• Adverse Monitor continuity of service rating <1 month

• Adverse Monitor continuity of service rating > 1 month

• A breach of Monitor Terms of authorisation

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

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

Financial Management • Small loss <£1K Governance Arrangements

Quality of Service

Extreme • Avoidable death

• 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 • 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

• 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

Involvement of Service Users Unable to deliver realistic medium term financial plan

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

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

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

As described on the BAF

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)

31/03/2014

4 16

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

27/06/2014 31/08/2015

5 15

As described on the BAF

3 15

Next Review

As described on the board assurance framework

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

30/10/2015

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

Residual Rating

Current Rating

Current Likelihood

Current Consequence

5 15

Done date

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

31/12/2015

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.

Treatment Plan

31/03/2014

31/12/2015

Failure to maintain Emergency Department performance

Due date

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

31/12/2015

Patient Safety Involvement of Service Users

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

Patient admitted to the right bed first time

Financial Management

Holden, Des - Medical Director Stevenson, Angela - Chief Operating Officer Simpson, Paul - Chief Financial Officer

Stevenson, Angela - Chief Operating Officer

Medical Director's Office Operations Operations Finance - Fin. Management

CORP CORP CORP CORP

23/01/2013 29/08/2013 19/09/2013 18/06/2014

Safety Responsiveness Responsiveness Executive Committee

1401 1491 1501 1603

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

Initial Rating

Risk Type

Risk Owner

Specialty

Directorate

Open Date

Committee

Title (Policies) Risk of outbreak of viral gastroenteritis

01/09/2014

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

4 16

5 15

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

Manage the number of IPs booked on lists to avoid cancellations Improve Theatre Utilisation Other actions per service risks

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

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

As described on the BAF

4 16

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

Actions described in the Agency PMO 31/03/2015 Focused interventions to support the Trust's 31/08/2015 Stress Management Policy (Anxiety/Stress/Depression has been highest reason for absence for past 8 months)

Risk of potential overspending from Risk of failure to meet the Trusts financial plan i) Divisions to implement action plans and operational pressures due to overspending. contingencies to control/or recover overspending. Specific action is required in all Divisions. ii) Agency PMO to deliver outputs in respect of reduced agency usage following recruitment. Position being reviewed (ongoing).

31/12/2015

As described on the BAF

30/11/2015

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.

31/12/2015

3 15

11/02/2016

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.

01/09/2014

31/12/2015

Financial Management Staffing - general Service Access

RTT Access Standards

Risk of not achieving financial plan as a result i) Delivery of savings managed through PMO of non-delivery of Cost Improvement Plans (ongoing)

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

Financial Management

As described on the BAF

31/12/2015

Financial Management

Risk of not being able to pay suppliers from in 1) Bi weekly review of forward cash flow by finance sufficient cash due to poor liquidity problem 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

Financial Management

Simpson, Paul - Chief Financial Officer Simpson, Paul - Chief Financial Officer Simpson, Paul - Chief Financial Officer

Stevenson, Angela - Parker, Yvonne - Director of Human Simpson, Paul - Chief Financial Officer Chief Operating Officer Resources

Finance - Fin. Management Finance - Fin. Management HR - Workforce Operations Finance - Fin. Management Finance - Fin. Management

CORP CORP CORP CORP CORP CORP

18/06/2014 09/12/2014 01/02/2015 23/03/2015 20/05/2015 01/04/2015

Executive Committee Executive Committee Workforce Responsiveness Executive Committee Executive Committee

1604 1663 1672 1678 1688 1689

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

As described on the BAF

3 15

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

Failure to maintain cancer access performance due to capacity (Outpatients, Diagnostics) / pathway issues (Trust and wider network) can impact on the effectiveness of treatment as well as the experience for the patient.

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.

4 16

31/12/2015

As described on the BAF

Review and develop plans; to brief the Board 30/09/2015 on progress against risks of establishment targets not being met and any potential action to review the Board's decision on implementation.

5 15

Dedicated cancer tracking team and system Patient Tracking List with associated escalation processes Cancer network

5 15

Quantify the demand vs capacity gaps Implement actions identified to resolve demand vs capacity Enhancements to tracking system being implemented Recruiting to agreed increase in tracking team Pilot of streamlined lung pathway commenced

30/06/2015 31/03/2016 30/11/2015 31/01/2015 30/11/2015

31/12/2015

Service Access

CIP PMOs and nursing agency PMO to deliver outputs in respect of reduced agency usage following recruitment. Position being reviewed (ongoing).

Failure to maintain cancer access standards

Jayne Oliver

Risk of failure to achieve financial plan as a result of overspending on agency staff

30/11/2015

Financial Management

Simpson, Paul - Chief Financial Officer Simpson, Paul - Chief Financial Officer

Financial Management

Finance - Fin. Management Finance - Fin. Management General Cancer Services / Oncology

CORP CORP Cancer

11/06/2015 11/06/2015 07/10/2015

Executive Committee Executive Committee Responsiveness

1696 1697 1724

Risk from agency overspending

30/06/2015

TRUST BOARD IN PUBLIC

Date: 26th November 2015 Agenda Item: 2.1 Patient Story Serious post-operative complication Dr Des Holden Medical Director Des Holden Medical Director

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

N/A

Action Required: Discussion (â&#x2C6;&#x161;) Purpose of Report: To inform the Board of an incident and actions taken in relation to a rare postoperative complication of thyroid surgery Summary of key issues All operations have recognised complications, some highly specific to the surgery carried out. Thyroid surgery carries the risk of bleeding which can through pressure cause airway compromise. In this case a patient suffered from this complication with delay to its recognition and early intervention. The report discusses actions taken as a consequence with individual staff members and with the wider team. Recommendation: To discuss incident and learning in the context of preparing for rare events. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring â&#x20AC;&#x201C; Ensure patients are cared for and feel cared about Corporate Impact Assessment: Legal and regulatory impact

Relevant to regulation

Financial impact

minor

Patient Experience/Engagement

Poor experience for patient and family

Risk & Performance Management

Integral to Trust processes

NHS Constitution/Equality & Diversity/Communication

N/A

Attachment:

TRUST BOARD REPORT â&#x20AC;&#x201C; 26th November 2015 Patient Story - Serious post-operative complication Incident Description Patient story - Airway compromise and Near Miss after neck surgery. A patient was admitted as an elective case for thyroidectomy for a benign indication. Preoperatively there were no issues and the operation went well. The patient had an uneventful initial recovery and was reviewed the following day on the ward round at which time there was minimal fluid in her surgical drains and these were removed. Later that day the patient reported that she felt unwell, her neck felt swollen and she reported that she felt it was more difficult to breathe. A small volume of bloody fluid discharged spontaneously through the surgical incision and provided relief. She was reviewed by the junior doctor on the ENT team who examined her and could find no problem, but asked her registrar to review the patient. The registrar was not resident as this was late evening and this is a non-resident post. The patient reported further difficulty in breathing, which became extreme and the ward staff sent out a medical emergency call. This is the call that requests emergency medical review and is recognised as serious deterioration and one stage short of cardiac arrest. The MET team responded and the ENT registrar arrived at the bed side at almost identical times. The ENT surgeon opened part of the surgical incision allowing blood and clot to decompress, which had an immediately beneficial effect for the patient who was again able to breathe. The patient was then taken back to the operating theatre by the registrar and consultant where a bleeding vessel was found and ligated. The patient was admitted to ICU as a precaution but made a subsequent routine recovery. Bleeding following thyroid surgery causing airway compromise is a recognised but rare complication of thyroid surgery, and as such is something that surgeons and nurses on a surgical ward dealing with patients who have these operations need to be prepared for. In the past the normal skin closure was a sub-cutaneous stitch and every patient had a stitch cutting blade by their bed side. The preferred closure now is staples but the practice of having an emergency staple remover at the bed side has persisted. The absolute incidence is 2%, but almost all of these occasions are due to venous ooze which is seldom life threatening. Most consultant surgeons will see only one episode of arterial bleeding threatening the airway and requiring return to theatre in their entire career. The incident was considered, but not recorded, as a serious incident because this is a recognised complication of surgery, however a full investigation has taken place. The family have complained, in particular about the recognition and early management of the complication. An after action review was conducted and the junior doctor involved in the initial review was taken out of service for a period of one week to receive intensive consultant delivered education, focusing in particular on ENT emergencies and post-operative problems. The exact complication suffered by the patient had been covered at induction which the doctor had attended. In addition to the training described above the doctor will attend an off-site emergency ENT course. All trainees in the department have undertaken further simulation based training on acute airway management and a formal airway simulation programme is being drawn up to provide training on a regular basis for future new ENT doctors and all nursing staff involved in post-operative care. Dr Des Holden â&#x20AC;&#x201C; Medical Director â&#x20AC;&#x201C; November 2015

2 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD IN PUBLIC

Date: 26 November 2015 Agenda Item: 2.2

REPORT TITLE:

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

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

N/A

Action Required: Approval (√)

Discussion (√)

Assurance (√)

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

The Safer Staffing report (October 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. Industrial action by non-consultant grade doctors Antibiotic resistance Pharmacy issues

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: N/A

Trust Board Report – 26th November 2015 Chief Nurse & Medical Director Report 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, a summary of the recent correspondence in relation to staffing and efficiency and on recruitment activity. 2.

Staffing Planned versus Actual – October 2015

Ward

Ward Specialty

Entries

RN Day

RN Night

NA Day

NA Night

Total Day

Total Night

Overall

Abinger Ward

430 - GERIATRIC MEDICINE

93.05%

100%

90.93%

100%

91.94%

100%

94.91%

Acute Medical Unit

300 - GENERAL MEDICINE

96.81%

99.54%

91.13%

89.52%

95.16%

95.89%

95.48%

Birthing Centre

501 - OBSTETRICS

90.32%

74.58%

N/A

90.32%

74.58%

82.64%

Bletchingley Ward

300 - GENERAL MEDICINE

98.41%

99.35%

98.53%

99.19%

98.47%

99.28%

98.76%

Brockham Ward

502 - GYNAECOLOGY

98.39%

100%

94.14%

100%

96.97%

100%

98.18%

Brook Ward

100 - GENERAL SURGERY

98.42%

96.77%

89.3%

71.43%

95.43%

94.2%

94.91%

Buckland Ward

101 - UROLOGY

98.37%

98.36%

95.71%

95.16%

97.49%

96.75%

97.22%

Burstow Ward

501 - OBSTETRICS

96.21%

78.49%

78.72%

91.8%

90.43%

83.77%

87.4%

Capel Annex l Ward

100 - GENERAL MEDICINE

97.3%

100%

96.4%

100%

96.91%

100%

98.04%

Capel Ward

430 - GERIATRIC MEDICINE

96.27%

98.92%

93.34%

96.77%

95.17%

98.06%

96.43%

Chaldon Ward

300 - GENERAL MEDICINE

94.88%

98.33%

95.07%

98.88%

94.96%

98.66%

96.22%

Charlwood Ward

301 - GASTROENTEROLOGY

96.45%

100%

98.12%

100%

97.06%

100%

98.23%

Copthorne Ward

301 - GASTROENTEROLOGY

97.58%

96.77%

98.98%

98.39%

98.06%

97.58%

97.87%

Coronary Care Unit

320 - CARDIOLOGY

90%

95%

288.52%

96.43%

95.68%

95.45%

95.57%

Delivery Suite

501 - OBSTETRICS

86.91%

91.94%

81.09%

95%

85.49%

92.68%

89.09%

Discharge Lounge

300 - GENERAL MEDICINE

91.63%

90.32%

91.73%

87.1%

91.68%

88.71%

90.63%

Godstone Ward (Haem)

303 - CLINICAL HAEMATOLOGY

99.44%

100%

N/A

99.44%

100%

99.72%

Godstone Ward (Med)

300 - GENERAL MEDICINE

83%

97.83%

120.29%

97.85%

97.04%

97.84%

97.38%

Holmwood Ward

320 - CARDIOLOGY

99.32%

100%

98.39%

100%

99.05%

100%

99.39%

TU/HDU

192 - CRITICAL CARE MEDICINE

98.26%

98.14%

108.46%

100%

99.91%

98.28%

99.14%

Leigh Ward

110 - TRAUMA & ORTHOPAEDICS

98.06%

100%

97.92%

100%

98%

100%

98.7%

Meadvale Ward

430 - GERIATRIC MEDICINE

88.99%

100%

93.5%

98.39%

91.36%

99.19%

94.08%

Neonatal Unit

420 - PAEDIATRICS

92.46%

100%

100.55%

93.33%

94.97%

97.83%

96.32%

Newdigate Ward

110 - TRAUMA & ORTHOPAEDICS

92.77%

101.61%

97.34%

93.55%

94.72%

97.58%

95.69%

Nutfield Ward

430 - GERIATRIC MEDICINE

98.7%

100%

98.2%

100%

98.51%

100%

99.01%

Outwood Ward

420 - PAEDIATRICS

96.66%

100.64%

92.94%

93.33%

96.18%

99.46%

97.56%

Rusper Ward

501 - OBSTETRICS

95.16%

90.32%

N/A

95.16%

90.32%

93.55%

Surgical Assessment Unit

100 - GENERAL SURGERY

94.35%

98.39%

90.32%

100%

93.55%

99.19%

96.06%

Tandridge Ward

300 - GENERAL SURGERY

92.36%

98.39%

97.62%

95.16%

94.59%

96.77%

95.38%

Tilgate Annex

100 - GENERAL MEDICINE

96.59%

97.01%

100%

97.84%

98.43%

98.04%

Tilgate Ward

300 - GENERAL MEDICINE

101.1%

100%

106.08%

100%

102.93%

100%

101.93%

Woodland Ward

100 - GENERAL SURGERY

85.81%

82.76%

100%

96.55%

91.13%

89.66%

90.66%

95.14%

96.87%

97.15%

96.9%

95.82%

96.88%

96.24%

Total

Commentary

The Trust has delivered planned versus actual staffing profile for October. The continued variance on Burstow Ward is due to staffing shortfalls in the maternity service and has been actively managed by the matrons with no adverse outcomes in relation to clinical care. The Hands on Help process and support from practice development staff ensured that there were no clinical concerns on these shifts. 16 registered midwives have commenced with a further 5 planned in the coming weeks. 4.

Nursing Recruitment

National and international nursing recruitment continues. The Filipino recruitment is continuing and it looks possible that the first cohort of staff will arrive in January 2016. European recruitment is continuing. 23 nurses have commenced in October with a further six expected in November with further Skype dates planned. Medical Directorâ&#x20AC;&#x2122;s report 5. Industrial action by non-consultant grade doctors The BMA has balloted junior doctors on industrial action is relation to unhappiness over a new contract which DoH is seeking to implement. The contract would give an increase in basic pay rates, but would regard a greater proportion of the working week as normal work hours. There is a promise that approximately 98% of doctors would not be financially worse off and pay protection would operate for a number of years. Doctors themselves are concerned that the changes would lead to reduced salary and an expectation of working more hours with a resultant detrimental effect on patient safety. Approximately 75% of eligible doctors voted and (*% of these voted for industrial action. Industrial action is planned for three days: 24h of action 1-2.12.15 where emergency cover, as per a bank holiday, will be maintained, followed by two further episodes of removal of all service on 8th and 16th December, each during the working day and ending at 5pm. We are preparing our plans to allow safe cover of patients presenting as emergencies and for those already being cared for on the wards at the present time and it

is likely that elective services in both out-patients and through the operating theatres will be affected on all three dates in order to preserve effective emergency cover.

6. Antibiotic resistance There continues to be regular coverage of the threats posed by antibiotic resistance by the press. This follows Dame Sally Davis (CMO England) statements that this is a global threat. Whilst central effort is being made to encourage the discovery and development of new antibiotics, most local NHS focus is around reduced antibiotic usage and screening at risk patients form carriage of resistant bacteria. Thus we screen patients who are being admitted to our services and have either been hospitalised abroad within the last 12 months, or have been hospitalised in London and are being transferred back for carbipenamase producing enterococci as recommended by NHSE. We continue to have a screening programme for MRSA and we continue to screen within the neonatal unit for carriage of any multi-resistant organisms. We have an antibiotic stewardship group which leads on both advice and audit of antibiotic usage in the trust and we help with various RCA that relate to community acquired infections. Since the last trust board we have had our third meeting with CCGs aro8nd RCA for CDiff diarrhoea. Having now looked together at the first 19 CDiff cases from this financial year we continue to have 2 cases where we are judged to have had a lapse of care, against a target of no more than 15 lapses. 7. Pharmacy issues We have had three patients experience apparent allergic reactions to the same IV contrast agent. We have liaised with the MHRA and no other organisation has reported a similar experience. The three patients received contrast from different batches of the drug, with different staff and different machines. We have suspended use of the product while awaiting advice from company and MHRA.

8. Recommendation To note and gain assurance from the report.

Fiona Allsop Chief Nurse November 2015

Des Holden Medical Director

Date: 26th November 2015

TRUST BOARD IN PUBLIC

Agenda Item: 2.3 REPORT TITLE:

Safety and Quality Committee Update

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

Richard Shaw, Chair Safety & Quality Committee Richard Shaw Chair Safety & Quality Committee n/a

Action Required: Approval ()

Discussion ( )

Assurance (ď&#x192;ź)

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

Compliance with CQC, MHRA and Audit Commission

Financial impact

Serious incidents often become claims

Patient Experience/Engagement

Included in the terms of reference

Risk & Performance Management

Reporting, investigation and learning from serious incidents informs risk management

NHS Constitution/Equality & Diversity/Communication

Included in the terms of reference

Attachment: N/A

Trust Board Report – 26th November 2015 Safety and Quality Committee Chair’s Report The Safety and Quality Committee met on 5th November 2015. It considered its standing agenda items; the reports from ECQRM and CQRM meetings and the SQC Quality Report. Recent Audits The committee discussed two recent audits. The first had been commissioned on mortality data quality, because of concerns about the accuracy of data recording the date of death, especially at weekends. The audit showed no recent improvement and staff will undergo refresher training, targeting the wards with the highest error rates. All errors will be corrected so that SUS holds accurate records. Quarterly audits will be reported to SQC. The second audit looked into a concern about patient access to stroke beds. This found that 17 out of 47 patients had breached the 4 hour access standard, for a number of reasons. These included missed diagnosis where the patient had co-morbidities and non-availability of a bed for the appropriate gender. An action plan is being developed and will be reported to a future meeting. ECQRM and CQRM VTE is one of the top five concerns raised by the Quality Report and was a focus for ECQRM during October. SQC discussed the IT problems that have led to a reduction in the electronic recording of VTE assessments, especially in Surgery. Following remedial action data was due to be up to date by 10 November. Assurance was given that this was a compliance issue and that the majority of patients had received appropriate VTE assessment and prophylaxis. An update will be provided in the Quality Report for December’s committee meeting. A concern was raised that no Single Performance Conversation with the CCG has taken place for some time. The Committee welcomed the intention to raise this with CCGS and the NHS. . Internal Controls As part of the Trust’s assurance processes, SQC was asked to review internal controls for Patient Systems and report to ACC at its meeting on 10 November. There are good controls in place. The main focus of attention was training for Children’s Safeguarding, rated amber, where an action plan is being pursued following an internal audit report in 2013. The position has improved, with 73% of staff now trained to Level 3. The Committee receives quarterly reports on both Adults and Children’s Safeguarding. Quality Report SQC finds the new Quality Report helpful in that it focuses attention on the areas of greatest concern and provides information about actions being taken, while also providing information about a wide range of safety and quality performance measures. We took good assurance from the fact that bed occupancy had fallen below 90% and that the length of stay in September was the lowest that it has ever been. This is attributed to a continuing focus on getting patients into the right bed first time, and to the impact of Breaking the Cycle in helping ring-fence and streamline access to elective beds. This appears to be leading to a sustained reduction in medical outliers. The Committee was updated on efforts to improve ambulance turnaround times, with a trajectory agreed with SECAMB and the CCG around planned improvement. The ED team is changing the way they work in order to deal with surges in activity, without compromising patient experience and care. We will monitor the impact on performance indicators.

Complaints The number of formal complaints received in the first two quarters of the years has increased to stand above the national average per inpatient spells. This may be a temporary trend but will be monitored. The main themes include attitude and communication problems, but in other respects correlate quite well to other indicators such as Incidents and include care implementation, appointments and clinical diagnosis. The Trust’s performance in responding in a timely fashion has improved. The Committee challenged as to whether sufficient attention was given to learning from “concerns” as distinct from formal complaints, and a PALS report will be added to the committee’s December agenda for assurance. The Parliamentary and Health Ombudsman’s latest report on Complaints about acute Trusts provided encouraging benchmarking information. This showed that during 2014/15 SASH had a lower number of referrals and complaints to the Ombudsman than most other acute trusts both nationally and regionally. Safeguarding The Committee received quarterly reports on Safeguarding of adults and children. It received clarification about patients reported missing to the police, a majority of whom leave ED before their treatment is complete, though some also leave wards. Work is being undertaken with Surrey Police to clarify which persons need to be reported and what action is expected. SQC will be briefed on the outcome of this work. The Action Plan for Children’s Safeguarding contains a number of actions due for completion in December and January. The Committee will monitor these in the spring but was assured that the plan is reviewed monthly at the Children’s Safeguarding meeting and shared with the Surrey Safeguarding Board. CQUINs and Clinical Audit Programme SQC received good assurance about management of the CQUINs and the Clinical Audit programmes. Next Meeting SQC will not meet in January as the planned date coincides with the post-Christmas Breaking the Cycle week. The next SQC meeting is at 2pm on 4th February.

Richard Shaw Chair – Safety & Quality Committee

Integrated Performance Report M07 â&#x20AC;&#x201C; October 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 – October 2015 Patient Safety • There were six SIs declared in October 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 October 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 October 2015. • The Two Week Cancer standard was not achieved in October 2015. • The Trust continues to deliver against incomplete pathways which measures % of patients still waiting at the end of each month.

Patient Experience • In October 2015 the Inpatient FFT decreased from 96.1% to 95.0%. The ED FFT decreased from 96.9% to 95.3% 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 – October 2015 Finance • At the end of month 7 the Trust has a YTD I&E deficit of £(3.6)m which is £(1.6)m adverse to the revised TDA plan. This is £0.3m adverse to the forecast profile. 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, RTT Access Standards and Failure to maintain cancer 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

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-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)

95.0%

93.0%

92.0%

91.3%

93.5%

92.0%

95.0%

92.2%

93.2%

95.4%

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

98.0%

96.0%

97.0%

96.0%

95.0%

96.0%

95.9%

97.3%

95.2%

97.7%

94.8%

96.7%

97.6%

95%

TBC

100%

98%

100%

96%

100%

98%

100%

98%

96%

100%

Serious Incidents - No per 1000 Bed Days

0.17

0.12

0.11

0.26

0.35

0.26

0.16

0.33

0.05

0.23

0.32

Percentage of Patient Safety Incidents causing Severe harm or Death

0.7%

0.2%

0.6%

0.7%

0.6%

0.2%

0.6%

0.5%

0.0%

0.2%

0.8%

0.6%

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

Number of overdue CAS and NPSA alerts

Trend

• Patient safety indicators continue to show expected levels of performance. • There were no Never Events reported in October 2015. • VTE risk assessment performance for October 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 Six SIs were declared in October 2015 (in all cases full investigations have been started): • 2015/31473 Fall The patient was admitted with known metastatic disease. In the early hours of the morning he climbed over the cotsides of the bed and fell. No obvious injuries were noted at the time, however the patient deteriorated and a subsequent CT scan showed a subdural haematoma. The patient subsequently died on 3 rd October 2015. • 2015/31482 Fall The patient was sitting on the edge of her bed. The nurses were attending to another patient in the same bay when they heard a bump and found the patient sitting on the floor; she appeared to have slipped off the bed. The patient is blind but mobile with guidance. The patient sustained a fractured neck of femur. • 2015/31710 Fall The patient had been repositioned, the nurse returned five minutes later to give medication and found the patient on the floor. Subsequent x-ray showed a fractured neck of femur. • 2015/33193 Treatment delay Patient was admitted to hospital on 31/01/2015 and had a chest x-ray. The patient’s notes show that although the chest x-ray was reviewed no abnormalities were noted. The patient was discharged the following day. When the chest xray was reported by a radiologist on 5/2/15 it was sent to the ED consultant with suspect imaging outlined and a recommendation that the patient be followed up within 3-4 weeks. The ED consultant referred the imaging to the AMU consultant (not the discharging consultant) there is no evidence that the imaging was acted upon at this time. The patient suffered further pain in her chest and a cough therefore GP direct referred her on 10/8/15 for another chest x-ray which showed that the lesion had grown in size. The GP referred the patient to respiratory. A subsequent CT scan confirmed metastatic lung cancer. The patient will have palliative chemotherapy and possibly radiotherapy. • 2015/33967 Adverse Publicity Intra uterine death recorded on 19/09/2015, probable cause of death due to knot in cord and cord around the babies neck. Body of baby sent to mortuary with no paperwork therefore the body was placed in mortuary storage. On scheduled date of release, 21/10/2015, the box was opened and consent/paperwork for request of non-invasive post mortem was found. This resulted in a delay in non-invasive post mortem and the possibility of genetic sampling being compromised. • 2015/33973 Fall Patient was walking out to the bathroom, tripped on a nephrostomy tube and fell. He sustained a fractured neck of femur.

An Associated University Hospital of Brighton and Sussex Medical School 5

Patient Safety Infection Control Indicator Description

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

MRSA BSI (incidences in month)

CDiff Incidences (in month)

MSSA

E-Coli

Trend

• There were no cases of MRSA in October 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

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

HSMR (56 Monitored diagnoses - 12 Months)

91.6

93.0

94.4

93.5

93.0

93.5

93.2

93.8

93.3

92.2

Emergency readmissions within 30 days (PBR Rules)

6.8%

7.2%

7.1%

6.9%

6.7%

6.6%

6.4%

7.0%

7.2%

7.7%

Aug-15

Sep-15

7.4%

7.2%

Oct-15

Trend

• Latest HSMR data for the Trust shows mortality remains lower than expected for our patient group when benchmarked against national comparators. SHMI data released in October shows Trust in similar position and third best in region. • The review of the Upper GI Bleed alert identified patients which needed to be recoded as well as improvements required to documenting cause of the bleed. Maternity Indicator Description

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

C Section Rate - Emergency

12%

14%

17%

18%

16%

17%

13%

17%

18%

14%

17%

14%

C Section Rate - Elective

12%

13%

11%

10%

11%

13%

Admissions of full term babies to neo-natal care

5.4%

3.8%

6.3%

6.0%

7.0%

6.2%

4.0%

5.0%

5.1%

5.8%

8.6%

Trend

• Maternity indicators continue to show expected performance. Admissions of full term babies was identified as a data quality issue and should reduce to around 6% once resolved.

An Associated University Hospital of Brighton and Sussex Medical School 7

Access and Responsiveness Emergency Department Indicator Description

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

94.3%

95.7%

93.3%

92.0%

91.3%

95.0%

96.8%

96.0%

94.8%

94.3%

96.1%

97.1%

95.5%

Ambulance Turnaround - Number Over 30 mins

151

183

344

163

259

247

199

170

206

238

220

225

212

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 October 2015 with performance of 95.5% • Over the first half of the year, overnight non-elective admissions are up 10% (7% for East Surrey CCG and 21% for Crawley CCG) compared to last year. • Ambulance turnaround performance remains a challenge and work is underway on internal processes and escalations as well as alterations to the physical environment to support handover of multiple patients at times of “surge”. • 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

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Cancer - TWR

93.8%

93.1%

93.3%

94.2%

93.1%

93.0%

89.6%

89.9%

Cancer - TWR Breast Symptomatic

93.3%

93.6%

93.5%

93.4%

96.3%

93.8%

90.6%

93.2%

93.3%

94.2%

93.8%

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

100.0%

99.1%

98.4%

97.1%

100.0%

98.2%

97.0%

96.2%

98.3%

99.1%

98.4%

97.4%

Cancer - 62 Day Referral to Treatment Standard

87.1%

86.3%

86.1%

85.4%

88.0%

83.7%

86.4%

83.9%

86.5%

80.7%

84.2%

86.2%

85.5%

Cancer - 62 Day Referral to Treatment Screening

83.3%

100.0%

92.3%

100.0%

92.3%

84.6%

92.3%

100.0%

87.5%

88.9%

100.0%

85.7%

Trend

• In October 2015, the Two Week Wait standard was not achieved. • As in September, patient choice was a key factor in a majority of these breaches but work is underway to ensure more slots are available when patients are contacted as well as to streamline the internal administrative processes in the pathway. This is starting to show a positive impact in November 2015. • In light of the performance above, the following risk is on the Significant Risk Register: • Failure to maintain cancer access standards - Failure to maintain cancer access performance due to capacity (Outpatients, Diagnostics) / pathway issues (Trust and wider network) can impact on the effectiveness of treatment as well as the experience for the patient. Risk score 15 (Likelihood of 5 and consequence of 3). Internal actions around capacity and tracking are underway and work is being undertaken with tertiary providers where relevant.

An Associated University Hospital of Brighton and Sussex Medical School 9

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

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

93.5%

93.3%

92.2%

92.1%

94.0%

93.7%

93.6%

93.5%

92.6%

92.2%

92.0%

92.1%

92.2%

RTT Admitted - 90% treated within 18 weeks

88.1%

81.4%

91.1%

90.2%

82.1%

88.4%

91.6%

90.1%

92.0%

84.0%

81.5%

77.9%

78.5%

RTT Non Admitted - 95% treated within 18 weeks

93.9%

92.8%

95.0%

91.7%

91.0%

93.5%

93.6%

95.3%

93.4%

89.4%

89.1%

88.7%

87.9%

Percentage of patients w aiting 6 weeks or more for diagnostic

0.0%

0.4%

0.1%

0.9%

0.7%

1.4%

1.0%

0.2%

0.8%

1.0%

0.1%

0.5%

0.3%

1.6%

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. Actions in Ophthalmology over recent months are now taking effect with the incompletes standard achieved at specialty level in October 2015.

• 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. • 41 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

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Inpatient FFT - % positive responses

97.0%

95.0%

95.7%

96.9%

94.2%

94.4%

95.1%

94.7%

95.1%

95.3%

96.1%

95.0%

Emergency Department FFT - % positive responses

95.0%

96.0%

93.0%

95.8%

97.1%

94.7%

95.4%

95.3%

93.7%

91.4%

95.8%

96.9%

95.3%

Maternity FFT - Antenatal - % positive responses

97.0%

95.0%

90.0%

97.6%

97.1%

97.0%

96.3%

100.0%

83.3%

94.1%

98.8%

94.3%

96.5%

Maternity FFT - Delivery - % positive responses

95.0%

93.0%

100.0%

95.5%

97.2%

100.0%

94.7%

97.0%

94.9%

93.8%

87.9%

95.4%

95.1%

Maternity FFT - Postnatal Ward - % positive responses

90.0%

92.0%

96.0%

85.9%

91.0%

97.3%

86.7%

91.0%

86.5%

90.0%

87.7%

87.9%

88.9%

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

Trend

• Inpatients/daycases – The October Friends and Family Test (FFT) score for inpatients/daycases has dropped slightly. The inpatient FFT response rate remains high, at 38%. The nationally quoted response rate is lower because it includes daycases.

• Emergency Department – The FFT score has also dropped back slightly. There has been a further increase in the response rate, from 20% in September to 24% in October • Maternity - The FFT scores for the antenatal touchpoint has improved from 94.3% in September to 96.5% in October. The score for the delivery touchpoint remains stable and there has been a slight increase in the postnatal ward FFT score. For touchpoints two and three the response rate is similar to the previous month, at 20%. For touchpoint one it has increased to 25% (compared to 13% in September). There has been a slight improvement in the postnatal community response rate but it remains very low (4.4%). Results are not shown for this measure due to the low response rate. • National FFT comparisons September - Inpatients/daycases – The national average FFT score for inpatients/daycases in September was 95.5%. SASH scored very slightly above this at 96.2%. ED - Our combined adult and paediatric ED Friends and Family Test score for September was 96.9%, well above the national average of 87.8%, ranking the Department 8th in England.

An Associated University Hospital of Brighton and Sussex Medical School 11

Workforce Workforce Indicator Description

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

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

96.4%

97.1%

95.1%

94.8%

95.9%

96.5%

96.8%

95.7%

96.9%

93.3%

92.5%

95.0%

95.1%

Average fill rate – care staff (%) - Day

95.3%

95.0%

93.1%

92.6%

93.8%

94.5%

96.1%

93.8%

93.5%

94.3%

94.5%

95.1%

97.2%

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

99.2%

99.4%

97.3%

97.2%

97.7%

96.7%

96.5%

97.1%

94.1%

95.2%

94.3%

96.4%

96.9%

Average fill rate – care staff (%) - Night

97.4%

95.3%

93.7%

93.3%

94.9%

95.2%

95.9%

94.9%

94.4%

93.8%

96.4%

96.9%

Overall Sickness Rate

4.4%

4.0%

4.5%

4.3%

4.4%

4.2%

4.3%

4.1%

3.9%

3.7%

4.4%

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

72%

69%

72%

67%

68%

73%

71%

68%

58%

56%

57%

64%

72%

15.3%

15.6%

15.7%

15.2%

15.5%

15.9%

15.6%

15.2%

15.0%

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 remains at 4.4% in October 2015 with absence related to ‘surgery’ being the highest reason for absence.

• 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 slightly to 15.0% in October 2015 and the Trust is developing initiatives to improve retention and staff experience. • 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

Oct-14

Nov-14

Dec-14

Jan-15

Outturn £m Surplus / (Deficit) - Plan

2.3

Outturn £m Surplus / (Deficit) - Forecast

2.3

YTD £m Surplus / (Deficit) - Plan

0.1

0.4

1.0

1.9

YTD £m Surplus / (Deficit) - Actual

0.1

0.5

1.0

Outturn UNDERLYING £m Surplus / (Deficit) - Plan

3.4

Outturn UNDERLYING £m Surplus / (Deficit) - Actual

1.0

(0.7)

(5.2)

YTD Savings £m - Actual

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

2.3

1.6

(2.5)

(2.4)

1.6

1.4

2.3

(0.8)

(1.2)

(2.0)

(1.1)

(0.7)

(0.6)

0.7

1.9

(2.9)

(2.4)

(0.8)

(1.1)

(2.0)

(1.3)

(2.6)

(3.3)

(3.6)

3.4

3.8

(5.2)

3.8

3.3

5.0

6.2

7.4

8.6

9.8

11.0

0.3

0.5

0.8

1.3

1.9

2.1

2.5

(8.5)

(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

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

3.8

2.8

4.8

3.8

2.6

3.2

2.9

2.6

2.5

3.0

3.9

4.8

YTD Liquid ratio - days

(7.0)

(4.0)

(8.0)

(18.0)

(21.0)

(20.0)

(21.0)

(23.0)

(22.0)

(25.0)

(19.0)

(13.0)

YTD BPPC (overall) volume £m

90%

85%

88%

87%

86%

82%

62%

75%

78%

76%

69%

59%

YTD BPPC (overall) value £m

92%

78%

84%

83%

81%

65%

73%

75%

74%

68%

61%

Outturn Capital spend Fav / (Adv) - forecast

19.4

19.3

17.1

OT Risk £m Surplus / (Deficit) - Assessment

Trend

• The Trust is reporting against the revised plan submitted to the TDA in September 2016. • At the end of month 7 the Trust has a YTD I&E deficit (after donated asset technical adjustments) of £(3.6)m which is £(1.6)m adverse to the revised TDA plan. This is £0.3m adverse to the forecast profile. • The position is mainly driven by the impact of emergency activity on costs and the overall income plan, and there is an adverse variance from the re-phasing of the elective income plan. • The underlying position at the end of October is a £(4.2)m deficit, reflecting the non recurrent use of the Trust’s balance sheet provisions. The Trust forecast position remains a £1.6m surplus. The unmitigated risk is estimated at £3.1m and recognising the level of risk, the Board is reviewing the forecast each month. • The Trust’s cash balance at the end of October 2015 was £4.8m, as a result of receiving a £4.4m capital loan. Cash is being managed, but the position is tight and the Trust requires a permanent working capital cash injection of £18m. • The capital spend forecast this year remains £17.1m

An Associated University Hospital of Brighton and Sussex Medical School 13

TRUST BOARD IN PUBLIC

Date: 26th November 2015 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 Corporate Governance Manager Audit & Assurance Committee – 10/11/15

Action Required: Approval (√)

Discussion ()

Assurance (√)

Purpose of Report: This report provides the Board with an executive summary of the September Audit and Assurance Committee. Summary of key issues The Committee discussed the Board Assurance Framework and took assurance from managements description of the overall liquidity position noting increased restrictions on access to cash. The Chair of the Safety and Quality Committee introduced management’s review of patient specific systems controls. The Committee took assurance from the planned actions to improve training compliance for children’s safeguarding. The Committee took assurance from management’s report on Trust’s losses and comps and noted guidance from External Audit on selection of Audit panel and changes to ‘value for money’ opinion. Recommendation: The Committee requests that the Board approve the AAC acting as the Trust's Auditor Panel - responsibility will include recommending to the Shadow Council of Governors on the appointment of our External Auditor. 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

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.

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 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. 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 – 26/11/2015 Audit & Assurance Committee Chair Update The Audit and Assurance committee met on the 10/11/2015; it was quorate. 1) Board Assurance Framework The Committee discussed the board assurance framework prior to the November public board. The Committee discussed the main financial risks in detail noting that both the Trust’s forecast and gross risk is expressed in Board papers. 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. The Committee asked to see an updated IT road map following the resent presentation to Board seminar. The Committee asked for assurances that efforts to improve quality and productivity within the Trust’s Outpatients services are on track and were reassured that appropriate management and focus was in place. The Committee noted the overall improvements in risk management which facilitates rich conversations at Executive level and has strengthened Trust governance. Noting that the BAF included assurances from third parties and had recently received a green Internal Audit. 2) Internal Controls The Chair of the Safety and Quality Committee presented management’s review of internal controls relating to patient systems. Management described how actions to improve training compliance for child safeguarding are being monitored internally and externally and are 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 took assurance from the report and took reassurance from both Internal and External Audit that the Trust’s management led 3) External Audit External Audit provided a rich horizon scanning review highlighting 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 new assessment will be based on proper practice and arrangements, including independent decision making, sustainability and working in partnership. The Committee requests that the Board approve the AAC acting as the Trust's Auditor Panel - responsibility will include recommending to the Shadow Council of Governors on the appointment of our External Auditor. 4) Losses and Comps Management presented the Trust’s midyear position for losses and comps. 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, noting that the overall value of losses was high which is linked to the development of the Integrated Discharge Unit.

3 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD IN PUBLIC

Date: 19 November 2015 Agenda Item: TBA

REPORT TITLE:

Charitable Funds Committee Chair Update

EXECUTIVE SPONSOR:

Paul Simpson (Chief Finance Officer)

REPORT AUTHOR:

Alan Hall (Non-Executive Director and Committee Chair)

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

No – Board Update

Action Required: Approval ()

Discussion ()

Assurance (√)

Summary of Key Issues This report briefs the Board on the key issues discussed at the meeting of the committee on 5 November 2015. Key points were: 

Fund raising update;



Fund Raiser recruitment update



Finance review

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

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

Legal and regulatory implications

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

Charitable funds received by the Charity are accepted, held and administered as funds and property held on trust for purposes relating to the health service in accordance with the National Health Service Act 1977, the National Health Service and Community Care Act 1990, the National Health Service Act 2009. These funds are held on trust by the corporate body. The fund is audited by the Trustâ&#x20AC;&#x2122;s External Auditor (Grant Thornton UK LLP) The report provides assurance about the financial management of the charitable fund. A deliberate positive impact from the use of the fund to support patient experience. The committee, and this report, provides assurance about risk management relevant to the fund. No compliance issue

Attachments: Report paper

2 An Associated University Hospital of Brighton and Sussex Medical School

Charitable Funds Committee Chair Update The Charitable Funds Committee met on 5 November 2015. Fundraising Update The Committee acknowledged continued efforts to raise the profile of the charity. Michael Wilson had met with Redhill Football Club (RFC) and has agreed common partnership principles. They have chosen SASH charity as one of their charities and there are plans to organise a fundraising event in collaboration with RFC in the Spring 2016. The Charity secured a place in the London Marathon and will be publicising the place to staff and externally to recruit a runner to participate in the London Marathon and agree to raise a minimum of £1,500 in support of the charity. Several donations had recently been received from patient families to the General Fund and to ICU. Fundraiser Recruitment Update The Committee was advised that Kat Swanston had now stepped down and therefore the Trust currently has no Fundraiser in place and that this position is proving difficult to recruit; however, a potential candidate will be interviewed later in November. There were questions raised by the Committee regarding the job description; appropriate banding of the post; and whether this should be a longer term position, and not advertised as a fixed contract. The Committee agreed that if the potential applicant is not successful, then the job description and post banding will need to be readdressed. The Committee supported a proposal to employ an interim administrator within the Communications Team, to help promote the charity and assist with general admin duties. Finance The fund balance as at September 2015 totalled £0.559m, with negative income year to date (donations of £50k but transfer of £75k from Cardiac Fund to SaSH as Trust income in respect of DVLA payments for reports). Expenditure amounted to £50k in the period to September 2015; COIF investment fund suffered devaluation by £11k as at M6 but fully recovered in M7. The Divisions are aware the available funds, and the majority have submitted spending plans, these will be reviewed at the end of the year. The audited annual accounts and report for 2014-15 were approved by the Committee have been filed with the Charity Commission. The Committee acknowledged that although considerable consolidation carried out few years ago the fund numbers are still quite high. Alan Hall Chair of Charitable Funds Committee 19 November 2015 [END]

3 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD IN PUBLIC

Date: 26th November 2015 Agenda Item: 4.1

REPORT TITLE:

Update from the Shadow Council of Governors

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

Gillian Francis-Musanu Director of Corporate Affairs Gillian Francis-Musanu Director of Corporate Affairs Shadow Council of Governors Meeting 20.10.15

Action Required: Approval (√ )

Discussion (√)

Assurance (√)

Purpose of Report: To provide an update to the Board on the establishment of the Shadow Council of governors and note the items from the inaugural meeting and to seek ratification for the Draft Code of Conduct and Expenses Policy. Summary of key issues Following successful governor elections in the summer, the Inaugural Council of Governors meeting took place on 20th October 2015. The Council will meet in Shadow form until the Trust is authorised as an NHS Foundation Trust. The meeting was quorate and very well attended by both elected, nominated governors, Trust Executive and NonExecutive Directors. A report on the work and activities of the Shadow Council of Governors will be provided to the Board on a quarterly basis. Recommendation: The Board is asked to note the establishment of the Shadow Council of Governors and to ratify the Code of Conduct and the Expenses Policy. 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 Financial impact Patient Experience/Engagement Risk & Performance Management

A Council of Governors is a statutory requirement for an NHS Foundation Trust and forms part of the governance structure Limited – mainly relating to claiming of reasonable travel expenses A significant and important part of the role of the Council of Governors Relevant aspects included in the report

NHS Constitution/Equality & Important to the role and function of the Council Diversity/Communication of Governors Attachments: - Shadow Council of Governors Code of Conduct and Shadow Council of Governors Expenses Policy

TRUST BOARD REPORT – 26TH November 2015 UPDATE FROM THE SHADOW COUNCIL OF GOVERNORS 1.

Introduction

Following successful governor elections in the summer, the Inaugural Council of Governors meeting took place on 20th October 2015. The Council will meet in Shadow form until the Trust is authorised as an NHS Foundation Trust. The meeting was quorate and very well attended by both elected, nominated governors, Trust Executive and NonExecutive Directors. A report on the work and activities of the Shadow Council of Governors will be provided to the Board on a quarterly basis. 1.2

Main Agenda Items

The following items were discussed during the inaugural meeting: •

Governor Declaration of Interest Register – In line with governance requirements, once finalised the register will be available on the Trust website

•

Draft Terms of Reference – This sets out how the Council will operate both in shadow form and post authorisation and gives clarity to the statutory role of the Council. Pauline Lambert was introduced as the Senior Independent Director

•

Trust Update and FT Progress presentation from the Chief Executive – an overview of the Trusts development, performance, safety and quality standards, progress in relation to the FT journey, VMI development and an opportunity for Governors to ask questions about the Trust

•

Governors Input into Trust Vision, Values and Strategic Objectives – The Director of Strategy gave an overview and governors were able to discuss, debate and in an interactive way give their input and views on the clarity and understanding of the Trusts vision, values and strategic objectives. The narrative supporting the strategic objectives were felt to require greater clarity

•

Draft Governor Code of Conduct – The Head of Corporate Governance set out guidance on the principles of behaviour and conduct expected from all governors based on national best practice and learning which is underpinned by the Nolan Principles

•

Communications Plan for Governors – The Head of Communications shared d a variety of forms and options of communication both with the Trust and for FT membership. The governor web pages will be developed to provide a private forum and a public place for sharing and publishing information both for governors and FT members

•

FT Membership Development Strategy – provided governors with an overview of achievement of membership targets during the last 18 months and a plan to develop and increase membership with a focus on a representative and engaged membership in each constituency. The Council agreed to set up a sub-group to further develop the action plan and will report back on progress at the next meeting.

â&#x20AC;˘

Governor Expenses Policy â&#x20AC;&#x201C; outlined the process for governor to claim reasonable travel expenses whilst undertaking their governor role. BACS payment was the preferred option. It was also agreed that partner organisations would be responsible for the expenses of nominated governors.

1.3 Overall the inaugural meeting was vibrant and positive and the Council will continue to meet on a quarterly basis.

Governors Code of Conduct and Expenses Policy

The Draft Code of Conduct and the Expenses Policy (attached) were both approved by the Shadow Council and are presented to the Board for ratification. 3.

Recommendation

The Board is asked to note the establishment of the Shadow Council of Governors and to ratify the Code of Conduct and the Expenses Policy.

Gillian Francis-Musanu Director of Corporate Affairs November 2015

CODE OF CONDUCT FOR NHS FOUNDATION TRUST (FT) GOVERNORS

As an NHS Foundation Trust Governor I will commit to actively support the Trust’s vision and values. I will seek at all times to represent the views of FT members or the organisation I represent. I will support the Trust in its aims and priorities and ensure that the needs and interests are of it patients are foremost in decision-making. VISION We are the district general hospital for our local community and our vision is: To provide: safe, high quality healthcare which puts our community first.

VALUES We aim to be the provider of choice for our local community, delivering excellent District General Hospital services and working in partnership with others to provide a broader range of services at East Surrey Hospital. We will achieve this through our values which underpin everything we do: • • • •

Dignity & Respect: we value each person as an individual and will challenge disrespectful and inappropriate behaviour One Team: we work together and have a ‘can do’ approach to all that we do, recognising that we all add value with equal worth Compassion: we respond with humanity and kindness and search for things we can do, however small; we do not wait to be asked, because we care Safety & Quality: we take responsibility for our actions, decisions and behaviours in delivering safe, high quality care

In undertaking the role of Governor of Surrey and Sussex NHS Foundation Trust I will: • • • • • •

•

Uphold the seven principles of public life as set out by the Nolan Committee (Appendix 1) Value and represent the views of Foundation Trust members Act with discretion and care in respect of difficult and confidential issues Maintain confidentiality with regard to information which is of a confidential nature Acknowledge that the Trust is an apolitical organisation If I am a member of a trade union, political party or other similar organisation, I recognise that I will not be representing those organisations but will be representing the constituency (public, patient or staff) that elected me or the partner organisation that nominated me Be honest and act with integrity and probity at all times

CoG Code of Conduct – Final – Oct 2015

• • • • • • • • • • • •

Respect and treat with dignity and fairness the public, patients, relatives, carers, NHS staff and partners in other agencies Seek to ensure that my Governor colleagues are valued and that judgements about them are consistent, fair and unbiased and properly founded Accept responsibility for my own actions Regularly attend Council of Governor meetings Have regard to this Code of Conduct and my responsibilities as a governor in any relationship or interaction with the media Show my commitment to working as a team member by working with colleagues in the NHS and wider community Seek to ensure that the membership of the constituency that I represent is properly informed and able to influence services Seek to ensure that no one is discriminated against because of their religion, belief, race, colour, gender, marital status, disability, sexual orientation, age, social or economic status or national origin At all times comply with the Constitution, Standing Orders and Standing Financial Instructions of the Trust Seek to ensure that the best interests of the public, patients, carers and staff are upheld in decision-making and will act as a critical friend to the Trust Ensure that decisions are not improperly influenced by gifts or inducements Answer to the Independent Regulator, Commissioners and the Public in terms of fully and faithfully declaring and explaining the use of resources and the performance of the total NHS in putting national policy into practice and delivering targets.

I declare that I have been elected/appointed to serve as a member of the Council of Governors on behalf of …………………………………………….. Constituency/ Organisation. I confirm that I am not prevented from being on the Council of Governors and am eligible to vote as a member of the Council.

Signature:……………………………………………………………………………………………………………………….

Print Full Name:…………………………………………………………………………………………………………….

Date:………………………………………………………………………………………………………………………………

CoG Code of Conduct – Final – Oct 2015

Appendix 1 – Nolan Principles The Nolan Committee set out ‘Seven Principles of Public Life’ which it believes should apply to all in the Public Service. These are:Selflessness Holders of public office should act solely in terms of the public interest. They should not do so in order to gain financial or other benefits for themselves, their family or their friends. Integrity Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might seek to influence them in the performance of their official duties. Objectivity In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit. Accountability Holders of public office are accountable for their decisions and actions to the Public and must submit themselves to whatever scrutiny is appropriate to their office. Openness Holders of public office should be as open as possible about all the decisions and actions that they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands. Honesty Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest. Leadership Holders of public office should promote and support these principles by leadership and example.

CoG Code of Conduct – Final – Oct 2015

Council of Governor’s Expenses Policy Status (Draft/ Ratified):

Final

Date ratified:

dd/mm/yyyy

Version:

Ratifying Board:

Trust Board (Please delete as appropriate)

Approved Sponsor Group:

Shadow Council of Governors

Type of Procedural Document

Policy

Owner:

Council of Governors

Owner’s job title:

Director of Corporate Affairs

Author:

Director of Corporate Affairs

Author’s job title:

Director of Corporate Affairs

Equality Analysis completion date:

dd/mm/yyyy

Date issue:

26/11/2015

Review date:

25/11/2018

Replaces:

New Policy

Unique Document Number:

To be completed by the Corporate Governance Officer

VERSION CONTROL SUMMARY

Version

Date

Author

Status

30/09/2015

Gillian FrancisMusanu

New policy

Comment

Contents Section

Page

Introduction

Purpose

Principles

Expenses

Office Expenses

Other Expenses

Taxis

Lunch, refreshments and food expenses

Individual, Committee Accountability & Responsibility

Process for reimbursement

Staff Governors

Appendices Appendix 1 - Mileage Rates

Appendix 2 - Governor Expenses claim form

Council of Governorsâ&#x20AC;&#x2122; Expenses Policy 1. Introduction 1.1 This document provides guidelines under which members of the Council of Governors may be reimbursed for legitimate expenses incurred while undertaking sanctioned activities for the benefit of Surrey & Sussex Healthcare NHS Trust. 1.2 The role of a governor on the Council of Governors is voluntary and it is a guiding principle of Foundation Trust status that governors do not receive any form of salary for being a governor. However, elected governors can claim for reasonable out of pocket expenses such as travel which have been incurred whilst undertaking their governor role. Noting that nominated governors should claim expenses from the organisations they represent. 2. Purpose 2.1 To set out reimbursement policy and procedures for elected governors of Surrey and Sussex Healthcare NHS Trust. 2.2 To encourage equal opportunities by facilitating participation for all governors by ensuring that individuals contributing their views or time are not excluded due to financial restraints. 2.3 To promote an ethos of fairness and delivering value-for-money by making clear the appropriate level of reimbursement of expenses incurred. At all times the spirit of fairness and value-for-money will prevail. 2.4 To promote equivalence of practice within the Trust. 3. Principles 3.1 This policy applies to elected members of the Trustâ&#x20AC;&#x2122;s Council of Governors who are not employees of the Trust. The policy is intended to create a parity of payment with other volunteers working with the Trust. This policy does not apply to Foundation Trust Members, who are not entitled to claim reimbursement of expenses. Reimbursement of expenses for employees and volunteers are covered under separate policies. 3.2 Governors participating in Foundation Trust events such as meetings of the Council of Governors, events, Committees or task groups as agreed or invited by the Trust and whose expenses are not paid by another organisation, should be entitled to claim expenses. Governors who attend public meetings or other meetings without specific invitation or prior agreement with the Trust will not receive reimbursement.

4. Expenses 4.1

Elected governors can claim reimbursement for out of pocket expenses incurred whilst attending meetings and events where the Trust has invited governors to attend or where governors are required to attend as part of their role.

4.2

Elected governors can claim reimbursement of expenses for attending the following: •

Official Council of Governor Meetings

•

Governor training sessions including Governor induction

•

Trust Board meetings

•

Trust group and sub-committee meetings

•

Membership recruitment and engagement events in the local community

•

Annual Members Meeting

•

Annual General Meeting

•

Any other Trust meetings/events where governors have been invited to attend in the capacity of their role

•

Meetings and events organised by the Foundation Trust Governor’s Association (FTGA) and NHS Providers (formerly known as the FTN)

Elected governors can also claim expenses incurred whilst attending external meetings and events but only by request or on behalf of the Trust in their capacity as a Governor. 4.2

Mileage rates will be paid in line with Agenda for Change mileage rates (see Appendix 1). Mileage rates may be subject to change. The Director of Corporate Affairs & Company Secretary and the Head of Corporate Governance will hold up to date rates.

4.3

Mileage will be calculated using the shortest most practical route calculated and paid rather than the distance actually travelled. Although they may exercise free choice and choose their route for their own convenience claimants must take this into account when planning their journeys as it may have financial implications. Elected Governors may only claim mileage for journeys up to and not exceeding the distance from their normal place of work (or residence) to the Trust/event i.e. that which would be usually incurred.

4.4

Claimants are responsible for ensuring that vehicle insurance policy covers fully third part insurance for use of the vehicle carrying tasks as a volunteer including cover against risk of injury to or death of passengers and damage to property whilst carry out tasks as a volunteer. The vehicle is currently being maintained in a road-worthy condition.

4.5

Parking and toll charges incurred as a direct result of attending authorised meetings will be reimbursed on production of a receipt or other supporting evidence of the cost (e.g. a parking ticket).

4.5

Reimbursement of travel expenses at a rate exceeding the amounts set out may only be made in exceptional circumstances and require the prior agreement of the Director of Corporate Affairs.

Office expenses Office support services should normally be undertaken by the Trust. Photocopying, stationery and other sundry items required in performance of their duties should be provided via the Trust.

Other expenses

6.1

Expenses of a companion required to enable a governor to participate may be paid by prior written agreement with the Trust. In these cases expenses may be claimed at the same rate paid to the governor.

6.2

Reimbursement of particular needs, such as linguistic support or specialist audio equipment, may be authorised by prior written agreement with the Company Secretary.

6.3

Under exceptional circumstances, the Trust will consider requests for additional financial support to enable performance of governorsâ&#x20AC;&#x2122; duties. Requests should be made to the Trust Company Secretary.

Taxis

7.1

The Foundation Trust Office can book taxis for governors to attend meetings/events but only under exceptional circumstances and only when the use of a taxi has been agreed in advance with the Director of Corporate Affairs or nominated Trust staff member, for example where public transport would not be appropriate or reasonable e.g. if a governor has mobility issues. Elected governors are asked to advise the FT Office of any travel requirements they may have, for example requiring a low vehicle for ease of getting in and out of vehicle or requiring the taxi to park as close as possible to the pick- up address. 6

Where the use of a taxi is required for a valid reason, the governor is required to inform the Membership Office at least 48 hours or a minimum of two days prior to the travel date. The Trust has a contract with an approved taxi service provider and this provider will be used to book taxis for governors. Once the taxi has been booked by the FT Office, governors will be provided with the booking details. If a pre-booked taxi is no longer required by a governor, the FT Office must be notified as far in advance as possible so that the booking can be cancelled. Reimbursement of expenses for the use of a local taxi will only be made in exceptional circumstances and only by prior agreement from the Director of Corporate Affairs. Where a Governor believes it is necessary for them to use a local taxi to carry out their duties and they wish the Trust to reimburse them for the cost of using a taxi, they must seek prior approval and state their reason(s) to justify why they need to use a local taxi. If it is agreed that a governor will be reimbursed for booking their own local taxi, a valid receipt must be submitted with the expenses claim. Please note reimbursement will not be made without a valid receipt. 8.

Lunch, refreshments and food expenses Where possible lunch and refreshments will be provided for meetings and events that are held between 12pm â&#x20AC;&#x201C; 2pm. However if an elected governor is invited to attend a meeting or event between 12pm â&#x20AC;&#x201C; 2pm and lunch is not provided, governors are entitled to claim for lunch/refreshment expenses. Where governors are required to attend a meeting after 5pm for example the Council of Governor Meeting, sandwiches and or light refreshments will be available at the meeting. Where food and refreshments are not provided, governors will be entitled to claim expenses and receive reimbursement for buying their own food and refreshments. There is a maximum total amount elected governors are entitled to claim for lunch, refreshments or food expenses. Governors wishing to claim this expense are asked to contact the FT Office beforehand to request the total maximum amount that governors can claim for this expense. To be reimbursed for lunch, refreshments or food expenses, a valid receipt must be submitted with the expense claim.

Individual, Committee Accountability & Responsibility

9.1

Governorsâ&#x20AC;&#x2122; responsibilities:

9.1.1 Governors are responsible for the completion and accuracy of their claims.

9.1.2 HMRC guidance at the time of writing outlines that reasonable expenses claimed whilst carrying out voluntary work are not liable to Income Tax. However, HMRC policy is subject to change and governors are responsible for their own personal tax arrangements. More information is available on the HMRC website: www.hmrc.gov.uk. 9.2

The Trust Company Secretary or the Head of Corporate Governance is responsible for authorising payment of expense claims in accordance with this policy.

9.3

The Governor Nominations Committee will be responsible for overseeing the appropriate operation of this policy.

10. Process for Reimbursement 10.1

Governors remain wholly responsible for the completion and accuracy of their claims.

10.2

Claims should be completed within one calendar month of the expense being incurred, accompanied by receipts for all items (or journey details for mileage claims).

10.3

A sample of the travel and expenses claim form is included in Appendix 2.

10.4

Completed forms should be sent to the Director of Corporate Affairs who will authorise and pass them for payment. Claims will normally be reimbursed by cheque or BACS. In order to revise reimbursement by BACS governors will need to provide banking details, using standard forms. This will be stored securely in accordance with Trustâ&#x20AC;&#x2122;s financial policies.

10.5

Governors are advised to keep a copy of their claim form in case of any queries.

10.6

The Trust will reimburse elected governors for reasonable travel expenses incurred through participation in pre-agreed governor activities. In line with Surrey County Councilâ&#x20AC;&#x2122;s commitment to encouraging greener travel, the general expectation is that where possible governors will use public transport to carry out their duties e.g. standard class rail return, bus and coach. However, if it is necessary to use a vehicle, mileage may be claimed as set out in Appendix 1. Please note that where vehicle use applies, the Trust will pay mileage and reasonable parking costs.

10.7

In extreme circumstances (for example, due to physical disability / medical reasons/late evening meetings in circumstances when personal safety may be compromised), reimbursement may be considered for reasonable taxi fares and agreed in advance by the Trust. Where this is the case the claimant may 8

be required to provide documentary evidence to support such a request, for example a doctor’s letter to confirm they are unable to use public transport or walk the required distance. 10.9

The Trust will also reimburse governors for any carer costs incurred during the course of carrying out their role.

11.0

Staff Governors

11.1

Staff governors will need to claim expenses in accordance with the Trust’s expenses policy and complete the relevant staff expenses claim form. These are available on the Trust’s intranet.

Appendix 1 Current rates of reimbursement applying to business journeys made on or after 1 July 2014 Type of vehicle/allowance

Annual mileage up to 3,500 miles (standard rate)

Annual mileage over 3.500 miles (standard rate)

Car (all types of fuel)

56 pence per mile

20 pence per mile

All eligible miles travelled

Motor cycle

28 pence per mile

Pedal cycle

20 pence per mile

Passenger allowance

5 pence per mile

Reserve rate

28 pence per mile

Carrying heavy or bulky equipment

3 pence per mile

Source: http://www.nhsemployers.org/your-workforce/pay-and-reward/nhs-termsand-conditions/nhs-terms-and-conditions-of-service-handbook/mileage-allowances

Appendix 2 Example Expense Request

GOVERNORâ&#x20AC;&#x2122;S EXPENSE REQUESTS

TRUST NAME

DATE

The following payments have been checked for correct authorisation & coding, and Surrey and Sussex Healthcare put on hold in the payment schedule. NHS Trust (RTP) PAYMENT DETAILS

PAYEE

ADDRESS

AMOUNT

COST CENTRE

ACCOUN T CODE

CHQ

Details:

(Please attach any other backing documents which may be available)

Payment requested by

Date

(Signature and title)

Director of Corporate Affairs (or Deputy)

Date

TRUST BOARD IN PUBLIC

Date: 26th November 2015 Agenda Item: 4.2

REPORT TITLE:

Rules of Procedure:- Annual Update & Review

EXECUTIVE SPONSOR:

Gillian Francis-Musanu, Director of Corporate Affairs

REPORT AUTHOR (s):

Colin Pink, Head of Corporate Governance

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

Executive Committee (18/11/2015) Annual sub-committee updates Shadow Council of Governors

Action Required: Approval (√)

Discussion (√)

Assurance ()

Purpose of Report: Annual review of ‘Rules of Procedure’ – Corporate Governance Manual Summary of key issues This update includes: • Includes reference to the ‘Council of Governors’ including the shadow council of governors Terms of reference • Revised terms of reference for the Executive Committee and the Executive Committee for Quality & Risk • Changes the divisional management board • Minor changes to relevant terms of reference to sub-committees mainly relating normal business All material changes are highlighted in yellow. Recommendation: To review and approve the annual review of the ‘Rules of Procedure’ 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 Financial impact Patient Experience/Engagement

Ensures integrated governance systems are updated As borne out in the role of the Board and its sub-committees Highlights national requirements in place to improve patient experience.

Risk & Performance Management

As noted in the relevant terms of reference

NHS Constitution/Equality & Diversity/Communication

Includes where relevant an update on the NHS Constitution and compliance with Equality Legislation

Attachment: Rules of Procedure

2 An Associated University Hospital of Brighton and Sussex Medical School

Rules of Procedure Board of Directors Integrated Governance Systems

VERSION 10.0 - November2015 NEXT REVIEW DATE: November 2016

Acknowledgements Surrey and Sussex Healthcare NHS Trust acknowledges the advice and assistance of Brighton and Sussex University Hospitals NHS Trust and the copyright expressed by them over their Rules of Procedure, on which this document is based.

Disclaimer Surrey and Sussex Healthcare NHS Trust has taken care in preparing the material included in this work. However, Surrey and Sussex Healthcare NHS Trust makes no representations or warranties (express or implied) as to the completeness, accuracy, reliability of the information contained herein. Any reliance you place on such information is strictly at your own risk. No liability (other than in respect of death or personal injury to the extent caused by our negligence) is accepted for loss, damage or inconvenience incurred as a result of reliance on any part of this work.

Contents About Surrey and Sussex Healthcare

Chapter One

Introduction

Chapter Two

Governing our Business and Services

Chapter Three

Board of Directors

Chapter Four

Committees of the Board of Directors

Chapter Five

Council of Governors

Chapter Six

Audit and Assurance Committee

Chapter Seven

Nomination and Remuneration Committee

Chapter Eight

Safety and Quality Committee

Chapter Nine

Finance and Workforce Committee

Chapter Ten

Charitable Funds Committee

Chapter Eleven

Executive Committee

Chapter twelve

Risk Management Responsibilities

Appendix 1

SASH Code of Conduct

Appendix 2

Best practice guidance

102

Appendix 3

Principal NHS regulators and other bodies

103

Appendix 4

Executive Team Responsibilities

104

Surrey and Sussex Healthcare Rules of Procedure

About Surrey and Sussex Healthcare What we do Surrey and Sussex Healthcare NHS Trust (SaSH) provides a comprehensive range of emergency and non-emergency services to the residents of East Surrey, north-east West Sussex, and south Croydon, including the major towns of Crawley, Horsham, Reigate and Redhill. Our proximity to the M25 and M23 motorways and Gatwick Airport means that we also treat many patients from outside the area and from overseas. At East Surrey Hospital (ESH), in Redhill, we provide acute and complex general hospital services. We also provide out-patient, diagnostic and less complex, planned services at Caterham Dene Hospitals and Oxted Health Centre in Surrey, and at Crawley and Horsham Hospitals in West Sussex. The Trust is a designated trauma unit. SaSH is an associated university hospital of Brighton and Sussex Medical School and has established partnerships with Royal Surrey County Hospital and Guy’s & St Thomas’ NHS Foundation Trust to provide specialist services at ESH.

We work in close partnership with our local GPs and commissioners to ensure that local health services are provided and improved in ways which best meet the needs of our patients and their families.

Foundation trust status SASH is on the journey become an NHS Foundation Trust by 2015/16.

Our Values – what Surrey and Sussex Healthcare NHS Trust stands for: Dignity & Respect: we value each person as an individual and will challenge disrespectful and inappropriate behaviour One Team: we work together and have a ‘can do’ approach to all that we do recognising that we all add value with equal worth Compassion: we respond with humanity and kindness and search for things we can do, however small; we do not wait to be asked, because we care Safety & Quality: we take responsibility for our actions, decisions and behaviours in delivering safe, high quality care

Chapter One Introduction 1.1

Good governance provides the key to effective leadership, meaningful challenge and real accountability. Effective governance is not about process; rather it is about successful leadership and living the values of the organisation.

1.2

Corporate governance is the system by which companies and other Board-led organisations, including hospitals, are directed and controlled. Good governance provides ambitious, effective but prudent direction that helps to deliver success over time. It is the business of the Board of Directors and is separate from day-today operational management, which is the responsibility of executives and the management structure they lead. Corporate governance is ‘what the Board does’ and is therefore the business of every trust.

1.3

These Rules of Procedure describe the corporate governance arrangements within Surrey and Sussex Healthcare NHS Trust (SASH). They should be read in conjunction with the Trust’s Standing Orders, Standing Financial Instructions and Scheme of Delegation, which describe in detail the roles, responsibilities and procedural requirements of the Board of Directors. These Rules of Procedure should also be read in conjunction with the SASH Policy for the Management and Development Procedural Documents.

1.4

The Board of Directors is responsible for providing effective and proactive leadership of the Trust within a framework of processes, procedures and controls which enable risk to be assessed and managed. The Board of Directors shall report upon this system of internal control in the Trust’s annual report and to the Shadow Council of Governors. The Board of Directors retains responsibility for delivering effective corporate governance but may delegate certain decisions to Board Committees or establish Committees to provide advice and guidance in this regard.

1.5

In these Rules of Procedure, words importing the masculine gender only shall include the feminine gender; words importing the singular shall import the plural and vice-versa. References to any statutory body shall be deemed to include any successor body or bodies which may from time to time assume all or substantially all of the functions of that original statutory body. References to any mandatory guidance issued by Monitor – Independent Regulator of NHS Foundation Trusts (“Monitor”) shall be construed to include a reference to the same as it may have been, or may from time to time be, amended, modified, consolidated or replaced.

1.6

These Rules of Procedure will be reviewed annually or earlier as necessary to reflect any changes as the trust revises policies and progress through its journey towards Foundation Trust status.

1.7

A separate version of this document will be developed to comply with Monitor’s requirements and will come to use once FT status has been achieved.

Surrey and Sussex Healthcare Rules of Procedure

Chapter Two Governing Our Business and Services 2.1

Overview

The Rules of Procedure sets out the Board of Director’s integrated governance systems at Surrey and Sussex Healthcare NHS Trust (SASH). This system supports the Board of Directors at its Trust Board meetings to fulfil its legal duties in relation to quality of services and financial management. It further ensures that the Board of Directors has appropriate and timely information from the Chief Executive Officer (CEO) as the accountable person, that the management systems in place are delivering the Board of Director’s strategy whilst ensuring quality in all trust services is achieved within the finances available. The Rules of Procedure focuses on the Trust’s Corporate Governance and as such details the linkages with the Trust’s Shadow Council of Governors.

2.2

Summary

The Board of Directors governs the Trust business including the delivery of the strategies it sets by seeking assurance that the managerial systems the Chief Executive Officer has in place deliver the desired outcomes and enable effective and timely reporting of significant issues that threaten its objectives. Prior to authorisation the Trust has established a Shadow Council of Governors who will begin to emulate the general statutory duties of a formal Council where practical and reasonable. The responsibilities of the Council of Governors are set out in the Monitor Code of Governance and the Health and Social Care Act 2012 and will operate in Shadow form until the Trust has been authorised as Foundation Trust (FT). The statutory duties of the Council of Governors (once authorised as an FT) are to; hold the non-executive directors to account (both collectively and individually) for the performance of the Board of Directors; represent the interests of the members of the Trust as a whole and the interests of the public; review and contribute to the forward plans of the Trust. The CEO has aligned his accountability framework and decision making authorities to the line management structures in place that deliver the day to day business. The alignment around the line management structures provides all staff and the Board of Directors with a simple and well understood way of communicating the Board’s objectives into day to day business and receiving feedback on how it is achieved. By this he has ensured that those with the authority can exercise it and have clear escalation processes if they are unable to do so. The escalation processes lead to individual directors and the Executive Committee on the way to the CEO as the accountable officer.

It further allows staff to see where they fit in the overall strategy and how their personal objectives support the Trust to deliver its objectives.

2.3

Board of Directors Committees

The Board of Directors has authorised a number of committees to scrutinise aspects of the Trust’s business relating to safety and quality of services, finance and workforce (including business planning). These are in addition to the Audit and Assurance, Nomination and Remuneration and Charitable Funds Committees. Each committee supports the Board of Directors in relation to its duties in seeking assurance about all aspects of the Trust’s business and providing sufficient capacity and focus to ensure appropriate scrutiny. Chaired by a Non-Executive Director with a membership that includes the CEO (with the exception of Nomination and Remuneration and Charitable Funds) the committees review, scrutinise and challenge the information they receive and allow the Board of Directors to be assured that the managerial processes are delivering outcomes to the required standards. The terms of reference of each committee sets out the remit of responsibility delegated by the Board of Directors. This in turn sets out the information requirements of the committee, how it should interact with the information it receives and use this to reach a conclusion about assurance. Where assurance cannot be robustly established the Chair of the Committee reports this to the Board of Directors. The Board of Directors receives a report from each Chair at every public board meeting. On receiving a report that identifies a lack of assurance in relation to an aspect of the business the Board of Directors can either hold the CEO to account (managerial aspects) or seek independent assurance commissioned by the Board of Directors or by referring the matter to its Audit and Assurance Committee.

2.4

The Chief Executive Officer

The Chief Executive Officer is accountable for the managerial delivery of the entirety of the Trust’s business and has personal responsibility as set out in the Accountable Officer Memorandum for safeguarding public funds. To enable the Board of Directors to fulfil their statutory duties in relation to quality of services, financial management and internal control he reports on managerial performance (quality, operational and financial) in the reports received from the Executive Committees (described below). The Board of Directors recognises that whilst the CEO remains the accountable officer, he has delegated day to day responsibility for managing the delivery of aspects of the business to his executive directors. The Board of Directors therefore receives reports in the relevant director’s name to ensure it has sufficient breadth and depth of information to conduct its business. However, the Board is aware that it is the CEO that is being held to account at all times for the Trust’s performance across all aspects of its business.

Surrey and Sussex Healthcare Rules of Procedure

At all levels in the Trust below Board of Directors committee level, the CEO has managerial systems in place to deliver the business. The Board of Directors governs by measuring the effectiveness of these managerial systems in delivering the required outcomes and addressing adverse performance in any area. The Chief Executive leads the Executive Team who are responsible for linking the strategic direction with operational delivery and for ensuring coordination of all functions of the Trust. Meeting on a weekly basis membership includes all executive directors and clinical chiefs of service. The Executive Team reports to the Trust Board through the Chief Executive Officer.

2.5

The Executive Committee

The Executive Committee is a senior managerial decision making group in the Trust. Its membership comprises the entire executive director team and the clinical divisions’ managerial teams. It has at least 50% clinical membership to ensure effective clinical leadership and decision making. The Chief Executive Officer has directed that the Executive Committee meets weekly to consider, on a rolling basis, managerial delivery of the Board of Directors’ strategy, quality of services provided and the effectiveness of risk management, the delivery and management of all performance and the management of each clinical division. The Executive Committee has specific terms of reference for each meeting to enable it to deliver its duties. The members attend all Executive Committee meetings across each month enabling them to be informed on the inter relationship between quality, operational and financial performance and strategy. This enables: • • • • • • •

effective trust wide decisions to be made to progress and action delivery of the Board of Directors’ objectives; each corporate directorate and clinical division to identify any impact of proposed decisions on its ability to deliver its services; resolution of issues that any corporate directorate or clinical division does not have the authority to resolve on its own; management of risk that is outside the authority of any individual corporate directorate or clinical division to control; effective allocation of limited resources; clinical divisions to be held to account by the CEO for their performance, quality of services and financial management; corporate directorates are held to account by the CEO for their performance and delivery of their services.

The Executive Committee is supported to make informed decisions by both holding the corporate directorates to account and by receiving independent information from its authorised management committees and groups.

2.6

Committees and Groups

The Executive Committee is responsible for ensuring that it is enabled to take effective decisions in relation to its focus (strategy, quality and risk or performance) as it has authorised an infrastructure of groups reporting to it that provides the expert trust wide view of an aspect of the service relevant to its terms of reference. (e.g. IPCAS). The authorised managerial groups are focused on providing expertise in an aspect of business, co-ordinating the trust wide approach especially in relation to improving systems, quality, safety and performance. These groups are either task and finish groups or advisory groups. They are not accountable for delivering trust performance of any required standard as this remains a line management accountability of day to day service delivery.

2.7

Corporate Directorates

Each corporate directorate is led by an executive director. Each executive director has delegated responsibility from the CEO for delivery of his portfolio of business. Whilst the ultimate accountability remains with the CEO and he holds each executive director accountable for delivering his portfolio of business. This enables the CEO to be held to account by the Board of Directors. The corporate directorates of Chief Finance Officer, Director of Corporate Affairs, Director of Informatics and Facilities, Director of Human Resources and Director of Strategy all have their staff predominantly within their directorate. They have a line management structure within their directorate to enable their delivery of the trust wide function to be held to account. Their staff are primarily focused on supporting the CEO and the clinical divisions to manage aspects of their business that require expert input. The majority of their customers are internal. The corporate directorates of the Chief Nurse, Medical Director and Chief Operating Officer predominantly have their staff within the clinical divisions. The effective delivery of their portfolios is primarily measured through the performance of the clinical divisions in relation to their services and trustâ&#x20AC;&#x2122;s aggregate performance. The executive directors hold the relevant staff to account and manage delivery of their portfolio through their line management structures both within corporate directorates and clinical divisions. The Executive Committee receives reports and information on the performance of all the corporate directorates at its relevant meeting at a trust wide level. The Executive Committee for performance is the only meeting where both the trust wide performance and the individual clinical division performance are managed. The executive directors are the single point of accountability for each corporate directorate.

Surrey and Sussex Healthcare Rules of Procedure

2.8

Clinical Divisions

There are four clinical divisions with each one being led by a Chief of Service. The Chief of the Division has single point of accountability for all aspects of divisional performance: quality, operational, financial and workforce to the relevant executive director. The CEO has required that the Chief must be a clinician to enable clinical leadership and to ensure that they can be held accountable for quality of services. The Chief of Service is accountable for ensuring that the clinical division has an internal infrastructure that reflects the business of the division and supports it to meet its duties. These duties relate to but are not exhaustive; quality and safety of services, management of risk, delivery of performance standards, management of financial resources and effective management of the workforce to meet required standards of competence to provide a positive patient experience. This includes authorised division wide groups which provide expertise on aspects of the divisions business. The Chiefs of Service are supported by an Assistant Director of the Division and, where relevant, a Divisional Chief Nurse/ Midwife. These persons are senior accountable professionals within the Division for their staff group and areas of responsibility. They support the Chief of the Service and are held to account by the Chief for their portfolio of responsibilities within the Division. Together they form the divisional management team. The Divisional management team in addition to holding accountability for their respective divisional portfolios also holds accountability for their respective professional groups. The Chief of Service is accountable for medical staff standards, the Divisional Chief Nurse for nursing professional standards and the Assistant Director for the non-clinical staff. Each of the Divisions has its own Divisional Governance Committees which has weekly meetings on a rolling agenda that mirrors the Trust Executive Committee agendas for strategy, quality and risk, performance and business. There are terms of reference for each of the Divisional Governance Committees. Some members of the divisional management teams are members of both the Divisional Governance Committee and the Trust Executive Committee. This enables timely divisional input into the trust wide decision making at the Trust Executive Committee level. The Divisional Governance Committee are responsible, under the Chair of the Chief of Service, for ensuring that each clinical specialty is delivering on its quality, performance, workforce and financial management duties. It holds the clinical leads for each specialty to account for their performance and action to address any adverse performance. The Divisional Governance Committee is the most senior decision making body in the Division and takes decisions that cannot be authorised within a single specialty. Each of the Divisions is made up of a number of clinical specialties. In each clinical specialty, as relevant, there is a Clinical Lead (medical), a Matron (nursing) and a Service Manager / Head of Department who are ultimately managerially and/ or professionally responsible to the Chief of Service. These individuals may be responsible for more than one clinical specialty.

2.9

Staff

All staff have job descriptions that explain their responsibilities and accountabilities in relation to their roles. In addition to this staff in professional groups have additional standards and accountabilities set by their relevant professional body. Staff are organised within the division in corporate directorates with some staff also being in clinical divisions. All staff has line managers to whom they are responsible to and who are accountable for working with each member of staff to assess their personal performance, developmental needs and impact on service users. Staff at all levels in the organisation should work within a framework of Trust policies which sets out expectations in respect of relevant trust processes.

2.10 Governance Structure SASH Corporate Governance Structure / Accountability Framework

1 Audit & Assurance

Council of Governors

Board of Directors

Safety & Quality

Finance and Workforce

Nomination & Remuneration

Charitable Funds

Board committees

Corporate governance Management

Accountability level CEO

Management Committees / Groups

Executive Committee and Executive Executive Committee and ECQR* Committee for Quality and Risk

POLICIES

Corporate Directorates

Clinical Divisions

Specialties

INFORMATION

55 Executive Sub Executive Sub Committees: Safety, Committees: Safety, Effectiveness, Effectiveness, Responsiveness, Responsiveness, Experience and Experience and Workforce Workforce

Staff

Surrey and Sussex Healthcare Rules of Procedure

Chapter Three Board of Directors Board of Directors Audit and Assurance Nomination Safety and and Quality Remuneration Remuneration

3.1

Finance and Workforce

Charitable Funds And Workforce and Workforce

Summary purpose

The Board of Directors provides proactive leadership of the Trust towards achievement of corporate objectives and oversight of the framework of sound internal controls, risk management and governance in place to support their achievement. The Board of Directors is responsible for: 1.

setting the Trustâ&#x20AC;&#x2122;s strategic aims;

setting the Trustâ&#x20AC;&#x2122;s values, standards and culture;

the safety and quality of services;

holding the organisation to account for the delivery of the strategy and through seeking assurance that systems of internal control are robust and reliable;

ensuring that the necessary financial, human and physical resources are in place to enable the Trust to meet its priorities and objectives and periodically reviewing management performance; and

ensuring that the Trust complies with these Rules of Procedure, Standing Orders, Standing Financial Instructions, Scheme of Delegation and statutory obligations at all times.

3.2

Self-regulation

3.2.1 The Board of Directors is responsible for implementing an effective system of assurance to support self-regulation. 3.2.2 The Chairman of the Board of Directors shall ensure that it monitors the performance of the Trust in an effective way and satisfies itself that appropriate action is taken to remedy problems as they arise. The Board of Directors must be satisfied with the assurance processes in place which support the preparation of accurate self-certification. The Board of Directors is responsible for establishing the outcomes required by the Trust to achieve the desired risk ratings and implementing processes to track progress and implementation.

Surrey and Sussex Healthcare Rules of Procedure

3.3

Membership of the Board of Directors

3.3.1 Currently the Board of Directors comprises: (i) A non-executive Chairman with a second and casting vote if necessary; (ii) Five non-executive Directors (iii) The Chief Executive and Accountable Officer; (iv) Chief Finance Officer (v) Medical Director (vi) Chief Nurse (vii) Chief Operating Officer (viii) Director of Corporate Affairs & Company Secretary (Non-voting) 3.3.2 The Board of Directors shall appoint one of the independent non-executive directors to be the Senior Independent Director (SID). The SID shall be available to employees if they have concerns which contact through the normal channels of Chairman, Chief Executive or Chief Finance Officer has failed to resolve or for which such contact is inappropriate. The Deputy Chairman has been nominated as the SID. 3.3.3 Other senior employees may be required to attend the Board of Directors for individual agenda items as the Board of Directors considers appropriate.

3.4

Roles and Responsibilities

3.4.1 Role of the Chairman As leader of the Board, the Chair has the overarching responsibility for ensuring that under his guidance the organisation meets its planned objectives for service delivery and clinical governance and has a clear understanding of its culture and values. The Chair will ensure that the Board establishes a proper communication strategy to keep all its stakeholders informed. Some of the communications which need to be established are to staff and their Trade Unions; to the local community; to reference groups established to obtain the views of patients, service users and carers; the local media; to elected representatives, including MPs and local councillors; to overview and scrutinise committees; the voluntary sector; and the wider health and social care community. The Board can only be effective if it is well informed. The Chair will facilitate the proper flow of information between executives and non-executives; between the Board and other partners in the health economy; and between the Department of Health (DoH) and the Board when new policies and priorities need to be disseminated. Non-executives will also need regular updates on the results and outcomes of strategies to keep them abreast of the organisationâ&#x20AC;&#x2122;s performance. The Chair will ensure that this information is timely and sufficiently comprehensive, but without including unnecessary operational detail that the Board does not need.

3.4.2 Role of the Non-Executive Directors Non-executive directors on NHS Boards share responsibility with the other directors for the success of the organisation and the duties of the Board. To add most value, the nonexecutive’s duties should not extend into operational matters. Accountability Non-executive directors are appointed by the NHS Trust Development Authority Appointments Committee on behalf of the local community. They therefore have a responsibility to ensure the Board acts in the best interests of the public and is fully accountable to the public for the services provided by the organisation and the public funds it uses. Strategy Non-executive directors should constructively challenge and contribute to the development of strategy. Performance Non-executive directors should scrutinise the performance of management in meeting agreed goals and objectives and monitor the reporting of performance. Risk Non-executive directors should satisfy themselves that financial information is accurate and that financial controls and systems of risk management are robust and defensible. People Non-executive directors are responsible for determining appropriate levels of remuneration of executive directors and have a prime role in appointing, and where necessary removing, senior management and in succession planning. 3.4.3 Role of the Chief Executive The Chief Executive has the responsibility for ensuring that the Board is empowered to govern the organisation and that the objectives it sets are accomplished through effective and properly controlled executive action. The NHS Leadership Academy’s Induction Guide for Chief Executives sets out the main roles and responsibilities as: Leadership The Chief Executive helps create the vision for the Board and the organisation to modernise and improve services and has the skill to communicate this vision to others and the ability to empower them to deliver the organisation’s agenda. Delivery planning The Chief Executive has the duty to ensure that the Board has sufficient information to agree a Local Delivery Plan or Service Level Agreements that meet the NHS Plan and other priorities and is based on realistic estimates of physical, workforce, financial capacity and patient and public involvement.

Surrey and Sussex Healthcare Rules of Procedure

Performance management The Chief Executive is responsible for ensuring that the Board’s plans and objectives are implemented and that progress towards implementation is regularly reported to the Board using accurate systems of measurement and data management. The Chief Executive also agrees the objectives of the senior executive team and reviews their performance. Governance The Chief Executive is responsible for ensuring that the systems on which the Board relies to govern the organisation are effective. This will enable the Chief Executive to sign the Statement on Internal Control on behalf of the Board, to state that the systems of governance, including financial governance and risk management, are properly controlled. Accountability The Chief Executive is accountable to the Board for meeting their objectives and, as Accountable Officer, to the Chief Executive of the NHS for the performance of the organisation. 3.4.4 Relationship between the Board and the Chief Executive This relationship is complex and many facetted but can be summarised as follows: What the Chief Executive does for the Board • Helps create the vision • Provides information and expertise • Provides operational leadership • Provides effective control systems • Delivers against operational objectives • Delivers the modernisation and change agenda What the Board does for the Chief Executive • Challenges and hones vision into high level strategic objectives • Supports the management of the organisation • Sets demanding but realisable operational objectives • Challenges and thereby reinforces the effectiveness of control systems • Supports the Chief Executive in making changes and taking risks by corporately agreeing plans and strategies and taking corporate responsibility for outcomes • Establishes a forward thinking, modernising and patient-focused culture for the organisation

3.5

Chairman and Chief Executive: Division of responsibility

Chairman of the Board of Directors

Chief Executive

The Chairman is not responsible for The Chief Executive is responsible for executive matters. executive matters. All members of the management structure report either directly or indirectly to him.

The chairman’s principal The Chief Executive’s principal responsibility responsibility is the effective running is leading the Trust. of the Board of Directors, and, on its establishment, the Council of Governors

The Chairman is responsible for ensuring that the Board of Directors as a whole plays a full and constructive part in the development and determination of the Trust’s strategy and overall objectives.

The Chairman is the guardian of the The Chief Executive is responsible for decision making process of the Board implementing the decisions of the Board of of Directors. Directors and its Committees.

The Chairman is responsible for the The Chief Executive is responsible for the general leadership of the Board of provision of information and support to the Directors. Board of Directors.

The Chairman is responsible for ensuring the agenda of the Board of Directors takes full account of the important issues facing the Trust and the concerns of all Board members. There shall be an emphasis on strategic, rather than routine issues.

The Chief Executive is responsible for ensuring that he maintains a dialogue with the Chairman on the important strategic issues facing the Trust and agreeing with the Chairman an agenda for the Board of Directors which reflects these.

Ensuring, (on the advice of the Board Secretary where appropriate, should one be in post), compliance with the Board of Directors’ approved procedures, including the schedule of matters reserved to the Board of Directors for its decision and each Committee’s terms of reference.

Ensuring, in consideration with the Chairman (and the Board Secretary as appropriate) that the Executive Committee complies with the Trust’s approved procedures, including the schedule of matters reserved to the Board of Directors for its decision and each Committee’s terms of reference.

The Chief Executive is responsible for developing and implementing the Trust strategy and communicating this to both internal and external stakeholders.

Surrey and Sussex Healthcare Rules of Procedure

Chairman of the Board of Directors

Chief Executive

Arranging informal meetings as required of the directors, including meetings of the non-executive directors at which the executive directors are not present, to ensure that sufficient time and consideration is given to complex, contentious or sensitive issues.

Ensuring that the Chairman is alerted to forthcoming complex, contentious or sensitive issues which significantly affect the Trust of which he might not otherwise be aware.

Proposing to the Board of Directors, in consultation with the Chief Executive, (Board Secretary) and Committee Chairmen as appropriate:

Providing input to the Chairman (and the Board Secretary) on appropriate changes to the schedule of matters reserved to the Board of Directors and Committee terms of reference.

â&#x20AC;˘ A schedule of matters reserved to the Board of Directors for its decision; and â&#x20AC;˘ Terms of reference for each Board Committee and other Board of Director policies and procedures.

Proposing the membership of the If so appointed, serving on any Committee of Board Committees and their the Board of Directors. Chairman for approval by the Board of Directors.

Taking the lead in providing a Contributing to the induction programme for properly constructed induction new directors and ensuring that appropriate programme for new directors. management time is made available for this.

Taking the lead in identifying and seeking to continually update the skills and knowledge both of individuals and the Board of Directors as a whole and meeting ongoing development needs.

Ensuring that the development needs of the executive directors and other senior management reporting to CEO are identified and met.

Ensuring that the performance of the Board of Directors as a whole, its Committees, and individual nonexecutive members of both are periodically assessed.

Ensuring that the performance reviews are carried out at least once a year for each of the executive directors. Providing input to the wider evaluation process of the Board of Directors.

3.6

Unitary Board

All members of the Board of Directors have joint responsibility for every decision of the Board regardless of their individual skills or status. This does not affect the particular responsibilities of the Chief Executive as the Trust’s Accountable Officer. All directors, executive and non-executive, have a responsibility to constructively challenge the decisions of the Board of Directors and help develop proposals on priorities, risk mitigation, values, standards and strategy.

3.7

Meetings of the Board of Directors

3.7.1 The Board of Directors shall meet at least ten times a year (including Board Seminars). The meeting shall be held in the last week of each month 1 (except December, when the meeting shall be in the second week) in order to ensure timely consideration of performance and financial information relating to the previous month. The meeting shall occur following the completion of the Board Committee meetings taking place that month (Audit and Assurance Committee, Safety and Quality Committee and Finance and Workforce Committee as programmed) to ensure that any matters that the Chairmen of these Committees believe need to be considered by the Board of Directors are done so on a timely basis. 3.7.2 The Board of Directors shall meet in public at least 6 times a year. It reserves the right to exclude members of the press and public to consider confidential business, publicity on which would be prejudicial to the public interest (as defined in the Public Meetings Act 1960). When exercising this provision, the Chairman presiding at the meeting shall summarise the nature of the business to be considered in closed session. 3.7.3 No business shall be transacted at a meeting unless a quorum is present, which requires at least one third of the total number of the Board of Directors to be in attendance including not less than one non-executive director and one voting executive director. 3.7.4 The Chairman may, if necessary, exclude any member of the press or public from a meeting if they are interfering with or preventing the proper conduct of a meeting by exercising the relevant power in the Public Meetings Act 1960.

3.8

Standing agenda of the Board of Directors

The agenda of the Board of Directors shall be risk-focused and driven by the Assurance Framework. Key items include:

•

annual approval of strategic plan and budget;

•

annual approval of financial accounts;

•

annual approval of quality accounts;

•

review of Assurance Framework;

To note – for 2011 Board meeting dates have already been set and therefore may not be in the last week of the month.

Surrey and Sussex Healthcare Rules of Procedure

•

review of effectiveness of Board, Directors and Committees of the Board of Directors;

•

performance and finance report demonstrating performance against strategic objectives; most recent minutes from each Committee of the Board of Directors; and safety and quality indicators.

•

3.9

SASH Code of Conduct

3.9.1 All members of the Board of Directors shall comply with the SASH Code of Conduct set out as Appendix 1 to these Rules of Procedure. 3.9.2 All members shall participate fully in the Board of Directors’ development programme. Where a session is missed, arrangements shall be made to ensure skill and knowledge gaps are addressed.

3.10 Administration 3.10.1 Agenda for all meetings shall be reviewed by the Chairman of the Board of Directors and shared with members ten working days ahead of each meeting. 3.10.2 Papers for all meetings shall be made available no later than five working days in advance of each meeting. Papers shall be prepared in accordance with the Board and Committee paper template available on the Trust’s intranet. 3.10.3 Papers shall only be tabled at meetings in exceptional circumstances and by agreement with the Chairman presiding at the meeting.

3.11 Decision Making 3.11.1 The rules below shall apply to meetings of the Board of Directors. 3.11.2 Decisions shall normally be made by agreement following full and open debate rather than by means of a formal vote. Failing agreement, decisions shall be reached by means of a vote when: (i) the Chairman presiding at the meeting feels that there is a body of opinion among members of the Board of Directors present at the meeting who disagree with a proposal or have expressed reservations about it; or (ii) when a member of the Board of Directors who is present requests a vote to be taken; or (iii) if the Chairman presiding at the meeting considers that a vote shall be taken. 3.11.3 Where a decision requires to be voted upon it shall be determined by a majority of the votes of the members of the Board of Directors present and voting on the question. The Chairman presiding at the meeting shall declare whether or not a resolution has been carried or otherwise. 3.11.4 In the case of an equality of votes, the Chairman of the Board of Directors, or, in his absence, the member presiding, shall have a second and casting vote. 3.11.5 The minutes of the meeting shall record only the numerical results of a vote, showing the numbers for and against the proposal and noting any abstentions. The minutes shall be conclusive evidence of the outcome. Votes shall not normally be

attributed to any individual member of the Board of Directors, but any member may require that their particular vote be recorded provided that he asks the Chairman presiding immediately after the item is concluded. 3.11.6 The Board of Directors may defer a decision on an agenda item so that it can be provided with additional information or for any other reason. The decision to defer, together with the reasons for doing so, shall be recorded in the minutes. 3.11.7 A senior employee who has been formally appointed to act-up for an executive director during a period of incapacity or to temporarily fill an executive director vacancy shall be entitled to exercise the corresponding voting rights. 3.11.8 A senior employee attending the Board of Directors to represent an executive director during a period of incapacity or temporary absence but who does not have formal acting-up status in accordance with paragraph 2.10.7 above shall not exercise the corresponding voting rights. Such a senior employeeâ&#x20AC;&#x2122;s status when attending a meeting of the Board of Directors shall be recorded by the Secretary in the minutes of the meeting.

3.12 Minutes of meetings 3.12.1 The nominated Secretary shall record the minutes of every meeting. 3.12.2 The Secretary shall submit the draft minutes to the Board of Directors in advance of its next meeting for agreement, confirmation or otherwise. 3.12.3 The record of the minutes shall include: (i)

the names of: (a)

every member present at the meeting;

(b)

any other person present; and

(c)

any apologies tendered by an absent member;

(ii)

the withdrawal from a meeting of any member on account of a conflict of interest; and

(iii)

any declaration of interest.

3.12.4 Minutes shall record key points of discussion. They shall not, however, attribute comments to specific members unless this is specifically required by the Chairman presiding at the meeting. Where personnel, finance or other restricted matters are discussed, the minutes shall describe the substance of the discussion in general terms.

3.13 Key Performance Indicators reviewed 3.13.1 The Board of Directors shall agree key performance indicators (KPIs) which relate to strategic objectives so that they can monitor the risk of not achieving them as part of the annual business planning process. KPIs shall be reviewed on at least an annual basis to ensure their ongoing relevance. 3.13.2 A report which details performance against the KPIs shall be received at each meeting of the Board of Directors.

Surrey and Sussex Healthcare Rules of Procedure

3.14 Assessment of Board effectiveness The Board of Directors is responsible for ensuring the effectiveness of the Trust’s corporate governance arrangements. The Board of Directors shall ensure a process of self-assessment is undertaken annually which considers the effectiveness of the arrangements in place and the overall contribution of the Committees to achievement of the Trust’s strategic objectives. This shall include the following actions: (i) (ii) (iii) (iv) (v) (vi) (vii)

assessment of Board effectiveness; review of assessment of Audit and Assurance Committee effectiveness; review of the Audit and Assurance Committee’s annual report; review of the Safety and Quality Committee’s annual report; review of the Nomination and Remuneration Committee’s annual report; review of the Finance and Workforce Committee’s annual report; and review of the Charitable Funds’ Annual Report.

3.15 Board Development programme A programme will be developed for the Board of Directors which ensures that the appropriate level of skill and knowledge training is provided to allow the members of the Board of Directors to fulfil their duties. This development programme shall be reviewed annually and reflect feedback from the assessment process summarised above. Development however should continue outside of any formal programme, as part of individual’s personal development plan and through a number of other opportunities including learning at Board Seminars.

Board of Directors: Terms of Reference 1. Constitution/Purpose The Board is responsible for setting strategy and monitoring performance, ensuring that the Trust meets its statutory and regulatory duties and effectively manages risks through the Trustâ&#x20AC;&#x2122;s Assurance Framework and Risk Register. The Board exercises all the powers of the Trust. These powers can be delegated to a committee of Directors or to an Executive Director.

2. Membership, Chairmanship and Quorum (a)

Membership A non-executive Chairman with a second and casting vote if necessary; Five non-executive Directors The Chief Executive and Accountable Officer; Chief Finance Officer Medical Director Officer Chief Nurse Chief Operating Officer Director of Corporate Affairs & Company Secretary (non-voting)

(b)

Chairmanship The Board shall be chaired by the Trustâ&#x20AC;&#x2122;s Chairman.

(c)

Quorum A quorum shall be one third of the membership, including at least one voting Executive Director and two Non-executive Directors.

3. Frequency of meetings, attendance and monitoring of attendance (a)

Frequency of meetings Meetings shall be held at least ten times per year and members must attend at least 70 per cent of all meetings but should aim to attend all scheduled meetings.

(b)

Attendance If a member fails to attend two consecutive meetings the Chairman will speak to the individual.

Surrey and Sussex Healthcare Rules of Procedure

(c)

Monitoring attendance The Director of Corporate Affairs & Company Secretary shall submit a report to the Committee about attendance on an annual basis.

(d)

Voting Voting members of the Board are listed above. In the event of tied vote, the Chairman will have a casting vote.

4. Duties The Board is responsible for: • • • • • •

Ensuring the Trust operates within its statutory and regulatory duties. Setting strategic direction, by defining objectives and agreeing plans to achieve them. Ensuring that service plans and quality plans reflect the needs of the communities that it serves. Monitoring the delivery of planned objectives and ensuring that appropriate correction action is identified and implemented when necessary. Ensuring the Trust’s financial viability is monitored through the establishment of effective financial stewardship. Establishing frameworks which ensure high standards of personal behaviour are implemented and monitored in the conduct of the Trust’s business.

5. Committees of the Board •

There are five formal sub-committees of the Board: o Audit and Assurance Committee o Nomination and Remuneration Committee o Safety and Quality Committee o Finance and Workforce Committee o Charitable Funds Committee

•

The Audit and Assurance Committee is constituted to provide the Board of Directors with an independent and objective review of its system of internal control. The Nominations and Remuneration Committee has delegated board responsibility for agreeing and setting the remuneration of the executive team. The Charitable Funds Committee acts independently of the Trust’s Board but shall report to the Trust’s Board for information and therefore has delegated responsibility for the Trust’ charitable funds. The Finance and Workforce Committee has delegated responsibility within any budgetary restrains imposed by the Board of Directors, to appoint external professional advisors, and to commission or purchase any relevant reports, surveys or information which it deems to be necessary. Approve the initiation of projects greater than £1m

• • •

•

The Safety and Quality Committee has delegated authority to ensure the ongoing development and delivery of the Trust’s Safety and Quality Strategy and that this drives the Trust’s overall strategy.

6. Terms of Reference The Terms of Reference of the Trust Board shall be reviewed by the Board of Directors annually.

Surrey and Sussex Healthcare Rules of Procedure

Trust Board of Directors: Meeting Timetable The expected timetable of the Trust Board is set out below: Trust Board

All meetings

Quarterly

Biannually

Annually

General Business 1.

Declaration of Interests



Reports from Board Committees



Annual reports from Board Committees



Committee and Board Attendance report



Clinical Presentation & Patient Story

 

Strategy 6.

Annual Plan

Foundation Trust update

Updated Estates Strategy



Updated IT Strategy



10. Updated HR & OD Strategy



11. Board Succession planning



12. Corporate Objectives



13. Trust annual report



14. Business Planning workshop



Safety & Quality 15. Staff Survey Results



16. Patient Survey Results



17. Health and Safety report



18. Quality Account



19. Security Management report



20. Emergency Planning report



Performance 21. Integrated performance & quality report (IPQR)



Finance 22. Approval of annual accounts



23. Sign-off annual budget



24. Sign-off annual capital plan



25. Auditors annual report



26. Finance report (part of IPQR)



27. Capital report (part of IPQR)



28. Review of SOs and SFIs



Trust Board

All meetings

Quarterly

Biannually

Annually

Risk and Regulatory 29. Assurance Framework & Significant Risk Register



30. Assurance Framework updated with new objectives



31. IG annual report



32. Registration update

 

33. Equality and Diversity report

Surrey and Sussex Healthcare Rules of Procedure

Board of Directors: Standing Agenda 1

General Business Chairmanâ&#x20AC;&#x2122;s welcome and apologies for absence Declaration of interests Minutes of previous meeting and Actions Minutes and Reports from Board Committees Chief Executiveâ&#x20AC;&#x2122;s Report

Safety, Quality & Patient Experience Clinical Presentation & Patient Story Safety & Quality Committee Chair Report Chief Nurse and Medical Directors Report

Strategy Update on strategic issues

Operational Performance Integrated Performance & Quality Report Operational & Quality Performance Indicators Workforce Performance Indicators Finance Indicators

Risk & Regulatory Assurance Framework and Risk Register Regulatory update (e.g. CQC Risk Profile)

Update from Committee Chairs

General Opportunity for members of the public to ask questions Any other business Date of next meeting

In addition, the Board of Directors shall consider succession planning at one of its meetings during any given financial year.

Surrey and Sussex Healthcare Rules of Procedure

Chapter Four Committees of the Board of Directors 4.1

Key duties of Board Committees and reporting timetable

The diagram below summarises the main duties of the Committees of the SASH Board of Directors: Shadow Council of Governors

Board of of Board Directors Directors Audit and Assurance Audit

 InternalFramework Control Assurance Systems  Assurance Regulators Framework  Review Disclosure Statements  Annual Governance Statement  Regulators

Nomination and Remuneration

For Executive Directors:

Safety and Quality

 

      

Appointment; Reward; Performance; Retention; Termination; Pension matters; Successful planning for senior management

 

Safety and Quality Strategy Safety and Quality Performance Safety and Quality among staff Health and Safety

Finance and Workforce

 

  

Strategic financial planning Delivering and Monitoring investment strategy Divestments Major investment decisions Workforce Strategy

Charitable Funds

   

Safe custody Compliance with legacies Accounts Income generation

Board Committees shall meet prior to the Board of Directors so that the Chairmen of the Committees have an opportunity to report matters that the whole Board needs to be aware of and take action upon. Minutes of Board Committees shall be circulated to the Board of Directors for information and any discussion as soon as they have been approved in draft by the Chairman of the relevant Committee.

4.2

Reporting arrangements

The inter-relationships between the Committees and the Board of Directors and the reporting responsibilities of the former to the Board of Directors is shown below:

Board of Directors

Receives papers from:

Receives minutes from:

Submits minutes to:

Submits annual reports to:

Audit and Assurance Committee

Nomination and Remuneration Committee

Safety and Quality Committee

Finance & Workforce Committee

■ Director Human Resources ■ External advisors

■ Divisional Safety and Quality Committees ■ Executive Directors ■ Periodic Reports from Committees of Executive Committee with respect to safety and quality

■ Executive directors ■ Senior Finance Team ■ Budget holders

■ Executive directors ■ External professional advisors (as appointed by the Board from time■ to-time) ■ Board Subcommittees

■ Executive directors ■ Internal Audit ■ External Audit ■ Local Counter Fraud Service ■ Board Subcommittees

■ Audit and Assurance Committee ■ Safety and Quality Committee ■ Finance and Workforce Committee ■ Nomination and Remuneration Committee ■ Charitable Funds Committee

■ N/a

■ Executive Committee Quality & Risk ■ Patient Experience Committee

■ N/a

■ Board of Governors (on establishment)

■ Board of Directors

■ On achieving FT status, Monitor and Parliament

■ Board of Directors

Surrey and Sussex Healthcare Rules of Procedure

4.3

Principles of Committees

4.3.1 Good governance is built upon effective engagement of Board and Committee members. To ensure that the framework set out in these Rules of Procedure operates effectively, it is important that performance against key performance indicators is measured and forms part of any self-assessment process. The standards with which all Board Committee members shall comply to ensure good governance are set out below.

4.4

Conduct

All Committee members shall comply with the Code of Conduct set out as Appendix 1 to these Rules of Procedure.

4.5

Attendance

4.5.1 The definition of a quorum shall be defined in the relevant terms of reference of each Committee. Business cannot be transacted in the absence of a quorum. 4.5.2 To ensure that good governance practices operate effectively and Committees make a positive contribution to delivery of corporate objectives, meetings where planned attendance would lead to there not being a quorum shall be reviewed and rescheduled as appropriate to minimise delays in decision making. 4.5.3 All non-executive directors are expected to serve on a minimum of one Committee. 4.5.4 Committee members shall attend at least two-thirds of the total number of meetings in any given twelve month period. Attendance rates shall be recorded by the Secretary of each Committee and published in the Trustâ&#x20AC;&#x2122;s annual report. Any issues concerning poor attendance shall be considered by the Chairman of the relevant Committee in consultation with the Chairman of the Board of Directors and acted on as appropriate. 4.5.5 All non-executive directors have a right of attendance of Committees of the Board of Directors. The Chairman shall not normally exercise this right of attendance in respect of the Audit and Assurance Committee.

4.6

Appointment to Committees

4.6.1 All non-executive directors shall be submitted for re-appointment or re-election at regular intervals. 4.6.2 Any term beyond six years (for example two three-year terms) shall be subject to a particularly rigorous review and shall take into account the need for progressive refreshing of a Committee.

4.7

Administration

4.7.1 Agenda for all meetings shall be reviewed by the Chairman of the Committee and shared with members ten working days ahead of each meeting unless a variation is stipulated in the Committeeâ&#x20AC;&#x2122;s terms of reference. 4.7.2 Papers for all meetings shall be made available no later than five working days in advance of each meeting unless a variation to this is stipulated in the Committeeâ&#x20AC;&#x2122;s

terms of reference. Papers shall be prepared in accordance with the Board and Committee paper template. 4.7.3 Papers shall only be tabled at meetings in exceptional circumstances and by agreement with the Chairman of the Committee. 4.7.4 The agenda of the meeting shall be reviewed to ensure that only tasks defined within the Committee terms of reference are included. 4.7.5 All Committee members shall undertake defined self-assessment procedures at least annually.

4.8

Decision making

4.8.1 The rules below in relation to decision making shall apply to Board Committees unless otherwise stated within their terms of reference. 4.8.2 Decisions shall normally be made by agreement following full and open debate rather than by means of a formal vote. Failing agreement, decisions shall be reached by means of a vote when: (i) the Chairman presiding at the meeting feels that there is a body of opinion among members of the Committee present at the meeting who disagree with a proposal or have expressed reservations about it; or (ii) when a member of the Committee who is present requests a vote to be taken; or (iii) if the Chairman presiding at the meeting considers that a vote shall be taken. 4.8.2 Where a decision requires to be voted upon it shall be determined by a majority of the votes of the members of the Committee and voting on the question. The Chairman presiding at the meeting shall declare whether or not a resolution has been carried or otherwise. 4.8.3 In the case of an equality of votes, the Chairman of the Committee, or, in his absence, the member presiding, shall have a second and casting vote. 4.8.4 The minutes of the meeting shall record only the numerical results of a vote, showing the numbers for and against the proposal and noting any abstentions. The minutes shall be conclusive evidence of the outcome. Votes shall not normally be attributed to any individual Committee member, but any member may require that their particular vote be recorded provided that he asks the Chairman presiding immediately after the item is concluded. 4.8.5 A Committee may defer a decision on an agenda item so that it can be provided with additional information or for any other reason. The decision to defer, together with the reasons for doing so, shall be recorded in the minutes. 4.8.6 A senior employee who has been formally appointed to act-up for an executive director during a period of incapacity or temporarily fill an executive director vacancy shall be entitled to exercise the corresponding voting rights at a Committee. 4.8.7 A senior employee attending a Board Committee to represent an executive director during a period of incapacity or temporary absence but who does not have formal acting-up status in accordance with paragraph 3.8.6 above shall not exercise the corresponding voting rights. Such a senior employeeâ&#x20AC;&#x2122;s status when attending a

Surrey and Sussex Healthcare Rules of Procedure

meeting of a Board Committee shall be recorded by the Secretary in the minutes of the meeting.

4.9

Minutes of meetings

4.9.1 The nominated Secretary shall record the minutes of every meeting. 4.9.2 The Secretary shall submit the draft minutes to the Committee in advance of its next meeting for agreement, confirmation or otherwise. 4.9.3 The record of the minutes shall include: (i)

the names of: (a)

every member present at the meeting;

(b)

any other person present; and

(c)

any apologies tendered by an absent member;

(ii)

the withdrawal from a meeting of any member on account of a conflict of interest; and

(iii)

any declaration of interest.

4.9.4 Minutes shall record key points of discussion. They shall not however attribute comments to specific members unless this is specifically required by the Chairman presiding at the meeting. Where personnel, finance or other restricted matters are discussed, the minutes shall describe the substance of the discussion in general terms.

4.10 Assessment of effectiveness 4.10.1 In order to ensure that they are delivering a positive contribution to the overall governance of the Trust, each Committee shall prepare an annual report to the Board of Directors. This report shall: (i) (ii) (iii)

summarise the programme of work conducted each year; confirm compliance with the Committeeâ&#x20AC;&#x2122;s terms of reference; and detail the positive contribution the Committee has made to the governance of the Trust and its contribution to the achievement of the Trustâ&#x20AC;&#x2122;s strategic objectives.

4.10.2 The Chairman of each Committee shall present this report to the Board of Directors.

Chapter Five Council of Governors Shadow Council of Governors: Terms of Reference

NAME OF GROUP

Shadow Council of Governors. 1.1.

AUTHORITY

Establishment: The Trust shall establish a Council of Governors prior to authorisation as an NHS Foundation Trust that will operate in shadow form and will emulate the functions of the Council where reasonable and practical without legal legitimacy or formal powers. The establishment of the Council of Governors is in accordance with the requirements of the NHS Act 2006 and paragraph 13 of the Trust Draft Constitution. Powers: The formal powers of the Council of Governors are detailed in the NHS Act 2006; Monitor’s NHS Foundation Trusts’ Code of Governance; Trust’s Scheme of Delegation and Constitution. Cessation: The Council of Governors is a statutory body and as such must remain for as long as it is empowered in statute.

1.2 Purpose of the Group The general statutory duties of the Council of Governors (once authorised as an FT) are to: •

Hold the non-executive directors to account (both collectively and individually) for the performance of the Board of Directors

•

Represent the interests of the members of the Trust as a whole and the interests Of the public

•

Influence the forward plans of the Trust.

COMPOSITION OF THE COUNCIL

2.1

The Chair

The Chair of the Board of Surrey and Sussex Healthcare NHS Trust will be the Chair of the Shadow Council of Governors. 2.2

Membership of the Council of Governors

The membership of the Council of Governors is determined by Annex 4 in the draft Constitution and is made up of both elected and appointed governors totaling 28. Membership of the Council of Governors is set out below:

Surrey and Sussex Healthcare Rules of Procedure

Elected Governors

Number of Governors

Constituency Class Public Mole Valley District Public Reigate and Banstead Public Tandridge District Public Crawley District Public Horsham Public Mid Sussex Public Croydon Total Public Governors

1 3 2 3 3 1 1 14

Patient

Staff A – Medical and Dental Staff B – Nursing and Midwifery Staff C – Other clinical Staff D – other not included above Total Staff Governors

1 1 1 1 4

Total elected Governors

Appointed Governors Name

Number of Governors

Surrey County Council

West Sussex County Council

Crawley CCG

Horsham and Mid Sussex CCG

East Surrey CCG

Surrey Downs CCG

Brighton & Sussex Medical School

Healthwatch

Council for Voluntary Services

Total Appointed Governors

Summary of Council Total Elected Governors

Total Appointed Governors

Total Number of Governors

In accordance with Monitorâ&#x20AC;&#x2122;s Code of Governance it is expected that the Shadow Council of Governors will invite the Chief Executive to attend all its general meetings and that other executive and non-executive directors will be invited to attend as appropriate. There may be occasions where directors are formally requested to attend Council meetings to explain concerns. It is anticipated that this will be only on rare occasions and such an occasion will be reported in the Annual Report. The Council may invite other non-members to attend its meetings on an ad-hoc basis, as it considers necessary and appropriate. The Director of Corporate Affairs as the Trust Company Secretary shall attend each meeting and provide appropriate advice and support to the Chair of the Trust and Council members. In line with the Standing Orders (Annex 7), members of the Council of Governors must ensure that wherever possible they attend every Council meeting. Attendance at meetings will be monitored and shall be reported in the Annual Report. Failure by any governor to attend three consecutive Council meetings in any one financial year shall be reported to the Chairman who will meet with the governor.

QUORACY

No business shall be transacted at a meeting of the Council of Governors unless at least one third of the whole number of governors elected or appointed are present; and that of those governors present public and patient governors are in the majority. Deputies: There is no constitutional provision for a deputy or substitute to attend on behalf of a governor. Non-quorate meeting: Non-quorate meetings may go forward unless there has been an instruction from the chair not to proceed with the meeting. Any decisions made by the non-quorate meeting must be reviewed at the next quorate meeting.

Surrey and Sussex Healthcare Rules of Procedure

Alternate chair: The Chair of the Council of Governors shall be the Chair of the Trust. In the absence of the Chair of the Trust, (or in the event of the Chair declaring an interest in an agenda item) the Deputy Chair of the Trust shall chair the meeting.

MEETINGS OF THE COUNCIL

Frequency: Meetings of the Council of Governors shall be held at such times as the Council may determine, however the Council of Governors will normally meet four times a year (plus the Annual Members’ Meeting). Meetings will be held in private and following FT authorisation will be held in public. This this shall not preclude any items of business being conducted in private. The items taken in private will be determined by the Chair. A full set of papers comprising the agenda, minutes of the previous meeting and associated reports and papers will be sent within 5 working days of the meeting. Urgent meeting: Any governor may, in writing to the chair, request an urgent meeting. The chair will normally agree to call an urgent meeting to discuss the specific matter unless the opportunity exists to discuss the matter in a more expedient manner. Minutes: The Director of Corporate Affairs shall ensure the minutes of the meeting are taken and will also ensure these are presented to the next Council of Governors’ meeting, and that these are signed by the Chair. The agenda, minutes and Council papers of each general meeting (excluding any confidential papers) shall be displayed on the Trust website, and the minutes will be presented to the Board of Directors for assurance and information.

ROLE OF THE GROUP

Training/induction for each of the roles defined below will be given as part of governor specific training prior to authorisation. 5.1 Purpose of the Group The general statutory duties of the Council of Governors are to: • Hold the non-executive directors to account (both collectively and individually) for the performance of the Board of Directors •

Represent the interests of the members of the Trust as a whole and the interests of the public

•

Influence the forward plans of the Trust.

5.2 Guiding principles when carrying out the duties of the Council of Governors In carrying out their duties, members of the Council of Governors must ensure that they act in accordance with the values of the Trust which are: • Dignity and Respect • One Team • Compassion • Safety & Quality Governors must also abide by the “Council of Governors’ Code of Conduct which all Governors must sign.

5.3 Duties of the Council of Governors Once authorised as a Foundation Trust, the Council of Governors will be required to carry out a number of statutory duties under the NHS Act 2006 (as amended by the Health and Social Care Act 2012). These are contained in the Constitution as follows (for avoidance of doubt the wording in the Constitution shall take precedence should there be any conflict between this document and the Constitution): • Hold the non-executive directors to account (both collectively and individually) for the performance of the Board of Directors •

Represent the interests of the members of the Trust as a whole and the interests of the public

•

Influence the forward plans of the Trust

•

To appoint and, if appropriate, remove the chair

•

To appoint and, if appropriate, remove the other non-executive directors

•

To decide the remuneration and allowances, and the other terms and conditions of office, of the Chair of the Trust and the other non-executive directors

•

To approve the appointment of the Chief Executive

•

Appoint the Deputy Chair of the Trust

•

To appoint and, if appropriate, remove the Trust’s auditor (i.e. the organisation that will, amongst other things, check the Trust’s finances each year)

To receive the Trust’s annual accounts, any report of the auditor on them and the annual report Approve (or not) by vote:

•

Entering into a significant transaction (a significant transaction is defined in the Constitution)

•

An application to Monitor (one of our regulators) for a merger with or the acquisition of another foundation trust or NHS trust

•

An application to Monitor for the separation or dissolution of the foundation trust

•

Developing, approving and implementing the Trusts Membership Development Strategy

•

Amendments to the Constitution

•

To decide to refer a governor’s question to Monitor’s Panel so that governors can determine if the Trust has failed or is failing to act in accordance with its Constitution or any provision made by or under Chapter 5 of the NHS Act 2006.

•

Ratifying the removal of any member of the Council of Governors for any reason as set out in Annex 6 (Additional Provisions) of the Constitution.

•

Agreeing a clear process for the appointment of the Chair of the Trust and the other nonexecutive directors

Surrey and Sussex Healthcare Rules of Procedure

•

Agreeing a process for the evaluation or appraisal of the Chair of the Trust and the other non-executives, including the outcomes of the evaluation of the Chair of the Trust and the non-executive directors

•

Assessing its own collective performance and its impact on the Trust and communicate to members how governors have discharged their duties

•

Taking the lead in agreeing with the Audit and Assurance Committee the criteria for appointing, reappointing and removing external auditors

•

Responding as appropriate to any matter when referred by the Board of Directors.

•

Participating in the development of the Trust’s strategy and values and giving a view to the Board of Directors of the Trust’s strategic plan.

RELATIONSHIP WITH OTHER GROUPS AND COMMITTEES

The Council of Governors may delegate some of its powers to formally constituted committees. Formally constituted committees of the Council of Governors are as follows: • The Appointments and Remuneration Committee (post FT authorisation) • The Membership Development sub-group Minutes from the above Committees shall be presented to the next scheduled meeting of the Council of the Governors following the committee meeting. When practicable, after the Board of Directors’ meeting the Board must send a copy of the minutes to the Council of Governors

DUTIES OF THE CHAIR

The chair of the Council is the Chair of the Trust Board and shall be responsible for: • Agreeing the agenda with the Director of Corporate Affairs • Directing the conduct of the meeting ensuring it operates in accordance with the Trust’s values. • Giving direction to the minute taker. • Ensuring all governors have an opportunity to contribute to the discussion. • Ensuring the agenda is balanced and discussions are productive, and when they are not productive they are efficiently brought to a conclusion. • Deciding when it is beneficial to vote on a motion or decision. • Checking the minutes. • Ensuring sufficient information is presented to the Board of Directors in respect of the matters discussed by the Council and ensuring that issues raised by the Council of Governors are appropriately reported to the Board. 7.

LEAD GOVERNOR

Post authorisation the Council of Governor will nominate one it its governors as the nominated lead governor. The role of the nominated lead governor is to facilitate direct communication between

Monitor and the Council of Governors in the limited circumstances where it may not be appropriate to communicate through the normal channels. 8.

SENIOR INDEPENDENT DIRECTOR

The Senior Independent Director (SID) is a non-executive director (NED) who is considered by the Board of Directors to fulfil the criteria of ‘independence’ set out by Monitor in the NHS Foundation Trust Code of Governance. The Chair is not eligible. In addition to the general duties of a NED, the SID has the following specific duties: • To be available to Members or Governors if they have concerns which have not or cannot be resolved through contact with the Chair, the Chief Executive or for which such contact is inappropriate. This will involve providing Members and Governors with a convenient means of making contact with the SID, and an obligation on the SID to respond to such contacts and to meet privately with Members or Governors if appropriate. •

To attend sufficient meetings of Members and Governors to gain a balanced understanding of the issues which are important to them and any concerns they may have. This should normally be accomplished by attending ordinary meetings of Members and Governors.

REVIEW OF THE TERMS OF REFERENCE AND EFFECTIVENESS

The Terms of Reference shall be reviewed and ratified annually by the Council of Governors. An early review of the terms of reference will be required following the Trust’s authorisation as a Foundation Trust. The Council of Governors must also carry out an annual assessment of how effectively it is carrying out its duties and make a report to its members including any recommendations for improvement.

10.

MONITORING

To comply with the Rules of Procedure (Governance Manual) the Trust will include certain details in all of its Terms of Reference documents. These details are included in the sections above.

Surrey and Sussex Healthcare Rules of Procedure

Chapter Six Audit and Assurance Committee Shadow Council of Governors

Board of Directors Audit and Assurance

Nomination and Safety and Remuneration Remuneration Quality

Finance and Workforce

Charitable Funds and Workforce

Conclude the adequacy of:

    

5.1

Internal Control Systems; Assurance Framework; Review Disclosure statements; Annual Governance Statement; Regulators.

Summary purpose and authority

5.1.1 In line with the requirements of The NHS Audit and Assurance Committee Handbook and the NHS Codes of Conduct and NHS Code of Accountability, which are consistent with Monitor’s NHS Foundation Trust Code of Governance, an Audit and Assurance Committee is constituted to provide the Board of Directors with an independent and objective review of its system of internal control, financial information, system of internal control and compliance with laws, guidance and regulations governing the NHS. 5.1.2 The primary role of the Audit and Assurance Committee is to conclude upon the adequacy and effective operation of the Trust’s overall internal control system. It is the role of the executive to implement a sound system of internal control agreed by the Board of Directors. The Audit and Assurance Committee provides independent monitoring and scrutiny of the processes implemented in relation to governance, risk and internal control. The Committee shall also review and challenge the Trust’s Information Assurance Framework to ensure that there are appropriate controls in relation to data quality. 5.1.3 The Audit and Assurance Committee’s work shall focus on the framework of risks, controls and related assurances that underpin the delivery of the Trust’s objectives. The Audit and Assurance Committee is a crucial function in reviewing the Trust’s external reporting disclosures in relation to finance and internal control, including the annual report and accounts, Annual Governance Statement and required declarations. At least one of its members must have recent and relevant financial experience.

5.1.4 Members of the Audit and Assurance Committee shall be independent nonexecutive directors who are financially literate and have the personal and professional characteristics necessary to be effective. 5.1.5 The Audit and Assurance Committee shall be informed, vigilant and effective overseers of the financial reporting process. To do this, Audit and Assurance Committee members must be prepared to invest the time necessary to understand why accounting policies were chosen, how they were applied, and whether the end result fairly represents the Trustâ&#x20AC;&#x2122;s actual status. This means that they need to understand the substance of complex transactions and determine that the financial statements reflect fairly their understanding.

5.2 External Auditor As an NHS Trust, the External Auditor is appointed by the Audit Commission and paid for by the Trust. The Audit and Assurance Committee shall ensure a cost-efficient service. If there are any problems relating to the service provided by the External Auditor, then this shall be raised with the External Auditor and referred on to the Audit Commission if the issue cannot be resolved.

5.3

Assessment of effectiveness

In order to ensure that it is delivering a positive contribution to the overall governance of the Trust, the Audit and Assurance Committee shall undertake a number of effectiveness reviews each year.

5.4

Annual Report to the Board of Directors

5.4.1 The Audit and Assurance Committee shall produce an annual report to the Board of Directors which details the programme of work conducted each year, adherence to the Committeeâ&#x20AC;&#x2122;s terms of reference, and details of the positive contribution the Audit and Assurance Committee has made to the governance of the Trust. 5.4.2 The Audit and Assurance Committee Chairman shall present this report to the Board of Directors.

5.5

Review of Audit and Assurance Committee effectiveness

5.5.1 The Audit and Assurance Committee shall complete an assessment of its effectiveness on an annual basis. A full evaluation shall be performed every three years. In intervening years, a shorter evaluation shall be performed. 5.5.2 In addition, members of the Board of Directors who are not members of the Audit and Assurance Committee shall also assess the effectiveness of the Audit and Assurance Committee.

5.6

Review of Internal Audit effectiveness

5.6.1 The Audit and Assurance Committee shall complete the Audit and Assurance Committee Instituteâ&#x20AC;&#x2122;s Assessment of Internal Audit toolkit annually to confirm compliance with best practice. A copy of the toolkit that has been completed by management shall be submitted to assist in this process.

Surrey and Sussex Healthcare Rules of Procedure

5.6.2 The Audit and Assurance Committee shall receive an annual report from the Head of Internal Audit which reports compliance with Internal Audit KPIs.

5.7

Review of External Audit effectiveness

The Audit and Assurance Committee shall complete the Audit and Assurance Committee Instituteâ&#x20AC;&#x2122;s Assessment of External Audit toolkit annually to confirm compliance with best practice.

Audit and Assurance Committee: Terms of Reference 1.

Introduction

1.1

These terms of reference build on the work of the Cadbury Committee, Greenbury Reports and the reports by Smith, Higgs and Turnbull (reference “Combined Code – Principles of Good Governance and Code of Best Practice”) and subsequent guidance and best practice in the private and public sector. They reflect the particular nature of audit committees in the NHS and the growing role of the committee in developing integrated governance arrangements and providing assurance that bodies are well managed across the whole range of their activities.

Constitution

2.1

The Board hereby resolves to establish a committee of the Board to be known as the Audit and Assurance Committee (The Committee).

2.2

The Committee is a non-executive committee of the Board and has no executive powers, other than those specifically delegated in these terms of reference.

Membership

3.1 3.2 3.3 3.4

The Committee shall be appointed by the Board from the non-executive directors of the Trust and shall consist of not less than three members. A quorum shall be two members. The Board will appoint one of the members to be Chair of the Committee. The Chairman of the organisation shall not be a member of the Committee.

Attendance

4.1

4.2 4.3 4.4

The Chief Finance Officer and the Director of Corporate Affairs and appropriate internal and external Audit representatives shall normally attend meetings. However, at least once a year the Committee should meet privately with the external and internal auditors. The Committee shall request the attendance of the Executive Directors when discussing risk or requiring assurance in relation to their areas of responsibilities. As Accountable Officer, the Chief Executive has an open invitation to attend each Board sub-committee The Head of Corporate Governance shall be the secretary to the Committee and shall attend to take minutes of the meeting and provide appropriate support to the Chairman and committee members.

Frequency

5.1

Meetings shall be held not less than five times a year and normally will take place every two months. The External Auditor or Head of Internal Audit or Counter Fraud may request of the Chair a meeting is held if they consider that one is necessary.

5.2

Surrey and Sussex Healthcare Rules of Procedure

Authority

6.1

The Committee is authorised by the Board to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Committee. The Committee is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of persons external to the Trust with relevant experience and expertise if it considers this necessary.

6.2

Duties The duties of the Committee can be categorised as follows:

7.1 Governance, Risk Management and Internal Control 7.1.1 The Committee shall review the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the organisationâ&#x20AC;&#x2122;s activities (both clinical and non-clinical), which supports the achievement of the organisationâ&#x20AC;&#x2122;s objectives. In particular, the Committee will review the adequacy of: -

all risk and control related disclosure statements (in particular the Annual Governance Statement and declarations of compliance with the Care Quality Commission (CQC) regulations, together with any accompanying Head of Internal Audit statement, external audit opinion or other appropriate independent assurances, prior to endorsement by the Board

the underlying assurance processes that indicate the degree of the achievement of corporate objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements

the policies for ensuring compliance with relevant Care Quality Commission regulatory frameworks, legal and code of conduct requirements

the policies and procedures for all work related to fraud and corruption as set out in Secretary of State Directions

clinical governance, patient safety and clinical risk using clinical audit and other assurance routes.

7.1.2 In carrying out this work the Committee will primarily utilise the work of internal audit, external audit and other assurance functions (for example the Trustâ&#x20AC;&#x2122;s clinical audit function) to ensure review is external, but will not be limited to these. It will also seek reports and assurances from directors and managers as appropriate, concentrating on the overarching systems of integrated governance, risk management and internal control, together with indicators of their effectiveness. 7.1.3 In relation to the Board Assurance Framework the committee will use this to guide its work and will provide assurance that the controls and actions taken to address any gaps are robust and support the delivery of corporate objectives.

7.2 Internal Audit The Committee shall ensure there is an effective internal audit function established by management, which provides appropriate independent assurance to the Audit Committee, Chief Executive and Board and meets mandatory NHS Internal Audit Standards. This will be achieved by: -

consideration of the provision of the internal audit service and the cost of audit

review and approval of the internal audit strategy, operational plan and the more detailed programme of work, ensuring this is consistent with the audit needs of the organisation as identified in its approved assurance framework

consideration of the major findings of internal audit work (and management’s response), and ensure co-ordination between the internal and external auditors to optimise audit resources

ensuring the internal audit function is adequately resourced

annual review of the effectiveness of internal audit (through external audit and performance against its work plan and performance indicators).

7.3 External Audit The Committee shall review the work and findings of the External Auditor appointed by the Audit Commission and consider the implications and management’s responses to their work. This will be achieved by: -

consideration of the appointment and performance of the External Auditor, as far as the Audit Commission’s rules permit

discussion and agreement with the External Auditor, before the audit commences, of the nature and scope of the audit as set out in the annual plan, and ensure coordination, as appropriate, with other external auditors in the local health economy

discussion with the External Auditors of their evaluation of local audit risks and assessment of the Trust and its associated impact on the audit fee

review all External Audit reports, including agreement of the annual audit letter before submission to the Board and any work carried outside the annual audit plan, together with the appropriateness of management responses

7.4 Other Assurance Functions 7.4.1 The Committee shall review the findings of other significant assurance functions, both internal and external to the organisation, and consider the implications to the governance of the organisation. These will include, but will not be limited to, any reviews by Department of Health Arm’s Length Bodies or Regulators/Inspectors (e.g. CQC, NHS Litigation Authority, etc.), professional bodies with responsibility for the performance of staff or functions (e.g. Royal Colleges, accreditation bodies, etc.), and reports by the Trust’s local counter fraud specialist.

Surrey and Sussex Healthcare Rules of Procedure

7.4.2 In addition, the Committee will review the work and function of other committees, working groups and senior responsible officers within the organisation, whose work can provide relevant assurance to the Committeeâ&#x20AC;&#x2122;s own scope of work. 7.4.3 In reviewing work of around clinical risk management, the Committee will wish to satisfy itself on the assurance that can be gained from the clinical audit function and outcome measures from the Trusts clinical benchmarking systems.

Management

The Committee shall request and review reports and positive assurances from directors and managers on the overall arrangements for governance, risk management and internal control. They may also request specific reports from individual functions within the organisation (e.g. clinical audit) as appropriate.

Financial Reporting

9.1 The Committee shall review the annual report and financial statements before submission to the Board, focusing particularly on: -

the wording in the Annual Governance Statement and other disclosures relevant to the terms of reference of the Committee

changes in, and compliance with, accounting policies and practices

unadjusted mis-statements in the financial statements

major judgmental areas

- significant adjustments resulting from the audit 9.2 The Committee should also ensure (through management reporting, internal and external audit reporting) the systems for financial reporting to the Board, including those of budgetary control, are effective and that reporting provides complete and accurate information about the Trustâ&#x20AC;&#x2122;s financial position.

10. Reporting 10.1 The minutes of the Committee meetings shall be formally recorded by the Trust Secretary and submitted to the Board. The Chair of the Committee shall draw to the attention of the Board any issues that require disclosure to the full Board, or require executive action. 10.2 Once accepted by the Board the minutes of the Committee shall be included in the agenda for the next Council of Governors meeting. 10.3 The Committee will report to the Board annually on its work in support of the Statement on Internal Control, specifically commenting on the fitness for purpose of the assurance framework, the completeness and embedding of risk management in the organisation, the integration of governance arrangements and the appropriateness of the self-assessment of provider compliance with CQC regulations.

11. Other Matters The Secretary to the Committee, whose duties in this respect will include the following, shall support the Committee administratively:

Agreement of agenda with Chairman and attendees and collation of papers

Organising the attendance of appropriate persons to meetings (other than those who would usually attend)

Taking the minutes and keeping a record of matters arising and issues/ actions to be carried forward

Advising the Committee on pertinent matters

Surrey and Sussex Healthcare Rules of Procedure

Audit and Assurance Committee: Standing Agenda

General Business Apologies Declaration of interests Minutes of previous meeting Agreed actions tracker

Risk Management Board Assurance Framework Risk Management Systems

Internal Control Systems Review annual governance statement Review internal controls Note business of other committees

Specific Duties Review annual accounts Reviews losses waivers and special payments

Independent Assurance Receive and approve annual internal audit plan and updates Receive and approve annual external audit plan and updates Receive and approve other sources of external assurance (Counter Fraud)

Specific Duties Review of other reports and policies as appropriate (e.g. changes to standing orders) Review of audited annual accounts and financial statements Review changes to standing financial instructions and changes to accounting policies

Audit and Assurance Committee: Meeting Timetable The meetings shall occur at regular intervals throughout the year and shall receive reports in a sequence that allows the Committee to review annual reports with foresight of other relevant assurance reports. The expected timetable of the Committee is set out below: Audit and Assurance Committee Timetable

March 1.

Plan how to discharge Audit Committee duties

Self-assess Committee’s effectiveness

Review Committee’s terms of reference

Produce annual Audit Committee report

Private discussions with internal and external audit

May

July

Sept

Nov

    



Risk Management 6.

Review the Board Assurance Framework in Full

Review the Assurance Framework in sections

Review the risk management system in full

Receive the Significant Risk Register

 



 



Internal Control Systems 10. Note business of other committees and review inter-relationships 11. Review draft Statement on Internal Control



12. Review Internal Controls and work plan 13. Review risks and controls around ﬁnancial and asset management 14. Review risks and controls around information governance and data quality 15. Review risks and controls around corporate and legal objectives

   

16. Review risks and controls around clinical governance

Surrey and Sussex Healthcare Rules of Procedure



17. Review risks and controls around patient experience 18. Review risks and controls around workforce

 

Specific Duties 19. Review of other reports and policies as appropriate – for example, changes to standing orders 20. Review of audited annual accounts and ﬁnancial statements 21. Review changes to standing ﬁnancial instructions and changes to accounting policies 22. Review of losses and special payments

 



 

Independent Assurance 23. Receive sources of assurance of external assurance 24. Review and approve annual internal audit plan



25. Review and approve internal audit terms of reference



26. Review the effectiveness of internal audit



27. Review internal audit progress reports 28. Receive annual internal audit report and associated opinions



30. Review the effectiveness of external audit



 



32. Receive the External Auditor’s report to those charged with governance



33. Receive the External Auditor’s annual audit letter



34. Review and approve annual counter fraud plan 35. Review counter fraud progress reports

 



36. Review the organisation’s assessment against CFSMS qualitative assessments 37. Review the effectiveness of the Local Counter Fraud Specialist 38. Receive counter fraud annual report to AAC

 

29. Agree external audit plans and fees

31. Review external audit progress reports



 

Chapter Seven Nomination & Remuneration Committee Board of Directors

Shadow Council of Governors

Audit and Assurance

Nomination and Safety and Remuneration Remuneration Quality

Finance and Workforce

Charitable Funds and Workforce

For Executive Directors:

      

Appointment; Reward; Performance; Retention; Termination; Pension matters; Successful planning for senior management

Summary purpose and authority

6.1

The Nomination and Remuneration Committee’s role is to appoint and, if necessary, dismiss the executive directors, establish and monitor the level and structure of total reward for executive directors, ensuring transparency, fairness and consistency. The Committee shall receive reports from the Chairman of the Board of Directors on the annual appraisal of the Chief Executive, and from the Chief Executive on the annual appraisals of executive directors, as part of determining their remuneration.

6.2

Levels of remuneration shall be sufficient to attract, retain and motivate executive directors of the quality and with the skills and experience required to lead the Trust successfully, but no more than is necessary for this purpose.

6.3

There shall be a formal and transparent procedure for developing policy on executive remuneration and for setting the remuneration packages of individual directors. No executive director shall be involved in deciding their own remuneration.

6.4

The Committee shall develop and implement an effective succession plan to identify and develop internal personnel to fill key senior management posts as part of ensuring the availability of experienced and skilled employees when posts become available. For executive directors other than the Chief Executive, the Committee shall take advice from the Chief Executive.

6.5

The terms of reference reflect the statutory requirements that apply to NHS Trusts. On authorisation as an NHS foundation trust, the Trust shall establish separate

Surrey and Sussex Healthcare Rules of Procedure

Nomination and Remuneration Committees, the terms of reference for which shall be prepared in advance of authorisation.

Nomination and Remuneration Committee: Terms of Reference 1.

Constitution

The Board hereby resolves to establish a Committee of the Board to be known as the Nomination and Remuneration Committee (The Committee).

Membership

The Committee comprises: • •

The Board Chair All Non-Executive Directors

As Accountable Officer, the Chief Executive has an open invitation to attend each Board sub-committee. Executive Directors, will be invited to attend the Committee in an advisory capacity but will withdraw when a matter concerning his/her remuneration package or other matter of individual confidentiality is being discussed or documented. The Director of Human Resources will also attend the Committee as adviser. The Director of Human Resources will be responsible for minuting the Meetings.

3. Quorum No business shall be transacted at a meeting unless the Chair of the Board or Deputy Chair and two Non-Executive Directors are present for the whole meeting.

4. Frequency The Committee will meet as required by the Chair of the Board and at least twice per year.

Authority

The Committee is authorised by the Board to investigate any activity within its terms of reference. In particular it may:

•

Seek advice from whatever source it deems to be appropriate.

•

Authorise the Chief Executive and HR Director to implement remuneration packages approved by the Committee, providing the sums are within the delegated powers in the Standing Orders and Standing Financial Instructions.

6. Duties The main functions of the Committee are: •

To advise the Board about performance, development, succession planning and appropriate remuneration and terms of service for the Chief Executive and all Executive Directors, guided by NHS policy and best practice. Advice to the Board on remuneration includes all aspects of salary as well as arrangements for termination of employment and other contractual terms.

•

To make such recommendations to the Board on the succession planning and on the remuneration, allowances and terms of service of the Chief Executive and, on the advice of the Chief Executive, the Executive Directors, to ensure that they are fairly motivated and rewarded for their individual contribution to the organisation – having proper regard to the organisation’s circumstances and performance and to the provision of national arrangements.

•

To monitor and evaluate the performance and development of the Chief Executive and, on the advice of the Chief Executive, the Executive Directors.

•

To advise the Board and oversee appropriate contractual arrangements for the Chief Executive and Executive Directors including the proper calculation and scrutiny of termination payments taking account of such national guidance as appropriate.

•

The Chief Executive is responsible for ensuring that the Director of Human Resources brings forward the necessary information in a timely manner to enable the Committee to discharge its functions and takes appropriate follow-up action.

7. Reporting Formal minutes will be recorded of each meeting of the Committee and will be distributed to those present at meetings. All recipients will hold minutes securely and Auditors may access the official Minute Book held by the Secretary with the prior approval of the Chair of the Board. The Committee will report in writing to the Board at least once annually the basis for its decisions and recommendations.

8. Review Date The Terms of Reference of the Committee will be reviewed annually.

Surrey and Sussex Healthcare Rules of Procedure

Nomination and Remuneration Committee: Standing Agenda

General Business Apologies Declaration of interests Minutes of previous meeting Agreed actions tracker

Executive Director Pay structure Review structure of reward Assess performance Review benchmarks Consider, and if appropriate, approve any changes

Nominations & Terminations Selection / termination process Succession planning

General Issues to report to the Board of Directors Date of next meeting Any other business

Nomination and Remuneration Committee: Meeting Timetable The Committee shall meet at least four times during the year and at other times when the Chairman of the Committee shall require and shall be ordered whenever there is an appointment or termination of an executive director.

Nominations Committee

and

Remuneration May

Sept

Nov

March √

Prepare an annual report to the Board of Directors

√

Update on Executives objectives

Update from CEO Objectives/Performance issues/concerns

Evaluation of performance and remuneration proposals

√

on Executive highlighting any

√

Surrey and Sussex Healthcare Rules of Procedure

Chapter Eight Safety and Quality Committee Shadow Council of Governors

Board of Directors

Audit and Assurance

Safety and Nomination and Remuneration Quality Remuneration

Finance and Workforce

Charitable Funds and Workforce

Scrutinise and review:

    

7.1

Safety and Quality Strategy; Clinical Governance Control Systems Safety of Patients Clinical Practice Patient Experience.

Purpose and authority

7.1.1 The second and final Francis Report, published February 2013, highlighted that the fundamental responsibility of providing safe care sits with the Trust Board, providing patient-centred healthcare leadership and that Boards will be held to account. Openness, transparency and candour is required throughout the system to ensure the right information is received and acted on appropriately by all those with responsibility to provide high quality, safe care. Accurate, relevant and useful information should be easily available to patients. 7.1.2 The Trust’s arrangements for seeking assurance reflect the trust-wide responsibility for greater quality in healthcare, with specific focus on safety, effectiveness and patient experience. This assurance responsibility is shared with the Executive Committee for Quality and Risk, the Safety and Quality Committee and the Board. This ensures wider ownership, clearer accountability and greater visibility of assurance of the Trust's clinical governance by all Board members, Senior Clinicians and Management. 7.1.3 Furthermore, in order for the Audit and Assurance Committee to execute its responsibilities to review and audit control systems across the organisation, SQC will seek assurance of the clinical governance controls systems. 7.1.4 As SQC plans to meet monthly, it will seek assurance that these systems have been adequately reviewed in the monthly EC which means that EC and SQC need to agree on areas of assurance for each clinical control system. In turn, AAC will require SQC to report on whether or not it was assured from the reports or other evidence-based assurances it receives.

7.1.5 The duties of the Safety and Quality Committee will be to review the performance of EC in executing its assurance responsibilities and to demand more detailed investigation where assurance does not meet expectations. It will also provide a forum for greater discussion on trust-wide implications of lessons learnt and more in depth debate on the key issues. 7.1.6. Both the EC and the Board can refer themes to the SQC for a more detailed discussion of any issues and a more detailed review of assurance.

7.2

Quality accounts

7.2.1 Quality accounts have been introduced to increase accountability to the public for quality. This requires Boards of Directors to provide a clear narrative explaining the quality of care they offer and how they seek to improve, taking account of the views of the local community. The Committee’s work plan and standing agenda shall be designed to ensure that the Board of Directors have adequate assurance over the data being reported. 7.2.2 As an applicant for NHS foundation trust status, SASH shall prepare its quality account in line with Monitor’s annual reporting guidance. This shall include a set of Board statements of assurance on the accuracy of reporting quality standards and targets. The Committee shall provide the Board of Directors with these assurances as part of its standing agenda. 7.2.3 The committee’s duties are designed to ensure there is ongoing assurance of delivery of the required standards for the legislated, mandatory aspects of the quality account including

•

Review of services

•

Participation in clinical audits

•

Reviewing Reports of national and local Clinical Audits

•

Information Governance including toolkit attainment

•

Participation in clinical Research

•

Use of the CQUIN payment framework

•

Statements from the regulator

•

Data quality including clinical coding error rate

Surrey and Sussex Healthcare Rules of Procedure

Safety and Quality Committee: Terms of Reference 1.

Background The Safety and Quality Committee (â&#x20AC;&#x153;the Committeeâ&#x20AC;?) is constituted as a standing committee of the Board of Directors. These terms of reference can only be amended by the Board of Directors. The purpose of the Committee is to assist the Board of Directors in executing their responsibility for seeking and monitoring assurance around safety, quality and patient experience. .

Authority The Board of Directors has delegated to the Committee the authority to deal with the matters set out in paragraph 6 below. The Committee is authorised by the Board of Directors to seek any information it requires from any employee of the Trust in order to perform its duties.

Membership and Attendance The members of the Committee shall be: (i)

The Chairman and three non-executive directors appointed by the Board of Directors;

(ii) (iii) (iv) (v) (vi)

Medical Director or Deputy; Chief Nurse or Deputy; Chief Operating Officer or Deputy Chief Financial Officer or Deputy. Clinical Chiefs of Service (6 including, Chief of Education and Chief Clinical Informatics Officer )

Members of the Board of Directors not specified in paragraph 3.1 above shall have the right of attendance. The Secretary shall circulate minutes of meetings of the Safety and Quality Committee to all members of the Board of Directors with Board papers. The Chairman of the Committee shall be a non-executive director appointed by the Board of Directors. As Accountable Officer, the Chief Executive has an open invitation to attend each Board sub-committee. The following individuals are required to attend part or all of the meetings as required by the Chairman of the Committee but shall have no voting rights: (i) (ii)

Divisional Chief Nurses Risk and Patient Safety Lead ;

(iii) (iv)

Director of Informatics, Estates and Facilities â&#x20AC;&#x201C; by invitation only when required; Director of Corporate Affairs - by invitation only when required;

(v) (vi)

Clinical Governance Compliance Manager Corporate Governance Manager

(vii)

Any other clinicians, nursing and midwifery staff and allied health professionals as appropriate to the business of the meeting concerned; and (viii) Accountable Officer for Controlled Drugs (by invitation only when required);

Quorum The quorum necessary for the transaction of business shall be five members, which shall include two non-executive directors, the Medical Director (or deputy) or Chief Nurse (or deputy), two Chiefs of Service or their deputies. A duly convened meeting of the Committee at which a quorum is present shall be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the Committee. In the absence of the Committee Chairman and/or an appointed Deputy, the remaining non-executive members present shall elect one of themselves to chair the meeting. Where a Committee meeting: (i)

is not quorate under paragraph 4.1 within one half hour from the time appointed for the meeting; or

(ii)

becomes inquorate during the course of the meeting,

The Committee members present may determine to adjourn the meeting to such time, place and date as may be determined by the members present.

Meetings The Committee shall meet monthly for two hours and at such other times as the Chairman of the Committee shall require. Risk and Patient Safety Lead â&#x20AC;&#x201C; or their nominee shall act as the Secretary of the Committee. Meetings of the Committee shall be summoned by the Secretary of the Committee at the request of the Committee Chairman. Unless otherwise agreed, notice of each meeting confirming the venue, time and date together with an agenda of items to be discussed, shall be forwarded to each member of the Committee no later than seven days before the date of the meeting. Supporting papers shall be sent to Committee members and to other attendees, as appropriate five days ahead of the date of the meeting.

Surrey and Sussex Healthcare Rules of Procedure

Duties The Committee shall support the Board of Directors with:

6.1.

STRATEGY The Committee will review and approve the Safety and Quality Strategy and the Quality Account following its development through EC and prior to presentation to the Board for approval.

6.2

CLINICAL GOVERNANCE CONTROL SYSTEMS The Committee will seek assurances that the following clinical governance controls are reviewed to provide assurance of the Trust’s statutory duties are executed and the control system’s design, function and performance is satisfactory, meets best practice and is benchmarked with leading Trust’s wherever possible. • • • • • • • • • • •

6.3

Clinical Audit CQC Compliance Incident management Mortality Infection, prevention and control NICE Compliance Complaints Patient Opinion Clinical Claims handling Safeguarding Clinical Data Quality

SAFETY The Committee will seek assurances that the safety of patients and any risk to their safety is managed effectively through EC. The Committee will specifically ask for evidence, via the minutes of EC meetings, that incident management metrics are reviewed and acted on, that timely root cause analyses are instigated for SUIs and HCAIs and lessons learnt, and that patients are safeguarded in patient areas and all transfers within the hospital and to the community. The Committee will review recurring themes and key trends of incidents to see that lessons are learnt are shared trust-wide to prevent recurrence of incidents. The Mortality group will report directly to the Committee on its findings and learnings. The Committee will look at the incidence of claims for compensation through the NHSLA scheme and how these are managed.

6.4

PATIENT EXPERIENCE The Committee will seek assurances that improving the Patient Experience is part of the trust’s everyday business. The trust’s Patient Experience Committee has been re-formed and will report to the Safety & Quality Committee, to provide additional assurance that the lessons are

learnt from patient experiences, surveys, patient opinion sites, complaints, claims, patient constitution issues and stakeholder feedback and are shared across the whole organisation. The Committee should have confidence in the way the trust source patient feedback and involvement, utilising various methods of collecting and responding to patient information in order to widen participation that is representative of all patient groups. The Committee will expect the Patient Experience group to report on its oversight of complaints - both the management of the process as well as substance and response to complaints and lessons learnt. The Committee will ask for periodic reviews of complaints in the trust direct from the Complaints team to triangulate its source of assurance with reporting from the Patients Experience group. The Committee will assure itself that different patient groups (selected by demographics or condition) have the optimal patient experience, safety and the quality of services by triangulating different data sources, hard and soft intelligence with commentary from clinicians. 6.5

QUALITY OF SERVICE The Committeeâ&#x20AC;&#x2122;s programme of work will include a review of the improving quality of services by looking for evidence of clinical improvements in the trust arising from mortality reviews and in response to other drivers e.g. Francis Report, SUI action plans, to assure the trust is implementing the best clinical practices. It will review the rationale for the design of the clinical audit programme, conduct progress reviews and seek assurance from the clinical audit results. Compliance with NICE directives is also an important benchmark of best practice where applicable to the Trust and the Committee will seek assurance that the trust responds and adopts NICE directives in a timely way with assurance of implementation via clinical audit. The Committee will seek assurance that clinical data is collated and reported accurately, timely and using the correct methodology. The Committee will seek assurance that the trust's responsibility to manage and safeguard patient information thought its adherence to the Information Governance policy and maintenance of minimum standards

6.6

COMPLIANCE The Safety and Quality Committee will receive assurance of compliance with CQC and other regulators by exception reporting of potential risks to compliance with CQC and other regulators from EC, which is responsible for evidencing compliance.

Reporting arrangements

7.1

The Committee Chairman shall report formally to the Board of Directors on its proceedings after each meeting on all matters within its duties and responsibilities.

7.2

The Committee shall make whatever recommendations to the Board of Directors and/or Executive Committee that it deems appropriate on any area within its remit

Surrey and Sussex Healthcare Rules of Procedure

where action or improvement is needed. In particular, the Committee shall refer any substantive issues or concerns on delivery of the Safety and Quality Strategy to the Audit and Assurance Committee, the Executive Committee for Quality and Risk and or to the Board of Directors for wider consideration in light of its overall responsibility for ensuring the safety and quality of services provided by the Trust.

Review

8.1

The Committee shall, at least once a year, review its own performance, membership and terms of reference to ensure it is operating at maximum effectiveness and recommend any changes it considers necessary to the Board of Directors for approval.

Safety and Quality Committee: Standing Agenda 1

General Business Apologies Declaration of interests Minutes of previous meeting Agreed actions tracker

Strategic & Regulatory

Safety

Patient Experience

Quality

General AOB Issues to report to Board Date of next meeting

Surrey and Sussex Healthcare Rules of Procedure

Safety and Quality Committee: Meeting Timetable The Committee shall meet monthly based on the indicative programme below: Subject

Quarterly

Biannually

Annually

Strategic & Regulatory 1

Approve Trust’s Safety and Quality Strategy

√

Approve Trust's Quality Account

√

Francis implementation

√

CQC Compliance/ regulatory updates

√

Safety √

Incident management

Infection, prevention and control

Mortality

Claim handling

√

Safeguarding

√

√ √

Patient Experience 10

Patient Opinion

√

Complaints

√

Patient groups (by demographics or condition)

√

Quality of Care

Clinical audit programme and audit results

Progress of clinical audit programme

Evidence at point of care

NICE Compliance

Information governance

Data Quality

√ √ √ √ √ √

Chapter Nine Finance and Workforce Committee

Shadow Council of Governors

Board of Directors

Audit and Assurance

Finance and Workforce

Nomination and Safety and Remuneration Remuneration Quality

    

8.1

Charitable Funds and Workforce

Strategic and Annual Financial planning for support functions Treasury management Delivering and monitoring investment strategy; Major investment decisions; Performance Management

Summary purpose and authority

8.1.1 The purpose of the Finance and Workforce Committee is to provide oversight of the Trust’s business planning in particular strategic, (three year plus) and annual planning oversee investment (treasury/working capital management and capital projects) and financial sustainability. The Committee is responsible for the following key areas: (i) (ii) (iii)

business planning, including strategic and annual financial, workforce, estates and IT planning; approving investment decisions, including capital projects, treasury and working capital management, and; monitoring delivery of significant projects and investments, and any potential new business combinations.

8.1.2 The Board of Directors sets the strategic direction for the Trust (in particular approving the Clinical Strategy and the Quality and Safety Strategy) and this Committee provides assurance to the Board that the Business Plan and Long Term Financial Model (LTFM) and supporting strategies, and Annual Operating Plans including the financial budget are in place and fit for purpose – the Committee is not writing the Trust’s strategy, it is ensuring that the supporting strategies are in place and are operationalised through the business plan. Linked to that, the Committee approves investment decisions that support the business plan and monitors

Surrey and Sussex Healthcare Rules of Procedure

implementation of those investments. It also reviews support functions e.g. Workforce, Estates, IT performance through KPI reporting. 8.1.3 On behalf of the Board the Committees scrutiny of monthly financial performance, and will expect to see linkage back to Trust planning where this is required to deal with issues from in-year performance. 8.1.4 The Committee will receive reports on Transformation and Productivity so that it is appraised of internal performance, the external environment and how commissioning intentions are shifting to allow it to provide advice to the Board on risks and to inform investment or other decisions within its (the Committeeâ&#x20AC;&#x2122;s) remit. 8.1.5 The Committee will provide the Audit and Assurance Committee with assurance over the efficacy of strategic and annual planning, the effectiveness of their delivery and investment decisions. It will also provide assurance over how well related processes are controlled. The Committee Chair shall be a member of the Audit and Assurance Committee. The Chair will be responsible for ensuring that the Committee is provides assurance to the Audit and Assurance Committee in the course of its annual work programme including the relevant aspects of the Trustâ&#x20AC;&#x2122;s Internal Control Framework. 8.1.6 The Committee is responsible for the review and approval of the treasury management policy, working capital policy, investment strategy and capital programme to ensure the overall security of resources and best return on investment. The Committee shall ensure sufficient liquidity to meet the Trustâ&#x20AC;&#x2122;s current commitments and planned capital expenditure. 8.1.7 The Committee shall scrutinise and challenge significant capital expenditure and major projects in line with the thresholds detailed within its terms of reference, which reflect the Scheme of Delegation, to ensure the most effective use of resources and manage costs. A framework for such challenge is set out as Appendix 4 to these Rules of Procedure. The Committee shall receive reports from the Capital Group, which reports to the Executive Committee, and which shall approve and monitor lower value projects. The Committee shall similarly receive reports from the Executive Workforce Group and the Executive Committee for Strategy. 8.1.8 The Trust is committed to becoming an exemplary body with a focus on its people, specifically, staff development and employee satisfaction. The Committee shall review Workforce strategy and annual plans to ensure alignment with Trust direction and strategic objectives. A key focus will be that strategic workforce plans support both strategic and annual plans support the identification of appropriate resource levels and skill mix in line with budgeted staff costs now and for the future. A further focus for the Committee will be staff development linked to organisational, divisional, team and personal objectives through a comprehensive performance monitoring and appraisal system. The aim will be the development and implementation of a Workforce Strategy which has a positive impact on staff job satisfaction and retention. The Committee shall receive regular reports as agreed from the Director of Human Resources.

8.2

Impact on foundation trust application

In order to attain NHS foundation trust status, the Trust will need to ensure that its business plan processes are integrated and that the Integrated Business Plan fully describes how the Trust will deliver its strategic objectives. It will need to have sound treasury management systems and a successful investment record that maximises benefit, including the capital programme. The Trust shall ensure policies and financial systems are in line with best practice as issued by Monitor prior to making an application.

Surrey and Sussex Healthcare Rules of Procedure

Finance and Workforce Committee: Terms of Reference Finance and Workforce Committee Terms of Reference

Background

1.1

The Finance and Workforce Committee (“the Committee”) is a standing Committee of the Board of Directors. These terms of reference can only be amended by the Board of Directors.

1.2

The purpose of the Committee is to assist the Board of Directors in exercising its business planning, financial and workforce and investment governance procedures in four key areas: i) monitoring Financial Performance ii) Business planning, including strategic financial and workforce planning; iii) approving investment decisions, as defined in these terms of reference, including capital projects, treasury and working capital management, and; iv) monitoring delivery of significant projects and investments, and any potential business combinations.

Authority

2.1

The Committee is authorised by the Board of Directors to investigate any activity within its terms of reference. The Committee is authorised by the Board of Directors to seek any information it requires from any employee of the Trust in order to perform its duties.

2.2

In connection with its duties, the Committee is authorised by the Board of Directors, at the Trust’s expense, within any budgetary restraints imposed by the Board of Directors, to appoint external professional advisors, and to commission or purchase any relevant reports, surveys or information which it deems necessary to fulfil its duties.

Membership and Attendance

3.1

The members of the Committee shall be appointed by the Board of Directors.

The members of the Committee shall be:

•

three non-executive directors, one of whom shall be appointed as Chairman of the Committee; another of whom shall be a member of the Audit and Assurance Committee;

•

Chief Financial Officer

•

Director of Corporate Affairs

•

Director of Human Resources

•

Director of Information and Estates

•

Chief Nurse

â&#x20AC;˘

Chief Operating Officer

3.2

As Accountable Officer, the Chief Executive has an open invitation to attend each Board sub-committee.

3.3

The following shall be invited to attend meetings as and when appropriate but shall have no voting rights:

3.4

(i) all other corporate members of the Management Board; and (ii) all other non-executives and executive members of the Board of Directors. The Committee may invite other Trust staff to attend its meetings as appropriate.

Quorum

4.1

The quorum necessary for the transaction of business shall be three, which shall include at least one non-executive and one executive director.

4.2

A duly convened meeting of the Committee at which a quorum is present shall be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the Committee.

4.3

In the absence of the Committee Chairman and/or an appointed Deputy, the remaining non-executive members present shall elect one of themselves to chair the meeting.

4.4

Where a Committee meeting: (i)

is not quorate under paragraph 4.1 within one half hour from the time appointed for the meeting; or

(ii)

becomes inquorate during the course of the meeting,

the Committee members present may determine to adjourn the meeting to such time, place and date as may be determined by the members present.

Meetings

5.1

The Committee shall meet monthly and at such other times as the Chairman of the Committee shall require.

5.2

The Chief Financial Officer or their nominee shall act as the Secretary of the Committee.

5.3

Meetings of the Committee shall be summoned by the Secretary of the Committee at the request of the Chairman and/or Chief Executive.

5.4

Unless otherwise agreed, notice of each meeting confirming the venue, time and date together with an agenda of items to be discussed, shall be forwarded to each member of the Committee no later than five days before the date of the meeting.

5.5

Supporting papers shall be sent to Committee members and to other attendees, as appropriate, at the same time.

5.6

Minutes of the Committee shall be circulated to Committee members and attendees, and the Board of Directors.

Surrey and Sussex Healthcare Rules of Procedure

Duties

6.1

Financial Performance The Committee shall provide oversight of the Trust Financial performance by reviewing financial and trading (income from activities) performance in delivering healthcare outputs and targets. The Committee shall consider and review income and activity (trading) reports focusing on:

(i)

The volume and complexity of activity and performance against Plans

(ii)

Reasons for variances, the impact financially and correct adverse performance

(iii)

Forecasts for the year, risks to that forecast and actions to mitigate risks

(iv)

Effectiveness of contractual processes, contractual notices and outputs with commissioners

(v)

Compliance with SOFIs particularly in terms of work being done by the Trust that is not contracted

(vi)

Cashflow management and Working Capital planning

(vii)

Major judgmental areas

delivery of actions to

The Committee shall consider and review financial reports focusing on:

6.2

(i)

Delivery to plans

(ii)

Reasons for variances and delivery of actions to correct adverse performance

(iii)

Forecasts for the year, risks to that forecast and actions to mitigate risks

(iv)

Delivery of Trust savings plans

(v)

Operation of Trust budgetary procedures and compliance with SOFIs

(vi)

Major judgmental areas

Business planning The Committee shall provide oversight of the Trustâ&#x20AC;&#x2122;s business planning and will recommend to the Board of Directors the sign off of the integrated business plan and annual operating plans. The Committee will also take stock of market and environmental analysis reports and make itself aware of developments in the local health economy and through transformation programmes and QIPP schemes. In doing so, the Committee shall approve: i) All relevant supporting strategies and policies, with the exception of the Clinical Strategy (which is signed off by the Board) and Quality Strategy i.e. Clinical Effectiveness, Safety and Patient Experience (which is approved by the Safety & Quality Committee) â&#x20AC;&#x201C; see below for workforce ii) The business planning timetable

6.3

Financial policy, management and reporting The Committee shall provide oversight of the Board of Directors’ financial policies, management and reporting with consideration to the overall financial performance of the Trust by ensuring the development and implementation of high levels of financial control are embedded into operational management of the Trust and financial plans are disseminated and understood across the Trust. In doing so, the Committee shall approve: (i) the financial policies of the Trust annually and make appropriate recommendations to the Board of Directors; (ii) the Trust’s medium and long-term financial strategy, in relation to both revenue and capital, including overseeing the development of financial plans for the Trust’s foundation trust application; (iii) the Trust’s annual financial targets; and (iv) the preparation of the annual budget prior to its submission to the Board of Directors.

6.4

Workforce strategy The Committee shall provide oversight of the workforce strategy, plans, management and reporting with consideration to the overall flexibility of resources, total staff costs and staff development. In doing so, the Committee shall approve: (i) the 3 - 5 year workforce strategy and relevant supporting policies that are relevant to the Committee (the Management Board will sign off most supporting policies) (ii) the organisational development strategy and annual plan (iii) the annual workforce plan including, the preparation of its establishment prior to the budget’s submission to the Board of Directors.

6.5

Investment policy, management and reporting The Committee shall: a.

approve and review, on behalf of the Board of Directors, the Trust’s investment strategy and policy the 3-5 year capital programme and the annual capital plan in order to maintain oversight of the Trust’s investments, ensuring compliance with the policy. The Committee shall: (i)

b. c.

establish the overall methodology, processes and controls which govern investments; (ii) ensure that robust processes are followed; and (iii) evaluate, scrutinise and monitor investments; approve and review the Trust’s treasury management and working capital policy annually or as required; approve proposals for major business cases with a capital value of over £1m or which require a revenue budget virement of over £1m. The

Surrey and Sussex Healthcare Rules of Procedure

6.6

Committee shall monitor the work of the Capital Group, which reports to the Management Board, for lower value investments; approve the initiation of projects greater than £1m on the information provided in the Project Initiation Document and Project Plan Outline Business Case and Full Business Case and other key project documents; monitor implementation of major projects (>£2.0m). This shall include: (i) developing sub-groups as needed and approving their terms of reference; (i) assisting in the evaluation of the bids at each stage or identifying the expert advice needed; (ii) giving approval to the Project Director to start each necessary stage of work upon completion of the necessary tasks from the previous stages; (iii) approving major alterations in the project plan; (iv) ensuring key areas are communicated across all stakeholder organisations; (v) ensuring the project is appropriately evaluated; (vi) ensuring propriety in placing and management of contracts; and (vii) ensuring risk assessment and management strategies are in place. evaluate the implementation and delivery of the business benefit of projects > £1m via a post implementation review.

Other duties

The Committee shall: 1. make any arrangements necessary to ensure that all members of the Board of Directors maintain an appropriate level of knowledge and understanding of key financial issues affecting the Trust; 2. examine any other matter referred to the Committee by the Board of Directors. 3. meet privately to consider commercially sensitive matters e.g. potential partnerships, marketing strategy 4. seek assurances that governance controls are reviewed to provide assurance that the trusts internal control framework system’s design, function and performance are satisfactory. 6.7

External advice

The Committee shall be exclusively responsible for establishing the selection criteria, selecting, appointing and setting the terms of reference for any external professional advisors who advise the Committee in the course of its work. Where external professional advisors are appointed, a statement shall be made available of whether they have any other connection with the Trust.

Reporting arrangements

7.1

The Committee Chairman shall report formally to the Board of Directors on its proceedings after each meeting on all matters within its duties and responsibilities.

7.2

The Committee shall make whatever recommendations to the Board of Directors and/or Management Board that it deems appropriate on any area within its remit where action or improvement is needed.

7.3

The Committee shall produce an annual report of the Trustâ&#x20AC;&#x2122;s financial, investment, project, procurement, and estates policies and practices which shall form part of the Trustâ&#x20AC;&#x2122;s annual report.

7.4

The committee shall review reports previously considered and approved by the Management Board for Strategy, the Workforce Group and the Capital Group.

Review

Surrey and Sussex Healthcare Rules of Procedure

Finance and Workforce Committee: Standing Agenda and Monthly timetable A G E N D A – PART 1 1

Welcome and Apologies for Absence Apologies

General

Declarations of Interest 2

Minutes and actions from previous meeting Minutes of previous meeting - for approval

General

Actions from Action tracker - for information 3

Business Case Investment Strategic Business Case - for approval Outline Business Case - for approval

Monthly as required

Full Business Case - for approval Post Implementation Review - for assurance 4

Business Planning Business Planning updates - for information 1. Timetable – February 2. Draft Budget and Capital Plan – January 3. Final Budget and Capital Plan – March 4. Financial Plan – March

Annual

Annual Strategies - for approval or review 5. Estates Strategy 6. IT Strategy 7. Communications Strategy 8. Workforce and Organisational Development Strategy 9. IBP 5

Finance Financial Performance - for assurance

Monthly

CIP Update - for assurance

Monthly

Workforce and Organisational Development Workforce & Organisational Development Report M06 - for assurance

Monthly

Capital & Estates Capital & Estates Report - for assurance

Monthly

IT IT Report - for assurance

Monthly

General Any other business General Issues to report to the Board of Directors Next Meeting

A G E N D A â&#x20AC;&#x201C; PART 2 1

Minutes from previous meeting

General

Productivity

Quarterly

Service Efficiency Programmes Quarterly Update - for information Other Initiatives Update - for information 3

Monthly as required

Service Developments Partnerships Update - for information Quarterly Benchmarking - for information Productivity Report â&#x20AC;&#x201C; for information

Monthly Quarterly Monthly

Marketing Market Development Plan - for approval

Finance Contract Report - for information Service Line Reporting - for information

Annual Monthly as required Monthly

General Any Other Business

General

Next Meeting

Surrey and Sussex Healthcare Rules of Procedure

Chapter Ten Charitable Funds Committee

Shadow Council of Governors

Board of Directors

Audit and Assurance

Nomination and Safety and Remuneration Remuneration Quality

Charitable and Workforce Funds

Investment and Workforce

   

9.1

Safe custody Compliance with legacies Accounts Income generation

Summary purpose and authority

To oversee the generation, management, investment and disbursement of charitable funds within the regulations provided by the Charities Commission and to ensure compliance with the laws governing charitable funds.

9.2 Charitable Funds Committee: Terms of Reference 1.

Background

Surrey & Sussex Healthcare NHS Trust Charitable Fund was formed from the merger of Crawley Horsham and East Surrey Charitable Funds in April 2001. Powers of the Trustees are contained within the original Trust Deed which was registered on 26 March 1996. The Charity Registration number is 1054072.

Constitution

The Charitable Funds Committee is established under the direction of the Trust Board (as stated in Standing Order 4.8 (5)). The Surrey and Sussex Healthcare NHS Trust is the Corporate Trustee of the Charity governed by the law applicable to Trusts, principally the Trustee Act 2000 and the Charities Act 2011. The NHS Trust Board has devolved responsibility for the on-going management of funds to the Charitable Funds Committee, which administers the funds on behalf of the Corporate Trustee. As such the Committee acts independently of the Board. Members of the Committee are not individual trustees under charity law but act as agents on behalf of the Corporate Trustee.

Relationships

Board upwards for information only. No sub committees.

Membership

The Committee shall be represented by both non-executive and executive directors. It shall be chaired by a Non-Executive Director and the membership shall include two Executive Directors, one of which shall be the Chief Finance Officer. Agreed membership is as follows: Trust Chair (Chair) Non-Executive Director (if for any reason the Chair is unable to attend they will nominate another member to chair the meeting) Other Members

2 x Non-Executive Directors Chief Finance Officer (CFO) Chief Nurse (links to patient experience)

Surrey and Sussex Healthcare Rules of Procedure

Director of Corporate Affairs Director of Information and Facilities Head of Financial Accounts Fundraising Co-ordinator Head of Communications

Attendance •

A quorum shall be no fewer than 4 members present – 2 x Executive Directors (Chief Finance Officer / Deputy plus Chief Nurse / Deputy) plus 2 x Non-Executive Directors.

•

In the absence of a quorate member, decisions will be followed up with the appropriate member.

•

As Accountable Officer, the Chief Executive has an open invitation to attend each Board sub-committee

Administration •

An agenda shall be available prior to each meeting and allow for additional items under General Business to be added to at the commencement of each meeting

•

Minutes will be taken by the CFO Executive Assistant (EA).

•

Responsibility for the running of the meetings and their organisation sits with the Head of Financial Accounts, with resource provided from the CFO EA

•

Review Date July 2013

Frequency •

The Charitable Funds Committee shall meet at least three times a year.

•

1 hour meetings, dates and times will be advertised in advance.

•

Notification of changes will be made available to all members in advance by the Chair.

•

It is permissible for the Charitable Funds Committee to make decisions, as required, off line where, for example, the next committee does not fall within a suitable time line or where the committee at which the decision / approval was to be made was not quorate.

Authority

The Group is autonomous and acts independently of the Trust Board but shall report to the Board for information (please see constitution).

The Committee delegates authority as follows: •

For authorising spend above £2,000: the Chief Finance Officer and the Chair of the Committee

•

For amendments to existing funds and establishing new funds: The Chief Finance Officer should authorise these changes subject to published procedures.

•

For the procurement of goods and services: The authorised fund managers will procure goods and services in line with published procedures.

•

For day to day management and administrative functions, including changes to Fund Managers: The Head of Financial Accounts subject to published procedures.

•

For the approval of cheque payment runs: Two senior managers in accordance with the cheque approval mandate

Monitoring Effectiveness •

The Committee will undertake an annual review of its performance against its work plan in order to evaluate the achievement of its duties. This review will inform the Committees annual report to the Board.

Core Duties 1.

Safe Custody •

To authorise expenditure where an individual item has a value of more than £2,000 in line with the Trust’s Scheme of Delegation. Note on delegated authority: Amounts below £2,000 can be approved by Fund Managers, above £2,000 they must be authorised by the Chief Finance Officer and the Chair of the Committee and reported to the Committee.

•

To review the income and expenditure transactions for all funds and to be satisfied (through the NHS Trust’s accounting systems) that there is an appropriate and robust system of control over income and expenditure.

•

To ensure that policies and procedures are in place to meet the requirements of the Charities Commission and the laws governing charitable funds.

Compliance •

To act on behalf of the Trust (as Trustee) in satisfying the duties and responsibilities of trustees in managing the funds. Note on delegated authority: for day to day management and administrative functions, including changes to Fund Managers: The Head of Financial Accounts is the authorised decision maker, subject to published procedures.

•

To authorise/agree the establishment of new funds and new charities Note on delegated authority: The Chief Finance Officer should authorise new funds subject to published procedures.

Surrey and Sussex Healthcare Rules of Procedure

•

To review legacies received and ensure that the Trust complies with the terms of the legacy

•

To encourage the appropriate use of Charitable Funds and to ensure Fund Managers to carefully consider the use of these funds based on the Donor’s intentions/wishes.

•

To receive and review all audit reports on charitable funds and to monitor implementation of audit recommendations.

Investments & fund raising •

To oversee the investment strategy of the Charitable Funds as required by the Trustee Investment Act 1961 and the NHS Acts

•

Consider future charitable campaigns including the nature of events and objectives

•

To ensure that donations and investment income or losses are attributed to individual funds appropriately.

Accounts and similar requirements •

The Draft Trustee Annual report (TAR) is reviewed and approved by the committee ahead of review by external audit. The TAR includes the annual accounts. The Chair of the Committee will be given delegated authority to approve any further changes to be made to the Draft TAR outside of committee.

•

The Committee will adopt the TAR and the Chair and Chief Finance Officer will sign it off in line with the requirements of the Charities Commission and the laws governing charitable funds.

•

An on-line submission is made of the Annual Return (paper copies of the return are no longer available). The return is completed by the Head of Financial accounts and reviewed by the CFO prior to submission to the Charities commission. The deadline for the return is 10 months after the financial period end date and in the case of this charity this will be the 31st January.

•

The Trustee Annual Report will be the formal report to the Trustee (the Trust) describing the status of the charity.

Income generation •

Other functions •

To consider generation of funds to increase income.

To consider matters requested by the Trust Board.

Chapter Eleven Executive Committee EXECUTIVE COMMITTEE Executive Committee and Executive Committee for Quality and Risk

Policy Executive

    

Committee

Executive Operations Committee for Quality & Risk - -

Current Divisional Issues Divisional Development Plans

 Divisional Governance Reports ? Review of Corporate Risks ? ? Regulatory Compliance Patient Experience ?Ongoing CQC compliance

Health and Safety

? NHSLA/CNST

Strategic priorities Operational Issues

Sub committees

? ? ?

    

Patient Safety Committee Clinical Effectiveness Committee Access and Responsiveness Committee Patient Experience Committee Workforce Committee

10.1 Executive Committee: summary purpose and authority 10.1.1 The Executive Committee supports the Chief Executive and its members (including the other Executive Directors) to deliver the Trust’s corporate objectives through implementing a sound system of internal control and driving forward an agenda to deliver them. 10.1.2 The Executive Committee shall split its agenda to manage both operational and strategic elements of the Trusts delivery of services through rotating its agenda and focussing on quality of Trust services and key risks to quality and long term strategy. 10.1.3 The Executive Committee shall establish standing agenda items which link to the strategic objectives as outlined in the Board Assurance Framework and dashboard outcomes. Additional agenda items shall be included each week as appropriate. 10.1.4 Executive directors shall be engaged as members of both the Safety and Quality Committee and the Finance and Workforce Committee as set out in their respective terms of reference. They shall also be invited to attend meetings of the Audit and Assurance Committee.

Surrey and Sussex Healthcare Rules of Procedure

Executive Committee & Executive Committee for Quality & Risk Terms of Reference

Membership and attendance

1.1

The members of the Executive Committee shall be: • • • • • • • • • • • • •

Chief Executive and Accountable Officer Chief Finance Officer & Deputy Chief Executive Medical Director Chief Nurse Chief Operating Officer Director of People and OD Director of Information and Facilities Director of Corporate Affairs Director of Strategy Director of Service Development Clinical Chiefs of Service (4) Chief of Education Chief Clinical Informatics Officer

In Attendance: • Head of Communications (Executive Committee) • Associate Directors of Operations, Divisional Chief Nurses and Deputy Chief Nurse (ECQR) • Other clinicians and managers at the request of the committee • The Virtual Team (ECQR) 1.2

The Chairman of the Executive Committee shall be the Chief Executive. The Chairman of the committee reserves the right to delegate chairing of the meeting to any standing member with appropriate notice.

1.3

In the absence of the appointed Chair, one of the other Executive Directors shall chair the meeting, normally the Deputy Chief Executive Officer.

1.4

If an Executive Committee member is unable to attend a meeting, they shall send their apologies in advance to the Secretary and, if they consider it necessary, arrange for no more than one deputy to attend in their absence.

1.5

Members of the Executive Committee are expected to attend at least two-thirds of the number of meetings in any given financial year. An annual attendance record shall be prepared by the Secretary and any issues concerning poor attendance of an Executive Committee member shall be considered by the Chief Executive and acted on as appropriate.

Secretary of the Executive Committee

2.1

The Director of Corporate Affairs will ensure that an agenda and action notes will be taken and circulated at least two days in advance of the meeting.

2.2

The Corporate Affairs team will ensure that an agenda and action notes will be taken and circulated at least two days in advance of the meeting in respect to all Quality, Risk and Clinical Care Committees.

Quorum

3.1

The quorum necessary for the transaction of business shall be one third of the membership of the Executive Committee.

3.2

A duly convened meeting of the Executive Committee at which a quorum is present shall be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the Executive Committee.

3.3

Where an Executive Committee meeting: (i)

is not quorate under paragraph 3.1 within one half hour from the time appointed for the meeting; or

(ii)

becomes inquorate during the course of the meeting,

The Executive Committee members present may determine to adjourn the meeting to such time, place and date as may be determined by the members present. 4.

Meetings

4.1

The Executive Committee shall meet weekly and at such other times as the Chief Executive shall require.

4.2

The Executive Committee for Quality and Risk shall meet on the 2nd and 4th Wednesdays of each month.

Notice of meetings

5.1

Meetings of the Executive Committee shall be called at the request of the Chief Executive.

5.2

Unless otherwise agreed, notice of each meeting confirming the venue, time and date together with an agenda of items to be discussed, shall be forwarded to each member of the Executive Committee no later than two days before the date of the meeting. Supporting papers shall be sent to Executive Committee members and to other attendees, as appropriate, at the same time.

Decisions of the Executive Committee

6.1

Decisions of the Executive Committee shall normally be made by agreement rather than by formal vote. Failing such agreement, decisions shall be reached by means of a vote when:

Surrey and Sussex Healthcare Rules of Procedure

(i)

(ii) (iii)

the Chairman presiding at the meeting feels that there is a body of opinion among members of the Executive Committee at the meeting who disagree with a proposal or have expressed reservations about it; or when a member of the Executive Committee who is present requests a vote to be taken; or any other circumstances in which the Chairman presiding at the meeting considers that a vote shall be taken.

6.2

Where a decision of the Executive Committee requires to be voted upon it shall be determined by a majority of the votes of the members of the Executive Committee present and voting on the question. The Chairman presiding at the meeting shall declare whether or not a resolution has been carried or otherwise.

6.3

In the case of equality of votes, the Chief Executive, or, in his absence, the member of the Executive Committee presiding shall have a second casting vote.

6.4

The minutes of the meeting shall record only the numerical results of a vote, showing the numbers for and against the proposal and noting any abstentions. The minutes shall be conclusive evidence of the outcome. Votes shall not normally be attributed to any individual member of the Executive Committee, but any member may require that their particular vote be recorded provided that he asks the Chairman presiding immediately after the item is concluded.

6.5

The Executive Committee may agree to defer a decision on an agenda item so that it can be provided with additional information or for any other reason. The decision to defer, together with the reasons for doing so, shall be recorded in the minutes of the meeting together with a proposed time for returning the matter to the Executive Committee for its consideration.

Minutes of meetings

7.1

The Secretary of the meeting shall record the minutes of every meeting.

7.2

The Secretary shall submit the draft minutes to the Executive Committee in advance of its next meeting for agreement, confirmation or otherwise.

7.3

The record of the minutes shall include:

(i)

the names of: (a)

every member of the Executive Committee present at the meeting;

(b)

any other person present; and

(c)

any apologies tendered by an absent member of the Executive Committee;

the withdrawal from a meeting of any member on account of a conflict of interest; and

any declaration of interest.

7.4

Minutes of any meetings of the Executive Committee shall record key points of discussion. Where personnel, finance or other restricted matters are discussed, the minutes shall describe the substance of the discussion in general terms.

7.5

The minutes shall be circulated to such staff as the Chief Executive and the Secretary consider appropriate.

7.6

An action log will be maintained to demonstrate completion of actions.

Duties

The Executive Committee shall:

deliver the Trust’s Safety and Quality Strategy, national outcomes framework and local Key Performance Indicators;

at least annually, review and refresh the hospital’s ambition and aims for agreement by the Board of Directors;

review performance against the Trust’s priorities;

at least annually, translate the hospital’s ambition and aims into an annual Priorities document and related plans;

agree with Clinical Divisions and Corporate Directorates annual plans and how these interrelate;

understand and interpret the wider local and national context for the development and growth of the Hospital through a consistent narrative for success and growth;

review and, if appropriate, approve recommendations on new schemes that demonstrably fit with the Hospital’s aims and resources; and

identify and mitigate strategic risk, escalating risks over a defined threshold to the Board of Directors for their consideration and mitigation as it considers appropriate;

review arrangements and agree action to address variations from compliance with the regulatory and statutory regime, including contracts with commissioners; oversee sound systems of internal control;

10. 11.

oversee the following accountable executive sub committees through a defined programme of periodic and exception reports, which shall be at least monthly:

Surrey and Sussex Healthcare Rules of Procedure



Patient Safety Committee



Clinical Effectiveness Committee



Access and Responsiveness Committee



Patient Experience Committee



Workforce Committee

12.

agree which issues shall be prioritised for communication to staff, patients and the public. Each member of the Executive Committee is responsible for timely and effective briefing of all staff in their area of responsibility.

13.

consider and, if appropriate, approve the Trust’s Policy for the Development and Management of Trust Policies;

14.

approve policies that require its approval in accordance with the Trust’s Policy for the Development and Management of Trust Policies, ensuring that they are sufficient for compliance with the regulatory and statutory requirements in force from time to time;

15.

oversee the development of reliable, relevant, accessible and timely information that enables robust, evidence-based decision making at all levels of the Trust;

Conflicts of interest

Executive Committee members shall comply with the SASH Code of Conduct. 10.

Reporting responsibilities

The Chief Executive shall determine and communicate to the Chairman of the Board of Directors how the business of the Executive Committee shall be reported to the Board of Directors and/or its Committees, which, as a minimum, shall include periodic reports on the delivery of an agreed set of corporate objectives set out in the Trust’s business plan from time to time. In the case of risk management, this shall be at least quarterly.

11.

Review

The Executive Committee shall, at least once a year, review its own performance, membership and terms of reference to ensure it is operating at maximum effectiveness.

12.

Authority

12.1

The Executive Committee has the authority to deal with the matters set out in paragraph 8 above.

12.2

The Executive Committee may seek any information it requires from any employee of the Trust in order to perform its duties.

12.3

In connection with its duties, the Executive Committee is authorised by the Board of Directors, at the Trust’s expense:

12.4

(i)

to obtain any outside legal or other professional advice; and

(ii)

within any budgetary restraints imposed by the Board of Directors, to appoint external professional advisors, and to commission or purchase any relevant reports, surveys or information which it deems necessary to help fulfil its duties.

The Executive Team will have authority to act in accordance with the Trusts Standing Orders, Standing Financial Instructions and Scheme of Delegation and Reservation of Powers. Specifically the committee has authority to: (i)

Approve revenue business cases with an annual value up to £1.0m (expenditure, so not net of income);

(ii)

Approve revenue budgets of any value but within the annual I&E (surplus or deficit) control total agreed by the Board and can approve a draft budget for submission to the Board to confirm the annual control total;

(iii)

Approve capital business cases with an annual value up to £1.0m;

(iv)

Approve vacancies, the appointment of consultants (medical staff) and any other HR related actions not requiring specific reference to the Board.

Surrey and Sussex Healthcare Rules of Procedure

Chapter Twelve Risk Management Responsibilities 11.1

Introduction –Accountability and Responsibilities for Managing Risk

Figure 1 sets out the framework of accountability for managing risk across SASH, which is operationalised within the overall context of ‘quality and risk management’ and which is operationally led by the Chief Executive Officer (CEO) and governed by the Board of Directors (the board). There are seven levels of accountability:

SASH Corporate Governance Structure / Accountability Framework f

1 Audit & Assurance

Board of Directors

Safety & Quality

Finance and Workforce

Nomination & Remuneration

Council of Governors

Charitable Funds

Board committees

Corporate governance Management

Accountability level CEO

Management Committees / Groups

Executive Committee and ECQR

INFORMATION

Corporate Directorates

Clinical Divisions

Specialties

POLICIES

5 Executive Sub Committees: Safety, Effectiveness, Responsiveness, Experience and Workforce

Staff

Figure 1 – SaSH accountability framework for managing risk

11.2

Board of Directors – Level 1

The Board of Directors is responsible for governing the management of risk within SASH. The Board exercises oversight of risk ensuring that through holding management to account for quality and risk management matters, Key Performance Indicators set out in section 11 of this policy are being met. In addition, the Board of Directors annually reviews and signs off the commitment to Health and Safety Statement of Intent.

11.3

CEO and Executive Committee (Quality and Risk) – Level 2

As ‘Accountable Officer’ the CEO is accountable to Parliament as well as to the Board of Directors. The CEO is responsible for maintaining a sound system of internal control, which includes effective arrangements for risk management. Each year, the CEO has to sign, on behalf of the Trust Board, a Statement on Internal Control that provides an assurance that risk management, control and review processes are in place and their effectiveness has been reviewed. The CEO is supported by the Executive Committee, which meets to review quality and risk matters monthly. The purpose of the Executive Committee (EC) is to ensure that the organization is safely and effectively managed on a day to day basis. The EC sets appropriate frameworks and policies and procedures to support delivery of the organisational objectives, including risk management. The EC is the most senior body concerned with the day to day management of risk across the trust. The EC is responsible for ratifying the risk management policy and related policies; for allocating resources at corporate management level to ensure effective management of risk; for dealing with conflicts; for holding directorates to account for monitoring the management of risk across the Trust; and for providing assurances relating to risk management performance to the trust board. In addition to the CEO’s ultimate accountability for managing risk across the trust, all other individual executive directors have responsibility for managing risks within their own span of responsibility. 11.4

Governing Risk

11.4.1 The role of the board According to the FTSE Company 2, “The role of boards is to govern, not to manage. It is about setting overall direction, establishing boundaries and controls, recruiting and motivating talented executives and overseeing their operation of the business.” Figure 2 sets out how the management of risk is governed at SASH under the auspices of the board of directors and the board’s audit and assurance committee. The Board monitors and reviews the trust risk register taking assurance as to the organisation’s management of risk. The Audit and Assurance Committee is responsible for oversight of the entire system of internal control within SASH and, as part of this responsibility, will provide independent assurance to the board on the effectiveness of the organisation’s system for risk management.

FTSE Company. Rewarding Virtue. www.ftse.com/Indices/FTSE4Good_Index_Series/Downloads/rewardingvirtue.pdf

Surrey and Sussex Healthcare Rules of Procedure

AGS

Safety & Quality Committee

TRUST RISK REGISTER

Figure 2â&#x20AC;&#x201C; The trust risk register and the board

11.5

The Board Assurance Framework (BAF)

The Board Assurance Framework (BAF) describes the principal risks that relate to the organisationâ&#x20AC;&#x2122;s strategic objectives and 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 BAF provides the Board with information on managing principal risks that provides assurances on the management of risk in relation to key organisational objectives. Wider consideration of the Trust risk register, through suitable reporting on significant risks to the Board by the executive directors, provides the board with more comprehensive assurances on management of the totality of risk facing SASH. 11.6

The Annual Governance Statement (AGS)

A further feature of Figure 2 is identification of the requirement on the CEO to sign off, on behalf of the Board, an Annual Governance Statement (AGS). This statement is underpinned by the risk management process and, in particular, the trust risk register and BAF.

Appendix 1 SASH Code of Conduct 1.

SASH aims to be an organisation where all patients and staff, whatever their background, are valued and have fair and equitable treatment. The conduct of Trust leaders plays a major part in leading by example and modeling professionalism for patients, staff and wider stakeholder communities. This Code of Conduct (“Code”) sets out the required standards.

This Code relates to the conduct of the Chairman, Chief Executive, members of the Board of Directors, Committee Members, Executive Committee members and other SASH leaders. It is intended that those to whom this Code applies shall use their best endeavors to comply with it, act in good faith and in the best interests of SASH at all times.

Members of the Board of Directors, Committee members and Executive Committee members agree to be subject to this Code of Conduct. Any member of the Board of Directors who significantly or persistently fails to adhere to these rules may be judged as failing to carry out the duties of their office. Any actions arising from this shall be a matter for consideration by the Chairman and/or Chief Executive, who shall decide on any appropriate action that should be taken.

The highest standards of propriety, involving integrity, impartiality and objectivity shall be maintained in relation to the stewardship of public funds and the management of SASH. Any conflict between personal interests and the discharge of public duties shall be avoided. Where this arises it shall be disclosed to the Chairman or Chief Executive so that decisions can be made in accordance with this Code. Individuals to whom this Code applies shall not seek to use their position to inappropriately or improperly gain material benefits for themselves, their families or their friends.

The Board of Directors is responsible for ensuring that its members personally, and SASH corporately, observe the seven principles of public life set out by the Committee on Standards in Public Life (“the Nolan Principles”): selflessness: holders of public office should take decisions solely in terms of the public interest. They should not do so in order to gain financial or other material benefits for themselves, their family or other friends; integrity: holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might influence them in the performance of their official duties; objectivity: in carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit; accountability: holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office;

Surrey and Sussex Healthcare Rules of Procedure

openness: holders of public office should be as open as possible about all the decisions and actions that they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands; honesty: holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest; and leadership: holders of public office should promote and support these principles by leadership and example. 6.

The Board of Directors shall comply with the SASH values: Dignity & Respect: we value each person as an individual and will challenge disrespectful and inappropriate behaviour One Team: we work together and have a ‘can do’ approach to all that we do recognising that we all add value with equal worth Compassion: we respond with humanity and kindness and search for things we can do, however small; we do not wait to be asked, because we care Safety & Quality: we take responsibility for our actions, decisions and behaviours in delivering safe, high quality care.

The Board of Directors shall take collective responsibility for the decisions made by it.

Equality and Diversity

8.1

The Trust employs and serves people from differing backgrounds and cultures and with different characteristics. This diversity is a source of richness and potential that benefits us all.

8.2

Treating everyone the same does not necessarily mean we are treating them fairly. It is our mission to provide fair and inclusive services and workplaces. We recognise our responsibility to observe equality legislation and the Trust’s equality policies. The Public Sector Equality Duty which came into force on the 6th April 2011 is a duty on public bodies to embed equality considerations into to their day to work so that they tackle discrimination and inequality and contribute to making society fairer. The duty encourages public bodies to engage with the diverse communities affected by their activities so that policies and services are appropriate and accessible to meet different people’s needs. This duty therefore requires that individually and collectively we:

(i)

seek to understand the perspectives put forward by our patients and staff and foster good relations between people of different groups

(ii)

treat our patients, colleagues, employees and potential employees with respect and dignity;

(iii)

support and implement measures advance equality of opportunity between people of different groups

(iv)

take action to eliminate harassment or bullying of our patients, colleagues and employees; and

(v)

take action to eliminate any form of unlawful discrimination or victimisation.

8.3

SASH recognises that tension and challenge can be part of operational culture but also that good manners and respect are necessary at all times.

Media and Public Relations A member of the Board of Directors other than the Chairman and Chief Executive shall, as far as possible, obtain the prior approval of the Chairman and Chief Executive (on the advice of the Director of Corporate Affairs), before responding to media enquiries with respect to SASH. Special care shall be taken about any invitation to speak publicly, including speaking to journalists. Care shall also be taken in the publication of any articles apart from those written in a personal professional capacity. In any such instance, the Chief Executive shall be informed in good time before such an article is submitted, or, in his absence, the Director of Communications, as appropriate, and in all cases views shall not be expressed that are at variance from agreed SASH policy. Neither shall any publication or public statement bring the Trust into disrepute. The Chairman, Board members, Committee members and Executive Committee members are not, however, restricted from access to the media in their personal non-SASH capacity, or in pursuit of a professional interest, for example, as experts. In the event of any uncertainty, members of the Board of Directors other than the Chairman and Chief Executive shall approach the Director of Corporate Affairs for advice.

10.

Conflicts of interest

10.1

Suspicion that a decision might be influenced in the hope or expectation of contractual gain with a particular firm or organisation shall be avoided. Accordingly, during their term of office no-one to whom this code applies shall seek or accept without consent any consultancy contracts, directorships or other form of employment or engagement in a healthcare sector body, without the consent of the Trust. Those to whom this Code applies are required to maximise value for money through ensuring that SASH operates in the most efficient and economical way, within available resources, and with independent validation of performance achieved wherever possible.

10.2

If a member of the Board of Directors, a Committee member or Executive Committee member knowingly has any interest or duty which is material and relevant or the possibility of such an interest or duty, whether direct or indirect and whether pecuniary or not, that, in the opinion of a fair-minded and informed observer would suggest a real possibility of bias in any matter that it brought up for consideration at a meeting of the Board or any committee of the Board or the Executive Committee, he shall disclose the nature of the interest or duty to the meeting. The declaration of interest or duty may be made at the meeting at the start of the discussion of the item to which it relates or in advance in writing to the Director of Corporate Affairs & Company Secretary. If an interest or duty has been

Surrey and Sussex Healthcare Rules of Procedure

declared in advance of the meeting, this shall be made known by the Chairman presiding at the meeting prior to the discussion of the relevant agenda item. In the event of the person not appreciating at the beginning of the discussion that an interest or duty exists, he shall declare such an interest as they soon as he becomes aware of it. 10.3

If a member of the Board of Directors or a Committee member or a Executive Committee member has acted in accordance with the provisions of paragraph 10.2 above and has fully explained the nature of their interest or duty, the members of the Board or committee or Executive Committee present shall decide whether and to what extent that person shall participate in the discussion and determination of the issue and this shall be recorded in the minutes and the extent to which the person concerned had access to any written papers on the matter. If it is decided that he should leave the meeting, the Chairman may first allow them to make a statement on the item under discussion.

10.4

Where the Chairman presiding at the meeting has a relevant interest then he shall advise the Board or Committee or Executive Committee accordingly, and with their agreement, and subject to the extent decided, participate in the discussion and the determination of the issue. This shall be recorded in the minutes and the extent to which he had access to any written papers on the matter. If it is decided that the Chairman presiding should leave the meeting because of a conflict of interest, another member or Committee member or Executive Committee member shall be asked to chair the discussion of the relevant agenda item.

10.5

SASH employees who are not members of the Board or a committee or the Executive Committee, but who are in attendance at a meeting of the Board or a committee or the Executive Committee, shall declare interests in accordance with the same procedures as for those who are members of the Board or Committee or Executive Committee. Where the Chairman presiding at a meeting rules that a potential conflict of interest exists, any SASH employee so concerned shall take no part in the discussion of the matter and may be asked to leave the meeting by the Chairman.

10.6

A member of the Board, Committee, Executive Committee or SASH employee shall be subject to the procedural arrangements for dealing with conflicts of interest as set out in paragraphs 10.7 to 10.15 below.

10.7

In the interests of transparency and accountability, members of the Board, Committee members or employees shall register those interests that might conflict with their duties.

10.8

The Director of Corporate Affairs & Company Secretary shall keep this Register. Members of the Board, Committee members, Executive Committee members or employees shall notify her any changes and are responsible for keeping their entry in the Register up to date. The Register shall be made publicly available on SASHâ&#x20AC;&#x2122;s website.

10.9

Every year, the Director of Corporate Affairs shall confirm with members of the Board, Committee members, Executive Committee members and employees that their interests have been registered. He may from time to time ask them to confirm

that their registered interests are up-to-date and that they have complied with these procedural arrangements. 10.10 It shall be confirmed SASHâ&#x20AC;&#x2122;s annual report that it has complied with these procedural arrangements. 10.11 Members of the Board, Committee members, Executive Committee members and employees to whom this Code applies shall register the following interests: (i)

remunerated employment, office or profession other than with SASH;

(ii)

other regular sources of remuneration;

(iii)

directorships, whether remunerated or not; and

(iv)

membership of public bodies (hospital trusts, governing bodies of universities, colleges and schools, and local authorities), trusteeships (of museums, galleries and similar bodies) and acting as an office holder or trustee for pressure groups, trade unions and voluntary or not-for-profit organisations.

10.12 From time to time a member of the Board, Committee member, Executive Committee member or employee may have or become aware of interests which do not have to be registered but which might, nonetheless, conflict with their SASH duties. As well as keeping their entry on the register up to date, they shall disclose to the Corporate Affairs Manager such interests as soon as they become aware that they may cause a conflict, for example, on receipt of an agenda or Board meeting papers. Such interests shall be disclosed whether or not they are entered on the Register. 10.13 The minutes of any SASH Board, Committee or Executive Committee meeting shall note the disclosure of any such conflicts and subsequent withdrawals from discussions. In addition, the Corporate Affairs Manager shall keep a permanent record of all such disclosures of interests made by any member of the Board, Committee member, Executive Committee member or employee. In considering whether to disclose such an interest, a member of the Board, Committee member, Executive Committee member or employee shall ask whether, in the opinion of a fair-minded and informed observer, the interest would suggest a real possibility of conflict on that personâ&#x20AC;&#x2122;s part. The following questions shall act as a general guide: 1. Do they have, or recently had (i.e. within the past two years) any material business or other pecuniary relationships with a stakeholder? 2. Do they have, or recently had any other relationships with another party, the existence of which might suggest a real possibility of bias on their part? 3. Have they taken a public position that might be seen as compromising their ability to deal objectively with a matter that is relevant to SASH?

Surrey and Sussex Healthcare Rules of Procedure

4. Whether, in the opinion of a fair-minded and informed observer, the interests of close family members would suggest a real possibility of bias on the part of the member of the Board, Committee member or employee? 10.14 In the event that a member of the Board, Committee member, Executive Committee member or employee receives a written paper on a matter on which they have a conflict of interest, they shall immediately return the paper to the Director of Corporate Affairs with an indication of the extent to which the paper has been read. 10.15 If a member of the Board, Committee member, Executive Committee member or employee becomes aware of a conflict during the course of any discussion, their interest shall be disclosed immediately and they shall, if appropriate, withdraw from the discussion and any decision relating the matter. However, in some circumstances they may, if the Board, Committee or Executive Committee permits, participate in such discussions as provided for elsewhere in this Code of Conduct. 11.

Gifts and Hospitality

11.1

All gifts or hospitality received or given to those to whom this code applies shall be recorded in the register of gifts and hospitality maintained by the Corporate Affairs Team, who, together with the Director of Corporate Affairs, shall keep a regular check on the register and advise the Chairman and Chief Executive accordingly in order to avoid any suggestion of actual or perceived bias towards any particular stakeholder. Personal gifts with a value greater than ÂŁ25 shall be declared. Non health related or non-educational general hospitality should be declined, all other hospitality shall be declared.

11.2

In deciding whether to accept a gift or offer of hospitality, including at entertainment or sporting events, consideration shall be given as to whether acceptance can stand up to public scrutiny. The decision to accept hospitality or a gift is a matter of judgement and personal integrity, and the advice of the Chief Executive or Chief Financial Officer may be sought. The following broad guidelines may be of assistance in assessing the relative merits of accepting an invitation:

11.3

event-based hospitality that presents networking opportunities with SASH stakeholders, and which might therefore inform or promote the work of, is generally acceptable;

work-related hospitality from a single stakeholder is acceptable where it can clearly be seen to be of value to SASHâ&#x20AC;&#x2122;s work and where there is no immediate commercial advantage to the party making the offer;

hospitality that benefits the recipient personally shall be avoided if it is difficult to justify as being of benefit to SASH, or if there is a risk of perceived bias or malign comment. Care shall be taken that no extravagance is involved with working lunches and other social occasions.

All invitations to attend industry or stakeholder events shall be referred first to the Chief Executive, or in his absence, the Director of Corporate Affairs for advice. Care shall be taken to ensure that there is appropriate representation at events, and that those attending are properly briefed in advance.

11.4

The Declaration of Educational Sponsorship and Hospitality guide / Registration form can be found on the trust’s intranet website under Policies and Procedures section.

12.

Board and Committee Etiquette

12.1

Showing our mutual trust, respect and honesty

a. We will respect each other’s individual and corporate skills, knowledge and responsibilities. b. We will treat all ideas and contributions with respect. c. We will be sensitive to colleagues’ needs for support when challenging or being challenged. d. We will make all contributions to discussions clear and to the point. e. We will demonstrate group support and loyalty to the Trust in all our dealings.

12.2

Continuing our commitment to attending and being well prepared:

a. Board papers will set a standard for providing succinct, intelligent reports and will be approved by the relevant Executive Director prior to inclusion in Board and Committee agendas. b. Board papers will be presented using the agreed Board template and the covering paper duly completed. c. Board and committee papers will be completed and posted in line with the agreed Board publication schedule. d. Minutes will be circulated and comments will be received by Executive Directors in line with the Board and Committee timetable before inclusion in the Board agenda. e. We will avoid using acronyms in Board papers (if they are used they will be spelt out in full on the first occasion used in a paper and in the covering report). f. We will commit to reading the papers and clarifying significant points of uncertainty with the g. author/Executive Director before the meeting. h. Papers which missed the agreed deadline will be deferred until the next meeting unless exceptional circumstances apply. i.

No papers will be tabled on the day of the meeting unless agreed in advance with the Chairman; however this will be on an exceptional basis.

We will present papers succinctly at the Board giving context and key points only.

k. Where other members of staff are giving presentations, the responsible Executive Director will brief them appropriately and on the need for brevity.

Surrey and Sussex Healthcare Rules of Procedure

Staff attending a Board or committee meeting will be informed of the etiquette and behaviours expected by their Executive Director.

m. We will give priority to attending Board development events and expect to attend at least 80% of them.

Encouraging Board debate:

a. We are a unitary Board and we all have the right to challenge each other. b. We will challenge rigorously but with respect. Our questioning will not be attacking, crushing or dismissive. All membersâ&#x20AC;&#x2122; views will be accorded equal value. c. We will all contribute to Board and Committee discussions to ensure the best decisions can be taken. d. Where possible, we will alert authors of papers of particularly challenging questions or questions where more information may be needed. e. It is acceptable for an Executive Director to undertake to find the answer to a question after the Board meeting and communicate the answer to the full Board by email or as a matter arising at the next meeting. f.

We will take responsibility for the effect that our questioning has on the recipient.

g. We will avoid giving offence by the style of our questioning and will apologise if we have done so. h. We will strive not to take offence at, or take personally, genuine challenge by other members of the Board. i.

We will make the best use of Board time by making our contributions concise and only raising substantive issues.

l. We will make all contributions through the Chairman, and not interrupt one another. m. The Chairman will actively encourage contributions from all members during the meeting. n. We will ensure that all challenge is fairly reported in the minutes. 0. Where senior managers or clinicians have played a significant role in the preparation of a Board paper, they should be invited by the Executive Director responsible to attend the relevant part of the Board Meeting.

4.0

Maintaining confidentiality and corporate responsibility: a. We will adhere to the NHS Code of Conduct and Accountability. b. We will treat all issues on the private agenda as confidential unless agreed otherwise by the Board. c. We will all accept the principle of corporate responsibility.

10 0

d. We will seek agreement with the Chairman and/or Chief Executive before making contact with the press on the activities of the Trust.

5.0

6.0

Attendance: •

We will plan to arrive at least 10 minutes before the scheduled start of the Board and take the opportunity to talk informally to colleagues and visitors. If we are unavoidably late, we will phone to let the Chairman/Chief Executive and let them know of our expected time of arrival.

•

We will attend all Board and committee meetings unless there are exceptional reasons why we cannot (we expect to attend at least 80% of the meetings)

•

We will turn off mobile devices / phones (or put on silent when a member is on call).

•

We will only utilise laptops and mobile devices for access to Board papers and supplementary information relevant to the Board meeting.

•

We recognise our ambassadorial role at Board and Committee meetings, the Annual General Meeting and at other events.

Reviewing our performance: At the end of each Board meeting we will review: -

Whether we used our time and resources well. Whether others should have been invited for any item. What went well or what could be improved.

The Board will participate in a review of Board skills and evaluate board performance at least once per year. If any member of the Board is unhappy with any aspect of Board conduct, he or she should approach the Chairman in the first instance or the Senior Independent Director. Responsibility for ensuring Board Etiquette is observed lies with the Chairman.

10 1

Surrey and Sussex Healthcare Rules of Procedure

Appendix 2 Best practice guidance The Healthy NHS Board: Principles for Good Governance, 2013, & 2010 www.nhsleadership.org.uk/ Monitor â&#x20AC;&#x201C; Independent Regulator of NHS Foundation Trusts The NHS Foundation Trust Code of Governance, March 2013 Compliance Framework 2013 March 2010 and July 2010 amendments Managing Operating Cash in NHS Foundation Trusts, December 2012 Best Practice in Treasury Management for NHS Foundation Trusts, June 2008 Risk Evaluation for Investment Decisions by NHS Foundation Trusts, February 2006 www.monitor-nhsft.gov.uk/ Audit Commission Corporate Governance Framework, July 2009 www.auditcommission.gov.uk/SiteCollectionDocuments/MethodologyAndTools/Guidance/CorporateGove rnanceInspectionJan09update.pdf The Commissioner for Public Appointments Code of Practice for Ministerial Appointments to Public Bodies, August 2009 www.publicappointmentscommissioner.org/webapp/plugins/spaw2/uploads/files/Code%20of% 20Practice%202009.pdf Financial Reporting Council UK Corporate Governance Code, June 2010 www.frc.org.uk/documents/pagemanager/Corporate_Governance/UK%20Corp%20Gov%20C ode%20June%202010.pdf Foundation Trust Network The Foundations of Good Governance, September 2010 www.nhsconfed.org/Publications/Documents/foundations_good_governance140910.pdf KPMG â&#x20AC;&#x201C; Audit Committee Institute (ACI) A Listing of Corporate Governance Resources, November 2007 www.kpmg.co.uk/aci/

10 2

Appendix 3 Principal NHS regulators and other bodies Principal NHS regulators •

NHS Improvement (Monitor & the Trust Development Authority)

• Care Quality Commission Third parties with statutory powers (with specific remit to healthcare) •

General Chiropractic Council

•

General Dental Council

•

General Medical Council

•

General Optical Council

•

General Osteopathic Council

•

Health Professions Council

•

Nursing and Midwifery Council

•

Royal Pharmaceutical Society of Great Britain.

Third parties with statutory powers (with general remit) •

Charity Commission (with respect to charitable funds associated with the NHS)

•

Equality and Human Rights Commission

•

Environment Agency

•

Fire Authorities

•

Health and Safety Executive

•

Information Commissioner’s Office

•

National Audit Office

• Public Accounts Committee Third parties with statutory role but no enforcement powers (with specific remit to healthcare) •

NHS Blood and Transplant Authority

•

Parliamentary and Health Service Ombudsman

•

Medicines and Healthcare products Regulatory Agency

•

National Institute for Health and Clinical Excellence (NICE)

• OFSTED Third parties with no statutory role but a legitimate interest (with specific remit to healthcare) •

Clinical Pathology Accreditation Ltd

•

NHS Business Services Authority

•

NHS Litigation Authority

10 3

Surrey and Sussex Healthcare Rules of Procedure

Appendix 4 Executive Team Responsibilities Executive Directors Role

Key Responsibilities •

Chief Finance Officer

• • • •

• •

Chief Operating Officer

• • Medical Director

• • • • • • •

Chief Nurse

• • • • •

10 4

Support the creation/maintenance of an NHS Trust whose services are appropriately resourced, provide good value for money and are financially sustainable in the long term. Provide financial governance and assurance. Manage the Trust’s cash and provide effective stewardship of the Trust’s resources. Provide confidence to external stakeholders about the Trust and its financial management that enhances the Trust’s reputation. Corporate responsibilities as an executive director and the delivery of organisational success through personal leadership, effective working with the executive team, Board, and, in particular, the Chief Executive Officer. Responsible for operational performance within the Trust Responsible for the planning and delivery of capacity to meet demand Emergency and Business Continuity Planning Accountable for non-nursing budgets Responsible for ensuring good clinical governance (with the Chief Nurse) and high standards of medical care Developing and implementing modern and effective clinical leadership Clinical ambassador for the Trust Ensuring clinicians have resources and structures to deliver high quality clinical care Ensure consultants job plans meet the needs of the Trust Leading the development of the Quality Account, & Clinical Strategy Ensuring that there are robust infection prevention and control systems in place to comply with the Health and Social Care Act / Hygiene Code. Professional and regulatory lead for nursing and midwifery, ensuring that the standards of practice support safe high quality care that ensures a positive patient experience. As the Director lead of Risk & Clinical Governance has responsibility for the programmes of clinical governance in the Trust. Supporting the maintenance of effective governance systems ensuring that the trust is appropriately governed. Delivery of organisational success through effective working with Board members and senior clinical colleagues Named board member for the safeguarding of children and vulnerable adults.

Role

Director of Information and Estates

Key Responsibilities • • • • •

Director of Corporate Affairs

•

Supporting the Chairman, Chief Executive and Board in managing corporate governance Leading the FT application process , co-ordinating the delivery of required outputs and assurances Leading the legal affairs, communications and Trust Headquarters functions Company Secretary

•

Employee Relations

•

Strategic management of Recruitment Services

•

Occupational Health

•

Learning and Development

•

Medical Staffing

•

Strategy development

•

Business planning

•

Transformation

•

Improvement

• •

Director of Human Resources

Director of Strategy

10 5

Leading the design and delivery of the Trust Health Informatics Strategy Ensuring Trust Estate and Facilities support the delivery of Safe, high-quality healthcare Leading the development and implementation of the Trust Estate Strategy Senior Information Risk Officer (SIRO) – all Trusts must have one of these at the Board Chief Knowledge Officer

Surrey and Sussex Healthcare Rules of Procedure

AUDIT & ASSURANCE COMMITTEE Meeting held on Tuesday 1st September 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: Alan McCarthy Paul Simpson Jamie Bewick Nick Atkinson Stuart Doyle Djarfer Erdogan John Kneller Nathaniel Johnston Colin Pink

MW PS JB DM SD DE JK NJ CP

Chief Executive Chief Finance Officer External Audit Internal Audit Local Counter Fraud Specialist Head of Financial Accounts Head of Workforce Relations (Section3.1) Head of Workforce Services (Section 3.1) Head of Corporate Governance

Action by 1

1.1

Welcome and Apologies for absence PB welcomed members to the meeting. Apologies for absence were received from Gillian Francis-Musanu.

1.2

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

1.3

Actions from previous meetings: The action tracker was reviewed and the committee noted that all actions had been closed prior to the meeting.

2.1

Review of BAF PS presented the latest revision of the BAF to the committee for review, prior to its monthly submission to the Executive Committee and Trust Board in September. The Board last reviewed and agreed the BAF in August. The Committee focussed on strategic issues that could be updated to reflect mitigations such as inclusion of details of the transitional care ward

Audit & Assurance Committee Minutes September 2015

An Associated University Hospital of Brighton and Sussex Medical School

Page 1 of 5

and plans for future IT developments. The Committee asked specifically that the strategic risk relating to the Trustâ&#x20AC;&#x2122;s foundation trust application be reviewed to reflect current status. Action CP to coordinate reviews of risks relating to operational pressures and foundation Trust journey. The Committee discussed the four main financial risks in detail noting the increase to risk score for the financial risk 4.3 which had been agreed by the Board. The Committee took assurance from PS comments on use of bank and agency and NA commentary on local benchmarking of issues and availability of temporary staff. The Committee took assurance from the detail of how safer staffing levels are being met by the Trust and subsequent impact on divisional budgets. PBi asked how confident management was on its ability to carry out historic due diligence when required. JB commented that the Trust accounts are in good shape which would both provide greater assurance and facilitate the due diligence review. PS agreed highlighting that plans are in place to carry out due diligence towards the end of the financial year if needed. The Committee accepted the board assurance framework.

2.2

Review of Significant Risk Register PS presented the latest revision of the SRR to the committee, ahead of its submission to the Board in September. The Committee considered in detail the risk relating to risk on financial overspend associated with agency, reflecting on earlier conversations noting the difficulties of reducing agency spend at a time where there is a significant gap in available substantive staff. PS told the Committee how the Trust was trialling new bank processes and monitoring impact on key performance indicators. The Committee discussed the balance between need to reduce agency spend whilst maintaining safer staffing ratios. The Committee accepted the significant risk register.

3.1

Internal Controls RD presented managementâ&#x20AC;&#x2122;s review of internal controls relating to the Trustâ&#x20AC;&#x2122;s workforce systems which had been discussed at the Finance and Workforce Committee. The risks had been rescored to better reflect current

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An Associated University Hospital of Brighton and Sussex Medical School

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position. The assessment included one red and five amber rated controls; temporary staffing (red), recruitment, training, achievement review, payroll and nurses and midwife revalidation. NJ highlighted specific systems particularly the development of metrics to monitor time to recruit, the recruitment planner and recruitment trackers used in PMO and strategic review of delivery of training. The Committee went on to note elements of triangulation between operational management, performance and the BAF. Management discussed implementation of a new suite of workforce KPIs including a recruitment planner and tracking system. The Committee accepted the overall assessment of workforce controls, it took assurance from the detail of planned mitigation and requested that an action plan was developed for the Finance and Workforce committee to review. RD stated that the FWC would be monitoring actions to strengthen controls, and would provide either a verbal update or a further paper at the May 2016 Committee. Action

The Committee accepted the report.

3.2

Final annual report (for information) CP introduced the report for information stating that it was with the printers for final layout and format changes. The Committee noted three minor factual amendments to terms of reference, attendance and typos. Action CP to communicate final amendments. The Committee noted the report.

4.1

Internal Audit Progress Report NA provided the regular update to the Committee on activity and audit completion. Noting that the Amber green opinion recorded for the recruitment element of the workforce strategy audit should have been updated and would be updated for later reports. The Committee discussed the recent Workforce Strategy audit which had focussed on recruitment, retention and managementâ&#x20AC;&#x2122;s actions to improve

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performance. AM and PS discussed the key performance indicators that are being monitored for recruitment. The Committee noted that the new metrics are being reviewed and refined to ensure they meet Trust needs by influencing desired outcomes. Internal Audits review of RTT data had highlighted no significant concerns and the Committee was assured by commentary on closure of open actions and improvement in compliance since previous audit. The Committee noted the internal audit action tracker and the actions that require completion. PBi thanked NA for the report and update.

4.2

External Audit Report JB indicated that there are no new specific issues to raise for discussion. The committee raised no questions for External Audit specifically.

4.3

LCFS Report SD provided the Counter Fraud update highlighting recent training publicity and policy work. The Committee noted recent investigation activity, sanctions and money that had been successfully recovered. PBi asked about the low reported response to fraud survey. SD stated that multiple avenues to increase responses had been adopted. PS reminded the committee that the fraud section of the annual national staff survey had provided strong assurances relating to financial fraud. The Committee discussed issues raised in radiology surrounding claim forms which had triggered a trust wide review. This had highlighted that controls could be strengthened and work was underway. The Committee thanked SD for the update.

5.1

AOB PBi asked for assurance that recent guidance on processes to ensure that

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An Associated University Hospital of Brighton and Sussex Medical School

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consultancy contracts in excess of ÂŁ50k are supported by a business case and that management is taking action to meet the new 3% agency target. PS and DE assured the committee that processes are in place to support both edicts and that there are no current consultancy contracts in excess of the threshold. No further business was discussed.

6.1

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

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An Associated University Hospital of Brighton and Sussex Medical School

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CHARITABLE FUNDS COMMITTEE 04 August 2015 2.00pm â&#x20AC;&#x201C; 3.30pm AD77

Attendees:

Pauline Lambert

In attendance:

Paul Biddle Paul Simpson Fiona Allsop Gillian Francis-Musanu Laura Warren Djafer Erdogan Janita Gardner

PL PB PS FA GFM LW DE JG

Chair of Charitable Funds / Non-Executive Director Non-Executive Director Chief Finance Officer Chief Nurse Director of Corporate Affairs Head of Communications Head of Financial Accounts Note taking

Apologies for absence PL welcomed members to the meeting. Apologies received from Ian Mackenzie, Alan Hall, Katrina Swanston and Helena Usman. PL advised members that Alan Hall will be taking over as Chairman of the Charitable Funds Committee (CFC) going forwards.

Minutes of last meetings The minutes of the last meeting held on 05 March 2015 were recorded as a true and accurate record.

Outstanding Issues from previous meetings Review following receipt of spending plans PS will review forecasts for Trust once plans received. Spending plans for charitable funds Expenditure plans had been received from 90% of fund holders and reviewed by PS/DE. It was noted that some unspent monies had been credited back into the general fund.

Action closed

PB questioned whether monies were spent from the General Fund for capital expenditure, which was confirmed by PS. Organ Donation Committee Acton : PL to discuss ideas and funding options with PS outside of the meeting, and bring back to the next CFC meeting.

Action 1

PL/PS

Expenditure Guidance To be discussed later on the agenda.

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

Page 1

Ward and Special Purpose Fundraising Legalities of pooling monies from various accounts into the general fund DE confirmed there were no significant issues to raise concern as the pooling was very limited and with fund holders consent following receipt of expenditure plans.. There is a need to raise our profile by spending out of the general fund. Action : LW to review how to make staff aware of existence of funds in their areas. Going forward, all subsequent fund raising takes place under the SASH Charity banner - to ensure a single identity. Action : A communication will be issued, directing staff to the intranet for information and guidelines.

Action 2

Action 3

LW/PS/DE

Action 4

It was also agreed the SaSH Charity would continue to focus on Elderly Care for 2015. FA/LW confirmed one story had been received to support this. Comfort blankets/mitts, which have been crafted by the local community, were now being widely used throughout the Trust. This has become a great attraction for the Charity and more stories need to be sought. Action : FA to gather more stories from her team. Finance Confirm balance in general fund of existing commitments going forward.

Action closed

Agree wording of directive and advise Divisions of their spending plan deadlines.

Action closed

Terms of Reference Amend CF expenditure guidance and appropriate Policy to be drafted for implementation and ToR. To be discussed later on the agenda. 4

Fund Raising Fund Raising Update LW confirmed that promotional activities had been arranged, including a staff quiz night and two of her team members had completed a sponsored run. The comfort blankets/mitts had received a good response, and this had been picked up by the local media and interviews conducted with the BBC. We continue to build on our partnership with Redhill Football Club. The club donated FA Cup tickets, which were sold in a raffle and raised ÂŁ700.

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

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To increase corporate awareness, Michael Wilson (MW) has met with Stewart Wingate, the CEO of Gatwick Airport, to explore how they may incorporate our charity within the airport. MW has also met with Lord Aster of Hever, who is a past patient of East Surrey Hospital. PB asked whether an option was for Hever Caste to be gifted to the charity to use for an event. LW acknowledged this could be explored as our relationship develops. PB asked whether we should designate a particular piece of equipment for which to raise funds. LW confirmed that this would need to be checked with fund holders and PS confirmed that large pieces of equipment were already identified within capital expenditure. The Committee reiterated that the charity was focusing on Care of the Elderly for 2015 and that new ideas would be put sought for 2016. Fund Raiser Recruitment Update LW/GFM confirmed that a successful candidate had been found in the last round of interviews, but unfortunately they had accepted an alternative offer. We will therefore be readvertising through NHS Jobs and the social media. KS is still assisting when she is able to. Governance Draft Action : This is to be followed up by PL and brought back to the next meeting. 5

Action 5

Action 6

ALL

Finance Management Accounts DE advised that there had been low activity and £654k still remained to be spent in the general fund. There is £21k outstanding commitments which had not gone through the management accounts. PS stated that, despite the momentum, income was not being raised as expected. More publicity was required to raise awareness of the charity, especially with local establishments. FA questioned whether we needed something more visible to promote this. PL reiterated the importance of employing a Fund Raiser. It was agreed that if we did not promote the charity we will run out funds. Action : Discuss at next meeting how to generate more funds. Fund Balances The General Fund balance is £107k.

Charitable Funds Committee – notes of 5 March 2015 meeting

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Special attention drawn to a £75k spend in the cardiac fund, which PS explained was for building new offices for cardiology and this was to be funded by the capital expenditure. However, the £75k will be transferred to SaSH revenue as it was confirmed that the income for reports from DVLA was Trust income and not donations. Action : PS/DE to resolve with cardiology.

Action 7

PS/DE

Action 8

Action 9

PS/DE

Action 10

PS/DE confirmed they were not aware of any other requests involving large amounts, but checks will be made into source of income of all funds. Action : DE to write to fund holders and confirm source of income for amounts in excess of £30k. Expenditure Plans DE verified these were within the purpose of the fund and that when requests for expenditure are received, they are fully scrutinised. All requests for expenditure in excess of £2k are authorised by PL/PS. PL queried an item on page 9 of the plan, which PS/DE agreed to check. Action : PS/DE to check. Annual Accounts and Report 2014-15 DE confirmed the accounts had been prepared and would be seen by an independent examiner in October, and brought to the CFC meeting in November for sign off. 6

Approved Funding Requests over £2,000 DE clarified the background to each of the items on the agenda.

Expenditure Guidance DE has amended the guidance to include training costs. Staff leaving within 1 year of their training will be asked to reimburse their training cost percentages according to the table within the guidance. This clause is already in place in the Finance Dept, but there is no policy within Divisions to cover these costs, only guidance. GFM/FA questioned whether this should be made formal across the Trust. PS envisaged this could prove problematic.

Terms of Reference CFC were happy with the document, but asked for the review date to be amended to 2016. Action : DE to amend review date.

Charitable Funds Committee – notes of 5 March 2015 meeting

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Trustee Role – Charity Commission Update July 2015 DE gave highlights of the Trustee Role, which was agreed by PL.

Work Plan 2015/16 Draft DE confirmed there was no change.

Savile Action Plan – Refresh FA had not received any queries from members. Only 2 lines within the report relate to charitable funds. FA confirmed that CFC already have policies in place that meet the necessary requirements. Page 17 – Managing Financial Donors Policy. We have yet to update our guidance to cover this. Action : DE/GFM to update expenditure guidance within 1 month.

Action 11

DE/GFM

Date of next meeting 5th November 2015 : 12 noon – 1.30pm in AD77 Dates of 2016 meeting to be advised.

Charitable Funds Committee – notes of 5 March 2015 meeting

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