Board papers September 2015 by Surrey and Sussex Healthcare NHS Trust

Surrey and Sussex Healthcare NHS Trust Board Papers

September 2015

Trust Board Meeting – IN PUBLIC Thursday 24th September 2015 - 11:00 to 13:30 AD77, Trust Headquarters, East Surrey Hospital, Canada Avenue, Redhill, RH1 5RH

AGENDA 1

11:00

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 27th August 2015 - For approval

A McCarthy A McCarthy

1.4

1.3_Minutes of Trust Board meeting held in

Action tracker A McCarthy 1.4_Public Board Action - Sept 2015.pd

1.5

Chairman’s Report For assurance

M Wilson Verbal G FrancisMusanu

1.6

Chief Executive’s Report For assurance

1.7

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

1.7_ BAF and SRR Report Cover Sheet -

1.7a_ BAF - Sept 2015.pdf

1.7b_SRR TB Sept 2015 Final.pdf

1.7.2 September 2015 BAF.pdf

11:30

SAFETY, QUALITY AND PATIENT EXPERIENCE 2.1

2.2

Consultants Revalidation Annual Report & Presentation For assurance & approval

A StaceyClaire

Chief Nurse & Medical Director’s Report For assurance

D Holden/ F Allsop D Holden

2.1_ Consultants Revalidation Annual R

2.2_ CN and MD Report - 24 Septemb

2.3

Quality Governance Assurance Framework Update For assurance

2.3_ QGAF Update cover sheet - 24.09.1

Paper

12:15

OPERATIONAL PERFORMANCE 3.1

12:55

3.2.1

Operational & Quality Key Performance Indicators

D Holden/ F Allsop

3.2.2

Workforce Key Performance Indicators

F Allsop

3.2.3

Finance Key Performance Indicators

P Simpson

Finance & Workforce Committee Update For assurance

R Durban

3.3

Audit & Assurance Committee Update For assurance

P Biddle

3.1_Integrated Performance Report -

3.3_AAC briefing BOARD Sept 2015 Fin

RISK, REGULATORY AND STRATEGY ITEMS Serious Incidents Report For assurance

F Allsop

Agency Nursing Ceiling Plan to the TDA For approval

F Allsop

4.3 Equality Delivery System and Workforce Race Equality Scheme For approval

Y Parker

4.2

13:25

A Stevenson

3.2

4.1

Integrated Performance Report (M05) For assurance

OTHER ITEMS

4.1_SI report - Public Trust Board Sept 201

4.2_Agency Nursing Ceiling Plan - TB Repo

4.3_Equality Delivery System and Workforc

5.1

Minutes from Board Committees to receive & note 5.1.1

Finance and Workforce Committee

5.1.2

Audit & Assurance Committee

All 5.1.2 _ACC Minutes July 2015.pdf

5.2

ANY OTHER BUSINESS

A McCarthy

5.3

QUESTIONS FROM THE PUBLIC

A McCarthy

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

5.4

DATE OF NEXT MEETING 29th October 2015 at 11.00am

Minutes of Trust Board meeting held in Public Thursday 28th August 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 (PB) Paul Bostock (PBi) Paul Biddle (RD) Richard Durban (PL) Pauline Lambert (AH) Alan Hall (RS) Richard Shaw

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

In Attendance (CP) Colin Pink 1.

Head of Corporate Governance (Notes)

General Business 1.1

Welcome and Apologies for absence The Chairman opened the meeting by welcoming Trust Board members, staff and members of the public. No apologies for absence were noted.

1.2

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

1.3

Minutes of the last meeting – 30th July 2015 The minutes of the meeting held on 30th July 2015 were discussed and with some minor administrative errors were approved as a true and accurate record. The Chairman highlighted the recent public Board question regarding the process around the procurement of drugs, stating that the Trust was keen to resolve the issue and that it was being managed via the ‘Freedom of Information’ route. Action 1:The Board asked the Audit and Assurance Committee to review the Trust’s policies and procedures to ensure compliance with the guidance detailed in the recently proposed ‘Sunshine Rule’.

1.4

Action Tracker The following actions were updated and closed. TBPU-03 : The Board noted that significant effort was being spent on managing emergency admission pressures and asked that the winter pressures BAF risk be Page 1 of 8

amended to reflect emergency admission pressures. TBPU-04 : FWC discuss targeting retention on new and junior nurses to influence retention rates. TBPU-05 : SJ to initiate an audit effectiveness of actions to reduce the use of temporary notes for outpatient clinics. (Closed to be passed to FWC to monitor) The remaining actions remains open and are carried forward to the future public board meetings TBPU-01: FA agreed to provide an update to the Trust Board in relation to the Temporary Staffing Contract in the coming months. TBPU-02: The FWC discuss the BAF risk relating to liquidity focusing on the level of risk and the balance between the amount of liquidity and the controls that continue to mitigate against adverse effect.

1.5

Chairman’s Report for Assurance The Chairman indicated that the main issues that he wanted to discuss where included in the agenda and as such had no specific issues to report.

1.6

Chief Executives report for Assurance The Board received and noted the Chief Executive’s report in advance of the meeting. MW introduced the report highlighting the changes in the ‘NHS Constitution’ and then moved on to focus on developments within the ‘Urgent Care Network’, which could have specific implications for placement of services. MW moved on to state the ‘Virginia Mason Development Programme’ was starting in earnest. This will be a clinically led programme focussing on 5 key elements, with potential gains in safety and quality as variation in patient care is reduced. The Board discussed the preliminary work to date and potential changes in culture. The Board duly noted and took assurance from the report.

1.7

Board Assurance Framework and Significant Risk Register for Approval and Assurance PS introduced the BAF and SRR for discussion and approval by the Board. Noting the 7 red risks to the Trust’s strategic objectives, including a proposed increased score for risk 5.3 related to delivery of medium term financial plan. The Board discussed and agreed to increase the risk score for risk 5.3 due to changes in the overall financial picture, financial position of the local health economy and lack of visibility of the future national tariff. The Board noted that the Finance and Workforce Committee would discuss the Trust’s liquidity risk in detail and management of mitigating actions. The Board discussed risk 5.5 relating to delivery of achievement review and Page 2 of 8

strategic impact. The Board accepted the current risk review, noting plans from management to achieve 90% completion by the end of October and timetabled review at FWC. The Board duly approved the report. 2.

Safety, Quality and Patient Experience 2.1 Patient Story for Assurance DH introduced the report which discussed an historic case that had involved the loss of a sample taken from a gall bladder during laparoscopic surgery. No harm had come to the patient but routine sampling was not possible. Although this historic incident had not reoccurred, four other cases of lost samples have been recorded. The Trust had commissioned a review group to look at all processes relating to sample collection and transport led by Dr Julian Webb, Chief of Patient Safety and Associate Medical Director (JW). The Board explored how a sample could go missing, noting that despite the simple nature of the process it is possible for the complexity of the surrounding environment, process and human factors that could lead to human error. The Board heard assurance that this incidents root cause was not related to workload or operational pressures. The Chairman asked what the impact for the patient involved had been. DH stated that the Trust had been completely open with the patient, to date no harm has been identified by the Trust and the patient remains philosophical to the incident. Action 2: The Board requested that Dr Julian Webb update the Board on findings and actions of the sample group. 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 Nurses report discussing the safer staffing level data and the mitigating actions being taken. FA went on to highlight that 25 midwives would be joining the Trust over the next two months. The Trust is awaiting guidance on temporary staffing and hourly rate caps, having commented on the national consultation. This will affect the review of contract with agency staff. Action 3: The Board noted that the FWC will review the procurement of agency and bank contracts. DH presented the Medical Directors report and began by highlighting the recent development of using ‘Skype’ to interview consultants. The initial interviews had proved very successful and four consultant radiologists will be joining the Trust. DH went on to discuss the Trust’s incidence of Clostridium difficile and ongoing conversations with the Trust Development Authority and Clinical Commissioning Groups on identification of lapses of care. The Board discussed the actions that had been taken and heard about planned developments to trial an electronic form of early warning score for the management of diarrhea. Page 3 of 8

DH went on to discuss the 15/16 CIP programme highlighting that the quality impact assessments indicated minimal negative impact on quality of care. The Board duly noted and took assurance from the report, welcoming increased visibility of CIPs and quality impact assessments. 2.3

Safety & Quality Committee (SQC) Update for Assurance The Board received and noted the report in advance of the meeting. RS introduced the report from SQC highlighting the encouraging trends in rates of falls with harm and assurances received on mitigating actions. The committee had discussed the number of safeguarding reports detailed in the paper, focusing on numbers of community related reports. The Board noted the difficulty in gaining assurance over the management of community safeguarding issues. The Board duly noted the report for assurance.

Operational Performance 3.1

Integrated Performance Report (M4) for Assurance

3.1.1

The Board received the Integrated Performance report in advance of the meeting. PB introduced the report highlighting the operational pressure and effect on performance. The Board focussed on ambulance handover metrics and was reassured to hear plans to revalidate data and improve systems and processes. MW highlighted how batching systems for managing patients referred by GPs to the emergency department had significant impact on patient flow and reassured the Board that he was in conversation with the Chief executive of South East Coast Ambulance Service. RD asked for greater clarity on the rate at which the Trust cancels operations. PB confirmed that this was possible and would be included in the report at the earliest convenience. FA highlighted reducing response rates for â&#x20AC;&#x2DC;friends and family testsâ&#x20AC;&#x2122; (FFT). The Board discussed how the issue relates to individual clinician engagement in the system and was reassured by previous success of mobile text messaging supporting feedback. FA highlighted that although the overall scores are good the response rate is getting close to the level at which it is no longer statistically relevant.

3.1.2

Action 4:The Board asked the SQC to focus on the management of FFT and patient feedback. FA introduced the workforce section of the report highlighting improvements in sickness absence and concerns over numbers of completed achievement reviews. The Board discussed turnover rate and the focus on retention of nurses gaining assurance over plans to review training budgets, peer support and increased possibility of multi-disciplinary team learning. Page 4 of 8

3.1.3

The Board noted that the FWC had asked for review of workforce KPIs. It the discussed the national difficulties associated to recruitment and retention of nursing staff. PS discussed the financial section of the report highlighting that the Trust is adverse to plan by £0.25m at month four with a £1.3 million deficit. Emergency activity levels remain higher than plan by 8.5% which is driving additional cost and providing other operational impacts within the Trust. Budget changes have been implemented to reflect this as part of quarterly action to match activity and spend. Recovery plan actions in the Medical Division are now three quarters complete with agreement over necessary staffing changes in ED to support activity and other steps to reduce overspending. The outturn forecast remains at £1.6m surplus. The Board reviewed the forecast at its last meeting and recovery actions are in place with Divisions and being monitored by PMO. Risks to the 2015/16 financial plan remain at £5.8m and are all mitigated, but there remains significant risk. The position will continue to be reviewed PS reported that cash support was being used to mitigate delays in payments from the CCGs. The Trust is borrowing Cash through a working capital facility. The Board asked for assurance over the process to alter divisional budgets midyear. PS and MW confirmed that the process allows for balanced conversations with division’s over material and unexpected changes in income rather than a weakening in individual accountability. Visibility of changes are recorded and included in private Board papers. The Chairman thanked management and staff for continuing to maintain and achieve targets despite operational pressures. The Board duly noted and took assurance from the report.

3.2

Finance & Workforce Committee Update for Assurance The Board received and noted the update in advance of the meeting. RD highlighted the key outputs of the August FWC that had not yet been discussed at this meeting. The outline business case to refurbish and expand the ED resuscitation unit and provide a CT scanner at a capital cost of £1.9m had been approved. The FWC had discussed and agreed the Executive’s assessment of the Workforce Internal Control Framework which showed 7 areas rated green, 5 rated amber and 1 rated red. An expanded action plan had been requested and the paper would now be presented to the Audit and Assurance Committee. The committee had received a comprehensive report on Nurse Recruitment and Retention which show the many and various actions in place to tackle the issue. The committee had good assurance from the post implementation review of ‘Hospital at Home’ with strong evidence of high quality of care and patient experience delivered within budget Page 5 of 8

The Board noted that in order to ensure 2016/17 cost improvement plans are reviewed appropriately that draft plans and quality impact assessments will be needed by end of December. The Board duly noted the report for assurance. 3.3

Charitable Funds Committee Update for Assurance

The Board received and noted the update in advance of the meeting. PL introduced the update paper stating that in future AH would be chairing the meeting. The paper highlighted the challenges in recruiting to the vacancy fundraiser post, development of divisional spending and efforts to increase visibility of the charity. The Board discussed the possibility of sharing resources between Trustâ&#x20AC;&#x2122;s where there is a shortage in experienced staff. The Board duly noted the report for assurance. 4.

Risk, Regulatory and Strategy Items

4.1

CQC Improvement Action Plan for Assurance The Board received and noted the report and action plan in advance of the meeting. FA presented the update on the CQC action plan providing assurance that actions are being delivered to improve management of waiting times and ad-hoc clinics. The Board discussed the management of ad-hoc clinics noting that the KPI was being reviewed, as not all ad hoc clinics are necessarily a negative issue. Adhoc clinics can be used to improve efficiency, the Board considered how the focus should be on reducing ad-hoc clinics set up at short notice. The Board noted that whilst it needed to remain assured that the actions taken following the CQC report were effective in improving patient care and a future rating the work on Outpatients was part of our strategy to drive productivity and as such asked that the report be taken by the FWC in future. Action 5:The Board resolved to take the item off the standing agenda, and asked RD and Sue Jenkins to discuss how reporting can be taken at FWC. The Board duly noted and took assurance from the report.

4.2

2014/15 Cost Improvement Plan â&#x20AC;&#x201C; Post Implementation Review for Assurance The Board received and noted the report in advance of the meeting. DH introduced the paper which evaluates whether the delivery of 14/15 CIP plan had any adverse effect on quality and patient care. The paper also listed plans that did and did not deliver and provided an insight into reasons for failure of schemes. Page 6 of 8

The Board noted the candid nature of the review of CIPs that failed to be delivered and thanked staff for their honesty during the process. DH highlighted that there had been a significant amount of learning for Trusts managers and that the review had yet to identify any adverse impact on quality of care. RD asked what management had learned from the process, DH commented that future plans are being scrutinised in greater detail during the planning phase and that quality impact assessments are now more robust. The Board noted that the Trust was anticipating a 68% delivery pf 15/16 CIPs and took assurance from the greater visibility of management of plans. DH noted that although the Trust had improved its systems for carrying out quality impact assessments the main driver of successful delivery was individual ownership of a scheme. In particular there is tangible benefit from a process which linked an assessment of the quality impact and a general post implementation review. The Chairman thanked DH and FA for the report. The Board duly noted and took assurance from the report. Other Items 5.1

Minutes of Board Committees to receive and note

5.1.1

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

5.1.2

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

5.1.3

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

5.2

Any Other Business The Chairman praised the operations, estates and facilities team for the management of the flood that had occurred in the Emergency Department on the 24th August 2015. No further business was discussed by the Board.

5.3

Questions from the Public There were no questions from the public.

5.4

Date of the next meeting Thursday 24th September 2015 at 11.00am in Room AD77, Trust Headquarters, East Surrey Hospital

Page 7 of 8

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 8 of 8

TRUST BOARD ACTION TRACKER Action Ref

Forum

Subject

Action

Date Open

Date Due

Date Closed

Status

ACTIONS FROM PUBLIC BOARD MEETINGs

TBPU-01

TBPU-02

TB Public

Chief Nurse report

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

25/06/2015

29/10/2015

OPEN

BAF & SRR

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

30/07/2015

30/10/2015

OPEN

The Board asked the Audit and Assurance Committee to review the Trust’s policies and procedures to ensure compliance with the guidance detailed in the recently proposed ‘Sunshine Rule’. PBi

TBPU-03

TB Public

Introduction

TBPU-04

TB Public

Patient story

TBPU-05

TB Public

TBPU-06

TB Public

Chief Nurse and Medical Director’s Report Integrated Performance Report

TB Public

CQC Improvement Action Plan

TBPU-07

The Board requested that Dr Julian Webb update the Board on findings and actions of the sample group. DH The Board noted that the FWC will review the procurement of agency and bank contracts. RD The Board asked the SQC to focus on the RS management of FFT and patient feedback. Action 5:The Board resolved to take the item off the standing agenda, and asked RD and Sue Jenkins to discuss how reporting can be taken at FWC. RD and SJ

28/08/2015

30/11/2015

28/08/2015

30/10/2015

28/08/2015 28/08/2015

28/08/2015

Closed Action dicussed and 01/09/2015 passed to AAC

Open

Open 30/10/2015

30/09/2015

Open

Closed Action dicussed and 22/09/2015 passed to FWC

Page 1

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

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

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

Director responsible

Chief Nurse

Initial Risk Current rating

S4 x L3 = 12 S4 x L2 = 8

Target risk score

S4 x L1 = 4

Linked to Risk

1009,1055

Controls in place (to manage the risk)

Gaps in Control

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

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

Potential Sources of Assurance (documented evidence of controls effectiveness)

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

1) 2)

Positive (+) CQC Chief Inspector of Hospitals Report (+) CQC risk rating, lowest possible (+) CNST level 2 Maternity (+) Numbers of Hospital Acquired Pressure Ulcers reduced and sustained (+) MUST 100% (+) QGAF assessment and action plan (+) New EWS trialed and audited (+) Increase in reporting trends (+) Meeting minutes and action plans, evidence of presentations and board discussion (+) Patient safety related KPI agreed and monitored at Board and Divisional Level (+) Datix incident reporting and analysis (+) Monthly trust wide reporting using national benchmarking (+) Falls Training data (+) Annual Falls Report 14/15 (+) Clinical Nurse Consultant for Falls and Patient Safety commenced 4 December 2014 (+) 15 Steps quality program (+) Annual Falls report 2013/14 reduction in falls with harm in year

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

Page 2

(+) 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) Develop Emergency Department falls pathway

Update by

Page 3

FA 18/09/15

Date discussed at board

Ongoing

To be discussed at September Board

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

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

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

Controls in place (to manage the risk) 1)IPCAS Team and Group in place, Weekly taskforce in place 2)Infection control manual in place and information resources available 3)Antibiotic policy and guidelines in place 4)Daily (Monday to Friday) Infection Prevention & Control Nurses (IPC), to facilitate assessment and advice for infection control issues. 5)MicroApp implemented for antimicrobial stewardship guidelines 6)Consultant led RCA and presentation of HCAI (MRSA, MSSA, C. diff). 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 â&#x20AC;&#x201C; ED, HDU and Hazelwood. 10) Developed a system where site team and matrons during the weekend are responsible in checking wards that have received positive results (See 4 above) 11)Focus on risk and mitigation of VHF involving ED/Micro/ITU/PHE 12)Antibiotic Stewardship group revitalized 13)Decontamination group informing development of strategy for IPCAS 14)Policy on screening appropriate patients from abroad for CP Enterococci. Potential Sources of Assurance (documented evidence of controls effectiveness) 1)KPI indicators 2)Reducing numbers of cases of C. diff year on year 3)Divisional and departmental governance meeting minutes 4)Output of CCG and Trust meetings regarding lapses of care in C. diff cases

Director responsible

Medical Director

Initial Risk

S3 x L4 = 12

Current rating

S3 x L4 = 12

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

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

Negative (-)Incidence of CDI 2015/16

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

Page 4

Assurance Level gained: RAG

Mitigating actions underway 1) Roll out of Urinary catheter Passport 2) Full list of actions in IPCAS Annual Programme of work (2015/16) 3) Ongoing discussion with commissioners about penalties applying only to cases with poor/inadequate care. This conversation is nationally mandated 4) Considering implementation of two low risk C.diff Antibiotics (Sidoxamicin and Chloramphenicol IV) Update by Date discussed at Board DH 18/09/15

Page 5

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Embedding 2) 2015/16 3) Ongoing 4) Under review To be discussed at September 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 18/09/15

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 September Board

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

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

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

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

Director responsible

Chief Operating Officer

Initial Risk

S5 x L3 = 15

Current rating

S5 x L3 = 15

Target risk score

S5 x L2 = 10

Linked to Risk

1221, 1480, 1601, 1405, 1547

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

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

Negative (-) Medically ready for discharge (100 pts vs target 90) (-) Nationally an outlier on emergency length of stay by 1 day (-) Unplanned increase in >1 LOS emergency admission patients (8% vs 2% plan) Gaps in assurance Assurance Level gained: RAG Agreed activity modelling across SECNational policy decisions and effective of general election Mitigating actions underway 1) CQC Action plan (Outpatient Action Plan) 2) Theatre efficiency action plan 3) Breaking the cycle and reducing LOS action plan 4) Implement transformation team 5) Build and open new Medically ready for discharge ward Update by PB 10/09/2015 Page 7

Date discussed at Board

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1)Ongoing 2)End of quarter 1 3)End of quarter 2 4)End of quarter 2 5)End of quarter 3 To be discussed at September Board

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

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

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

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

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

Director responsible

Chief Nurse and Medical Director

Initial Risk Current rating

S3 x L4 = 12 S3 x L5 = 15

Target risk score Linked to Risk

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

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

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

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

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

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

4. Implement plans to manage staffing issues in Theatres 5. Increasing direct entry nursing students by 100% (40 to 80) from February 2016 Update by Date discussed at Board FA 18/09/2015 and DH 18/09/2015

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 September Board

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

4.A.1 Deliver access standards

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

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

Director responsible

Chief Operating Officer

Initial Risk Current rating

S4 x L4 = 16 S4 x L4 = 16

Target risk score

S4 x L2 = 8

Linked to Risk

1220, 1491

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

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

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

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

Page 10

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

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

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

Agreed breaking the cycle 2 encompassing internal and external bodies

Update by

Page 11

PB 10/09/15

Date discussed at Board

Assurance Level gained: RAG

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) July 2015 2) July 2015 3) Aug 2015 4) Sep 2015 To be discussed at September 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 Control 1) Original risk share agreement (for emergency activity) with Sussex CCGs and Sussex Community Trust could not be agreed – ongoing discussion over MRET adjustments are now looking more favorable and a new risk share possible. 2) The strategic management of activity is not currently effective, but the Trust is doing all it can to support making it so – progress on data sharing with new system (SHREWD), however. 3) CCG plans make assumptions on activity reductions that are only partly adjusted in Contract plans – to be reviewed – dialogue is ongoing with CCGs; 4) Activity growth above CCG assumptions, including market share, is referred to as an assumption in Activity Planning schedule but not in activity plans;; 5) Some actions long stopped to resolve – this includes ambulatory attendance pricing and payment for hospital @ home services – not all deadlines have been met but all are in an agreed process. 6) NHS England instruction for CCGs to increase volume of activity in plans not being applied to local CCGs, with NHS England agreement.

Actual Assurances: Positive (+) or Negative (-) Positive (+) 2014/15 activity and income met the Plan (noting that individual elements (e.g.: elective activity) did not) (+) Reconciliation process working with CCGs in 2014/15 and year end settlement achieved with all commissioners in 2014/15 with no outstanding disputes. (+) Contracts include clauses to allow inclusion of growth in indicative activity plans, and (vice versa) for any emergency activity reductions Negative (-) Risk over income growth assumptions. (-) Adverse income variance at M05 (although forecast remains on track) (-) Monitor response to MRET complaint provided no useful application in 2015/16 (-) Too much non elective activity, not enough elective – risk over emergency demand in 2015/16.

Gaps in assurance Red 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

Assurance Level gained: RAG

Mitigating actions underway 1) COO meetings have been held, COG updated and action plans being provided to manage urgent care activity better across the health system. Business intelligence meeting looks likely to establish effective data sharing 2) Complete all contractual commitments by revised long-stop dates (end date â&#x20AC;&#x201C; now Q2 reconciliation); 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 was improvement in all these areas at M04) 5) Action around integrated discharge unit is gaining momentum with Surrey County Council and East Surrey CCG â&#x20AC;&#x201C; in Sussex the risk share with the community trust is back on the table, with the potential for new schemes ahead of winter to improve Trust capacity. Update by Date discussed at Board PS 16/09/15

Page 13

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

To be discussed at September 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 been made – this is less of a gap) 3) At M05 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 against agreed forecast control totals at M05 (although recovery plan actions in Medicine are now largely complete) 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] Negative (-) Emergency activity pressures have continued to be greater than expected (-) Overall agency costs remain very high, with escalation still in use and significant. (-) At M05 there continues to be overspending in Divisions and adverse delivery on the medical agency and escalation CIPs, and anticipated adverse performance on nursing agency as the year progresses. (-) The forecast describes significant risk to delivery of the Plan.

Gaps in assurance Assurance Level gained: RAG Overspending is the main area of risk and the ability of the Trust to reduce the rate of spend while maintaining services adequately. Mitigating actions underway Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) PMO/Performance structure continues - Divisions have been required to produce recovery plans Actions proceeding to timetable and PMO meetings have become weekly, 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 16/09/15 To be discussed at September 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 16/09/15 To be discussed at September 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)

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 NOTE: THIS RISK BEING DISCUSSED AT FWC 22 SEPTEMBER.

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

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

Overall rating “red” noting risk to forecast I&E. Assurance RAG "amber" - no current cash problem but underlying problem unresolved. Gaps in assurance Assurance Level gained: RAG In terms of cash flow management to end year, no material gaps in assurance. In terms of resolving the actual risk (liquidity), there is no confirmation of additional cash to resolve SoFP weakness. Mitigating actions underway Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Day to day cash control is main action currently, coupled with actions to maintain service income and Actions proceeding to timetable manage spend 2) Long term financial model, and TDA plan now provides additional validation of the level of cash injection required and the interaction from an improving financial position within the model 3) Discussion will continue with the TDA as the FT timeline progresses. Update by Date discussed at Board PS 16/09/15 To be discussed at September Board

Page 16

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

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

3) 4) 5) 6)

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

Director responsible

Director of Human Resources

Initial Risk Current rating

S3 x L3 = 9 S3 x L3 = 9

Target risk score

S3 x L2 = 6

Linked to Risk

910, 1674

Gaps in Control 1) 2) 3) 4)

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

Potential Sources of Assurance (documented evidence of controls effectiveness)

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

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

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

Gaps in assurance

Assurance Level gained: RAG

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

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

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

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

Update by Page 17

18/09/2015 JM

Date discussed at Board

1) 31 March 2016 2) 30 October 2015 3) Complete and ongoing 4) February 2016 5) 31 March 2016

To be discussed at September 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 (+/-) Awaiting national guidance on future FT model Assurance Level gained: RAG

Mitigating actions underway 1) Elections to the Council of Governors completed in July 2015 and shadow Council being set up 2) Monitor formal assessment in progress Update by Update by GFM 17/09/15 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 September Board

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

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

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

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

Director responsible

Director of Information and Facilities

Initial Risk

S5 x L3 = 15

Current rating

S4 x L3 = 12

Target risk score

S3 x L3 = 9

Linked to Risk

1428, 999, 1483

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

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

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

Assurance Level gained: RAG

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

Update by Page 19

IM 18/08/15

Date discussed at Board

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

Appendix 1

Page 20

Abridged consequence table taken from Trust guidance

Risk Type Patient Safety

Insignificant • No obvious injury / harm

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

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

Health & Safety

• Avoidable death

• Minor harm event involving >5 patients

• Moderate harm event involving >5 patients

• Major harm incident involving >5 patients

• Minor unsatisfactory patient experience related to treatment / care given

• Unacceptable patient experience related to poor treatment / care

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

• Informal complaints raised / PALS contacted

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

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

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

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

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

• No harm injury

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

• Medical treatment required

• 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

Page 21

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

TRUST BOARD IN PUBLIC

Date: 24th September 2015 Agenda Item: 1.7

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

Board Assurance Framework & Significant Risk Register Gillian Francis-Musanu Director of Corporate Affairs Colin Pink Corporate Governance Manager Audit Assurance Committee 01/09/2015 Executive Committee 16/09/2015

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. The main point of discussion is the proposed change to risk 5.6 which relates to the Trust’s foundation trust application. There are 13 significant risks recorded on the Trust risk register, including 5 new risks (4 financial and one quality). Specifically relating to the Trust’s medium term financial plan, liquidity, risk to cost improvement plan, contract income and supervision of adolescent mental health patients. 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 • Agree the change in title for risk 5.6 relating to the Trust’s foundation trust application. • 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 1

An Associated University Hospital of Brighton and Sussex Medical School

sustainability around a clinical leadership model 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: September 2015 BAF and the current SRR

An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT – 24th September 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

An Associated University Hospital of Brighton and Sussex Medical School

5. Well Led - become an employer of choice and

deliver financial and clinical sustainability around a clinical leadership model

Total

One of the purposes of the BAF is to ensure that all risks are mitigated to an appropriate or acceptable level. It is expected that not all risks will be able to have mitigating controls that reduce the risk to green (low impact, low likelihood). 2.1 Updates since last Board Review Since the last board meeting the Executive has reviewed and updated the BAF to reflect current as detailed in descriptions. There have been minor amendments throughout regarding controls, actions and assurances. The main points of note are the proposed change to the title of risk 5.6 following the discussion at the August Private Board meeting. The proposed title change is as follows: Original description

Proposed description

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

2.2 Headline information by objective (BAF) Objective 1 - Safe Deliver safe services and be in the top 20% against our peers

Initial Risk Rating: Severity x Likelihood

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

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

Current Risk Rating: Severity x Likelihood

Target Risk Score

S4 x L3 = 12

S4 x L2 = 8

S4 x L1 = 4

S3 x L4 = 12

S3 x L3 = 9

Initial Risk Rating: Severity x Likelihood

Current Risk Rating: Severity x Likelihood

Target Risk Score

An Associated University Hospital of Brighton and Sussex Medical School

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.

S3 x L3 = 9

S3 x L2 = 6

S3 x L1 = 3

S5 x L3 = 15

S5 x L2 = 10

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

S3 x L4 = 12

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

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

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

Target Risk Score

S3 x L2 = 6

Initial Risk Rating: Severity x Likelihood

Current Risk Rating: Severity x Likelihood

Target Risk Score

S4 x L4 = 16

S4 x L2 = 8

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

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

Target Risk Score

S5 x L3 = 15

S3 x L2 = 6

S5 x L3 = 15

Proposed 5 x 3 = 15

S4 x L2 = 8

S5 x L3 = 15

S4 x L3 = 12

S3 x L3 = 9

S3 x L2 = 6

S4 x L2 = 8

S4 x L1 = 4

S5 x L3 = 15

S4 x L3 = 12

S3 x L3 = 9

S4 x L2 = 8

An Associated University Hospital of Brighton and Sussex Medical School

2.3.

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 Trustâ&#x20AC;&#x2122;s ability to maximize financial and quality benefits. 4.1 Failure to maintain Emergency Department performance because of lack of capacity in health system to manage pressures has a significant impact on the Trust's ability to deliver high quality care 5.1 Failure to deliver income plan 5. 2 Failure to stop divisional overspending against budget 5. 3 Unable to deliver medium term financial plan 5. 4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position

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 S5 x L3 = 15

S4 x L2 = 8 S3 x L2 = 6 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 now 13 risks on the Trust significant risk register (increase by 5). Each is in date and has mitigating actions to reduce the level of risk to an acceptable level. The five risks escalated to the SRR relate; to specifically relating to the Trustâ&#x20AC;&#x2122;s medium term financial plan (1603), liquidity (1604), risk to cost improvement plan (1663), contract income (1689) and supervision of adolescent mental health patients (1710). Risk 1710 is a new risk on the Trust risk register whilst the other 4 risks have recently increased in risk rating. 3.1 SRR Breakdown ID

1401

Title Risk of outbreak of viral gastroenteritis

Initial Rating 16

Current Rating 15

Residual Rating 9

Next Review 30/10/2015

An Associated University Hospital of Brighton and Sussex Medical School

Title

Initial Rating

Current Rating

Residual Rating

1491

Failure to maintain Emergency Department performance

1501

Patient admitted to the right bed first time

1603

Unable to provide realistic medium term financial plan

1604

1663

Liquidity: Inability to pay creditors/staff resulting from insufficient cash due to poor liquid position Risk of not achieving Cost Improvement Plan

1678 1688

Risk of potential overspending from operational pressures

1689

Risk of Contract income below plan

1696

Risk from agency overspending

1697

1710

Financial risks linked to National Quality Board Paper, 7 day working and Carter productivity report Inability to provide appropriate care and supervision of adolescent mental health patients

30/09/2015 25/09/2015 25/09/2015

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

1672

Next Review 30/09/2015

25/09/2015 30/09/2015

11/02/2016 25/09/2015 25/09/2015 30/09/2015 26/08/2015

9 30/09/2015

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 • Approve the proposal to change the title for risk 5.6 • Note the updated risks included in the Significant Risk Register

An Associated University Hospital of Brighton and Sussex Medical School

Gillian Francis-Musanu Director of Corporate Affairs September 2015

Colin Pink Corporate Governance Manager

An Associated University Hospital of Brighton and Sussex Medical School

Appendix 1: Risk Appetite â&#x20AC;&#x201C; 2015/16 The Board of Directors has developed and agreed the principles of risk that the Trust is prepared to accept, seek and tolerate whilst in the pursuit of its objectives. The Board actively encourages well-managed and defined risk management, acknowledging that service development, innovation and improvements in quality requires risk taking. This position is based on the expectation that there is a demonstrated capability to anticipate and manage the associated risks as well. The key following principles further define this stance with an opinion from the Board: Quality: The quality of our services, measured by clinical effectiveness, safety, experience and responsiveness is our core business. We will only put the quality of our services at risk only if, upon consideration, the benefits of the risk improve quality are justifiable and the management controls in place are well defined and practicable. Target: Green Innovation: The Trust is highly supportive of service development and innovation and will seek to encourage and support it at all levels with a high degree of earned autonomy. We recognise that innovation is a key enabler of service improvement and drives challenge to current practice both internally and across the wider health economy. Target: Amber Well Led: The Board acknowledges that healthcare and the NHS operates within a highly regulated environment, and that it has to meet high levels of compliance expectations from a large number of regulatory sources. It will meet those expectations within a framework of prudent controls, balancing the prospect of risk reduction and elimination against pragmatic operational imperatives. The Board will seek to innovate and take risks where there is potential to develop inspirational leadership as it recognises that this is key to both becoming the local employer of choice and developing strategic partnerships with new bodies. Target: Green Financial: The Trust is prepared to invest for return and minimise the possibility of financial loss by managing risk to a tolerable level. The Board will take decisions that may result in an adverse financial performance rating in the face of opportunities that balance safety and quality and are of compelling value and benefit to the organisation. There will be an expectation of aggressive risk reduction strategies and increased scrutiny of mitigating actions. Target: Amber Reputation: The Board is prepared to take decisions that have the potential to bring scrutiny of the organisation, provided that potential benefits outweigh the risks and by prospectively managing any reputational consequences. Target: Green Workforce: The good will of our staff is important to the Trust. Any decision that places at risk staff morale and has the potential to adversely affect any aspect of the working life of our employees will be balanced very carefully against any potential consequent benefits and will only be considered if the inherent risk is low. The Board recognises the complications attached to recruitment and retention that are caused by geographical and national position and takes this into account when reviewing workforce related risks. Target: Amber 9

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

• Death (RIDDOR reportable)

• Minor loss £2K to £100k

• Moderate loss, £100k - £1M

• Major loss, £1M-£10M

• Loss > £10M

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

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

• Adverse Monitor continuity of service rating <1 month

• Adverse Monitor continuity of service rating > 1 month

• A breach of Monitor Terms of authorisation

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

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

Financial Management • Small loss <£1K Governance Arrangements

Quality of Service

Extreme

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

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

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

Major

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

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

• 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

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

Potential Sources of Assurance (documented evidence of controls effectiveness)

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

1) 2)

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

Page 2

Gaps in assurance

Assurance Level gained: RAG

Ability to benchmark in real time

Mitigating actions underway

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

1) Develop Emergency Department falls pathway

Update by

Page 3

FA 18/09/15

Date discussed at board

Ongoing

To be discussed at September Board

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

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

Director responsible

Medical Director

Initial Risk

S3 x L4 = 12

Current rating

S3 x L4 = 12

Negative (-)Incidence of CDI 2015/16

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

Page 4

Assurance Level gained: RAG

Page 5

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

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

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

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

DH 18/09/15

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 September 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

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

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.

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

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

Page 9

Assurance Level gained: RAG

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

4.A.1 Deliver access standards

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

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

Director responsible

Chief Operating Officer

Initial Risk Current rating

S4 x L4 = 16 S4 x L4 = 16

Target risk score

S4 x L2 = 8

Linked to Risk

1220, 1491

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

Page 10

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

Agreed breaking the cycle 2 encompassing internal and external bodies

Update by

Page 11

PB 10/09/15

Date discussed at Board

Assurance Level gained: RAG

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

Gaps in assurance 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

Assurance Level gained: RAG

Page 13

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

To be discussed at September 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

Director responsible

Chief Finance Officer

Initial Risk Current rating

S5 x L3 = 15 S5 x L3 = 15

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

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

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

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

3) 4) 5) 6)

Director responsible

Director of Human Resources

Initial Risk Current rating

S3 x L3 = 9 S3 x L3 = 9

Target risk score

S3 x L2 = 6

Linked to Risk

910, 1674

Gaps in Control 1) 2) 3) 4)

Potential Sources of Assurance (documented evidence of controls effectiveness)

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

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.

Update by Page 17

18/09/2015 JM

Date discussed at Board

1) 31 March 2016 2) 30 October 2015 3) Complete and ongoing 4) February 2016 5) 31 March 2016

To be discussed at September 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

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

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

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

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

Assurance Level gained: RAG

Update by Page 19

IM 18/08/15

Date discussed at Board

Appendix 1

Page 20

Abridged consequence table taken from Trust guidance

Risk Type Patient Safety

Insignificant • No obvious injury / harm

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

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

Health & Safety

• Avoidable death

• Minor harm event involving >5 patients

• Moderate harm event involving >5 patients

• Major harm incident involving >5 patients

• Minor unsatisfactory patient experience related to treatment / care given

• Unacceptable patient experience related to poor treatment / care

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

• Informal complaints raised / PALS contacted

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

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

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

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

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

• No harm injury

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

• Medical treatment required

• Death (RIDDOR reportable)

• Minor loss £2K to £100k

• Moderate loss, £100k - £1M

• Major loss, £1M-£10M

• Loss > £10M

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

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

• Adverse Monitor continuity of service rating <1 month

• Adverse Monitor continuity of service rating > 1 month

• A breach of Monitor Terms of authorisation

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

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

Financial Management • Small loss <£1K Governance Arrangements

Quality of Service

Extreme

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

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

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

Major

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

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

Page 21

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

Patient Safety Involvement of Service Users Financial Management Financial Management

Involvement of Service Users

Des Holden Paul Bostock Paul Bostock Paul Simpson Paul Simpson

Medical Director's Office Operations Finance - Fin. Management

Finance - Fin. Management

Operations

CORP CORP CORP CORP CORP

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

Safety Responsivene ss Responsiveness Executive Committee Executive Committee

1401 1491 1501 1603 1604

Failure to maintain Emergency Department performance

Patient admitted to the right bed first time

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.

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

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

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

Risk of not being able to pay suppliers from in sufficient cash due to poor liquidity problem

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)

16 3

20 4

Treatment Plan

Done date

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

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

As described on the board assurance framework

31/03/2016

30/09/2015

30/09/2014

31/03/2014

25/09/2015

As described on the BAF

15 5

27/06/2014 31/08/2015

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

As described on the BAF

15 5

30/10/2015

30/09/2015

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

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

Next Review

Due date

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

Residual Rating

Current Rating

Current Likelihood

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.

Current Consequence

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

01/10/2014

25/09/2015

Financial Management Staffing - general Service Access Financial Management Financial Management Financial Manageme nt Financial Management Patient Safety

Paul Simpson Yvonne Parker Natasha Hare Paul Simpson Paul Simpson Paul Simpson Paul Simpson Dr Debbie Pullen

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

Finance Fin. Finance - Fin. Management Manageme nt

CORP CORP SURG CORP CORP CORP CORP WACH

09/12/2014 01/02/2015 23/03/2015 20/05/2015 20/05/2015 11/06/2015 11/06/2015 07/07/2015

Executive Committee Workforce Responsiveness Executive Committee Executive Committee Executive Committee Executive Committee Safety

1663 1672 1678 1688 1689 1696 1697 1710

Risk of not achieving Cost Improvement Plan

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

i) Delivery of savings managed through PMO (ongoing)

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

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

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

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

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

Risk of potential overspending from Risk of failure to meet the Trusts financial plan due i) Divisions to implement action plans and contingencies to control/or recover operational pressures to overspending. overspending. Specific action is required in all Divisions. ii) Agency PMO to deliver outputs in respect of reduced agency usage following recruitment. Position being reviewed (ongoing). Risk of Contract income below plan Risk the Trust does not achieve its financial plan i) Quarterly reconciliation with CCGs will inform variations to the monthly as a result of lower than planned contract income. contract values (over 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. Iii) Ring fence elective beds after new capacity has opened and monitor delivery.

Risk from agency overspending

As described on the BAF

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

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

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.

Inability to provide appropriate care Increase in number of adolescent patients with and supervision of adolescent mental health issues such as attempted suicide, mental health patients self harming, eating disorders and absconding admitted to general paediatric ward. Nursing staff on the ward are not mental health trained to provide appropriate care and support for this cohort of patients.

Cohorting patients to enable supervision Use of Agency RMN's Close liaison with hospital security team and site management team

15 3

16 4

15 5

16 4

15 3

02/10/2014

25/09/2015

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

31/03/2015 31/08/2015

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

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

As described on the board assurance framework

31/03/2016

As described on the BAF

03/10/2014

09/02/2015 05/08/2015

11/02/2016

25/09/2015

30/09/2015

25/09/2015

As described on the board assurance framework

31/03/2016

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

30/09/2015

Meet and agree, processes for early CAMHS assessment, with mental health service providers

30/10/2015

30/09/2015

9 26/08/2015

30/09/2015

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

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

Potential Sources of Assurance (documented evidence of controls effectiveness)

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

1) 2)

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

Page 2

Gaps in assurance

Assurance Level gained: RAG

Ability to benchmark in real time

Mitigating actions underway

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

1) Develop Emergency Department falls pathway

Update by

Page 3

FA 18/09/15

Date discussed at board

Ongoing

To be discussed at September Board

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

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

Director responsible

Medical Director

Initial Risk

S3 x L4 = 12

Current rating

S3 x L4 = 12

Negative (-)Incidence of CDI 2015/16

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

Page 4

Assurance Level gained: RAG

Page 5

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

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

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

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

DH 18/09/15

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 September 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

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

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.

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

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

Page 9

Assurance Level gained: RAG

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

4.A.1 Deliver access standards

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

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

Director responsible

Chief Operating Officer

Initial Risk Current rating

S4 x L4 = 16 S4 x L4 = 16

Target risk score

S4 x L2 = 8

Linked to Risk

1220, 1491

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

Page 10

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

Agreed breaking the cycle 2 encompassing internal and external bodies

Update by

Page 11

PB 10/09/15

Date discussed at Board

Assurance Level gained: RAG

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

Gaps in assurance 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

Assurance Level gained: RAG

Page 13

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

To be discussed at September 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

Director responsible

Chief Finance Officer

Initial Risk Current rating

S5 x L3 = 15 S5 x L3 = 15

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

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

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

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

3) 4) 5) 6)

Director responsible

Director of Human Resources

Initial Risk Current rating

S3 x L3 = 9 S3 x L3 = 9

Target risk score

S3 x L2 = 6

Linked to Risk

910, 1674

Gaps in Control 1) 2) 3) 4)

Potential Sources of Assurance (documented evidence of controls effectiveness)

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

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.

Update by Page 17

18/09/2015 JM

Date discussed at Board

1) 31 March 2016 2) 30 October 2015 3) Complete and ongoing 4) February 2016 5) 31 March 2016

To be discussed at September 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

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

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

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

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

Assurance Level gained: RAG

Update by Page 19

IM 18/08/15

Date discussed at Board

Appendix 1

Page 20

Abridged consequence table taken from Trust guidance

Risk Type Patient Safety

Insignificant • No obvious injury / harm

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

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

Health & Safety

• Avoidable death

• Minor harm event involving >5 patients

• Moderate harm event involving >5 patients

• Major harm incident involving >5 patients

• Minor unsatisfactory patient experience related to treatment / care given

• Unacceptable patient experience related to poor treatment / care

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

• Informal complaints raised / PALS contacted

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

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

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

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

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

• No harm injury

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

• Medical treatment required

• Death (RIDDOR reportable)

• Minor loss £2K to £100k

• Moderate loss, £100k - £1M

• Major loss, £1M-£10M

• Loss > £10M

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

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

• Adverse Monitor continuity of service rating <1 month

• Adverse Monitor continuity of service rating > 1 month

• A breach of Monitor Terms of authorisation

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

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

Financial Management • Small loss <£1K Governance Arrangements

Quality of Service

Extreme

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

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

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

Major

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

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

Page 21

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

A Framework of Quality Assurance for Responsible Officers and Revalidation

Presentation Title Annual Board Report, 36pt Arial Bold

Surrey and Sussex Healthcare NHS Trust Sub heading 24pt Arial

September 24th 2015 Adam Stacey-Clear

Executive Summary

•

This report Follows the NHS England template as outlined in the Framework for Quality Assurance and is an annual requirement for all designated bodies.

•

The annual Organisation Audit findings for Surrey and Sussex Healthcare NHS Trust will be presented

•

245 doctors with a GMC connection to The Trust were included in the audit, April 1st 2014-March 31st 2015

•

A statement of compliance confirming compliance with The Medical Profession (Responsible Officers) regulations 2010 needs to be signed by either the CEO or Chairman following this report.

Governance Arrangements

•

Surrey and Sussex Healthcare NHS Trust (SASH) has a Medical Appraisal Policy on the Trust website which is available for all doctors to read.

•

A record of all doctors connected with the Trust is maintained

•

The Responsible Officer is Adam Stacey-Clear who regularly attends network RO meetings, and attended as visiting Peer review RO to Portsmouth Hospitals NHS Trust on 8th September 2015.

•

The human resources dept. maintains a list of employed doctors at the Trust.

•

All completed appraisal forms are read by AS-C.

Pre-employment background checks

•

Medical staffing check qualifications against persons specifications for the post. DBS (formerly a CRB)

•

Photographic ID

•

Visa or Biometric card as proof of the right to work in the UK

•

2 proofs of address

•

GMC registration check

•

Must be on specialist register- substantive consultants

•

2 references

•

Occupational health check Locums employed through medacs

Slide 4

Access, Security and Confidentiality

•

All appraisals are stored in a secure folder on the G drive

•

No patient identifiable data is stored in any appraisal folders

•

No information management breaches.

•

The GMC have provided ASC with a secure link which lists all doctors with a prescribed connection to the Trust (designated body).

•

The list is regularly updated.

•

Transfer of information between designated bodies.

Slide 5

Conduct and Performance

•

All Trust doctors are subject to the organizational policies e.g. capability and disciplinary in line with Maintaining High Professional Standards best practice. The Trust recognizes the BMA code of conduct.

•

The Trust reviews doctors performance in the yearly job plan, supported by the annual appraisal process for all medical and dental staff.

•

The clinical effectiveness strategy supports Medical and Dental staff in their practice by ensuring evidence is practice based and clinically effective.

•

The complaints procedure is Trust policy. This is part of doctor’s feedback and concerns are raised at job planning stage to enable improvement in doctor’s practice and patient care.

Slide 6

Responding to Concerns

•

The Trust responds to concerns in respect of a doctor’s practice by supporting them with regular and ongoing development opportunities.

•

Fitness to practice concerns from The GMC about a doctor are dealt with following the GMC guidelines.

•

The Trust has an active whistleblowing (raising concerns) policy

Slide 7

Recommendations submitted to the GMC •

114 revalidation recommendations made.

•

14 deferrals

•

100 positive recommendations

•

Deferrals mainly due to lack of supporting information

Slide 8

Medical Appraisal

•

245 doctors were included in this audit, 166 consultants and 79 associate specialists/Trust doctors

•

161 consultants completed an annual appraisal between 1/4/2014 and 31/3/2015, of which 2 were approved and 3 unapproved.

•

78 associate specialists/Trust doctors completed an appraisal, the late appraisal being unapproved.

•

Audit sheet for late appraisals is maintained.

•

Late appraisals default to the original due date the next year

Slide 9

Appraisers

•

44 trained appraisers in faculty of appraisers.

•

Rather unequal distribution of appraisals from those who responded to request for number of appraisals carried out.

•

Appraisal year runs from April 1st to March 31st.

•

Recent guidelines from NHS England recommend new appraisal categories:

•

Measure 1a- Appraisal took place 9-15 months from previous appraisal, signed off , all between 1 April and 31 March

•

1b-1 April-31 March but less than 9 months or more than 15, or signed off 1 April-28 April of following appraisal year, or signed off more than 28 days after appraisal meeting

•

2-approved incomplete appraisal- neither 1a or 1b-but RO gave prospective approval for cancellation or postponement

•

3- unapproved incomplete or missed appraisal-1a,1b or 2 do not apply.

•

Trust is going to stick with annual appraisals, +/- one month.

Slide 10

DISTRIBUTION OF APPRAISALS Appraisal number 20 18 16 14 12 10 8 6 4 2 0

Slide 11

Comparator Report

•

Nationally 731 designated bodies (ALL), 58 in same sector (SS)= NHS England south.

•

SASH compared with both groups.

•

Completed appraisal consultants 97% SASH, ALL 87%, SS 87%

•

Completed appraisal SAS/Trust doctors 98% SASH, ALL 84%, SS 81%.

•

Approved late appraisals consultants 1.2% SASH, ALL 6.3%, SS 6.7%

•

Approved late SAS/Trust doctors 0% SASH, ALL 8.6%, SS 9.1%

•

Unapproved appraisals consultants 1.8% SASH, ALL 6.5%, SS 5.6%

•

Unapproved SAS/Trust doctors 1.3% SASH, ALL 7.5%, SS 5.6%.

Slide 12

Are doctors organised?

•

Some are

•

The good ones are excellent ambassadors for the Trust and proud of their achievements

•

Some need direction

•

Brownian (Robert Brown) motion-random movement of water vapour particles, bumping into each other.

•

Wilson’s cloud chamber (Charles Thomson Rees Wilson)- water vapour condenses on ionizing particles from a powerful alpha emitting source (MW)

Slide 13

http://wwwoutreach.phy.cam.ac.uk/camphy/cloudchamber/cloudchamber1_1.ht m http://wwwoutreach.phy.cam.ac.uk/camphy/cloudchamber/cloudchamber4_1.ht m http://wwwoutreach.phy.cam.ac.uk/camphy/cloudchamber/cloudchamber9_1.ht m

Slide 14

Famous Michael Wilsons •

Michael Henry Wilson (1901-1985) British anthroposophist and founder of Sunfield Children's Home, Clent

•

Michael Wilson (writer) (1914-1978), Hollywood screenplay writer

•

Michael Wilson (Australian politician) (born 1934), member of the South Australian House of Assembly

•

Michael Wilson (Canadian politician) (born 1937), Canadian politician and diplomat

•

Michael G. Wilson (born 1942), producer and screenwriter of James Bond films

•

Michael Wilson (guitarist) (born 1952), Jamaican guitarist for Burning Spear from 1977 to 1984

•

Michael Wilson (cyclist) (born 1960), Australian cyclist

•

Michael Wilson (director) (born 1964), artistic director of Hartford Stage

•

Michael Wilson (Australian footballer) (born 1976), Australian rules footballer for Port Adelaide

•

Michael Wilson (New Zealand footballer) (born 1980), New Zealand association football player

•

Michael Wilson (ice hockey) (born 1987), Canadian ice hockey defenceman

•

Michael Wilson (presenter), British journalist and business presenter (formerly on Sky News)

•

Michael Wilson (basketball), former player of the Harlem Globetrotters aka 'Wild Thing'

Slide 15

Quality assurance

•

Currently conducting an external review of appraisers using an NHS England toolkit concentrating on the appraisal outputs and PDP.

•

External verification visit due soon from NHS England south.

•

Appraisee feedback working well, reliant on appraisal sign off certificate.

•

Six month PDP review working well

•

Appraiser support group meetings carried out in June 2015 (three sessions spread over 2 days)

•

PDP includes a Trust quality improvement activity

Slide 16

Risks and Issues

•

Information transfer for visiting doctors whose designated body is not SASH.

•

Appraisals in March

•

Feedback for locums

•

Patient feedback-database setup.

Slide 17

Board Reflections

•

Working party to explore patient and public involvement in revalidation

•

PDP six month check

•

Verification visit

•

Appraiser quality assurance audit

•

Transfer of information form between SASH and other organisations

•

Improved appraisee feedback

Slide 18

TRUST BOARD IN PUBLIC

Date: 24 September 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 Chief Nurse • The Safer Staffing report (August 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. • The recent PLACE assessment and action plan is described Medical Director • The clinical chiefs have met and agreed new ways of working as clinical leaders. • The Ideas to Innovation Factory has launched. Recommendation: To note the report. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment: Legal and regulatory impact

Yes

Financial impact

Yes

Patient Experience/Engagement

Yes

Risk & Performance Management

Yes

NHS Constitution/Equality & Diversity/Communication

Yes

Attachment:

2 An Associated University Hospital of Brighton and Sussex Medical School

Chief Nurse/ Medical Director Report – 24 September 2015 Chief Nurse Report 1. Introduction To provide an update to the Board on nursing staffing in relation to planned versus actual staffing, a summary of recent changes to National Institute for Clinical Excellence (NICE) guidance in relation to safer staffing for nursing and the impact of DH advice regarding agency staffing spend. 2.

Staffing Planned versus Actual – August 2015

Ward

Ward Specialty

Entries

RN Day

RN Night

NA Day

NA Night

Total Day

Total Night

Overall

Abinger Ward

430 - GERIATRIC MEDICINE

86.83%

100%

93.74%

100%

90.44%

100%

94.09%

Acute Medical Unit

300 - GENERAL MEDICINE

93.42%

96.31%

94.4%

94.35%

93.71%

95.6%

94.54%

Birthing Centre

501 - OBSTETRICS

90.32%

85.48%

100%

N/A

90.63%

85.48%

88.1%

Bletchingley Ward

300 - GENERAL MEDICINE

92.87%

98.06%

96.89%

97.58%

94.81%

97.85%

95.92%

Brockham Ward

502 - GYNAECOLOGY

92.74%

90.32%

92.53%

96.77%

92.67%

91.94%

92.38%

Brook Ward

100 - GENERAL SURGERY

100%

90.61%

100%

96.78%

100%

98.14%

Buckland Ward

101 - UROLOGY

94.99%

90.32%

98.45%

91.94%

96.08%

91.13%

94.21%

Burstow Ward

501 - OBSTETRICS

78.35%

67.74%

70.83%

86.67%

75.83%

75.16%

75.53%

Capel Annex l Ward

100 - GENERAL MEDICINE

99.19%

100%

97.1%

100%

98.3%

100%

98.92%

Capel Ward

430 - GERIATRIC MEDICINE

89.88%

97.85%

90.96%

100%

90.22%

98.71%

93.93%

Chaldon Ward

300 - GENERAL MEDICINE

92.57%

88.73%

95.48%

91.49%

93.82%

90.3%

92.59%

Charlwood Ward

301 - GASTROENTEROLOGY

90.58%

100%

93.85%

98.39%

91.73%

99.19%

94.72%

Copthorne Ward

301 - GASTROENTEROLOGY

99.19%

96.67%

99.45%

93.33%

99.28%

95%

97.61%

Coronary Care Unit

320 - CARDIOLOGY

80%

100%

150%

84.38%

81.44%

94.68%

87.96%

Delivery Suite

501 - OBSTETRICS

93.01%

84.95%

86.73%

93.1%

91.47%

86.89%

89.19%

Discharge Lounge

300 - GENERAL MEDICINE

87.58%

86.67%

92.78%

90.32%

90.01%

88.52%

89.48%

Godstone Ward (Haem)

303 - CLINICAL HAEMATOLOGY

101.05%

98.39%

N/A

101.05%

100%

100.53%

Godstone Ward (Med)

300 - GENERAL MEDICINE

85.23%

97.7%

94.44%

92.22%

88.7%

94.92%

91.35%

Holmwood Ward

320 - CARDIOLOGY

95.26%

98.33%

91.84%

96.61%

94.29%

97.48%

95.42%

TU/HDU

192 - CRITICAL CARE MEDICINE

97.21%

98.18%

90.16%

96.88%

96.17%

98.08%

97.08%

Leigh Ward

110 - TRAUMA & ORTHOPAEDICS

96.5%

91.8%

95.46%

83.87%

96.06%

87.8%

93.27%

Meadvale Ward

430 - GERIATRIC MEDICINE

92.62%

98.39%

100%

95.73%

99.2%

96.95%

Neonatal Unit

420 - PAEDIATRICS

91.45%

98.36%

96.81%

95%

93.17%

97.25%

95.14%

Newdigate Ward

110 - TRAUMA & ORTHOPAEDICS

93%

91.94%

99.74%

74.19%

95.87%

83.06%

91.5%

3 An Associated University Hospital of Brighton and Sussex Medical School

Nutfield Ward

430 - GERIATRIC MEDICINE

89.72%

98.39%

100%

98.36%

93.65%

98.37%

95.2%

Outwood Ward

420 - PAEDIATRICS

97.3%

101.17%

89.64%

83.87%

96.3%

98.51%

97.25%

Rusper Ward

501 - OBSTETRICS

87.6%

72.58%

100%

N/A

87.77%

72.58%

82.67%

Surgical Assessment Unit

100 - GENERAL SURGERY

91.13%

87.1%

100%

91.94%

92.9%

89.52%

91.4%

Tandridge Ward

300 - GENERAL SURGERY

89.57%

98.33%

93.64%

90.32%

91.29%

94.26%

92.36%

Tilgate Annex

100 - GENERAL MEDICINE

96.99%

86.25%

96.76%

101.67%

96.9%

92.86%

95.44%

Tilgate Ward

300 - GENERAL MEDICINE

93.52%

98.91%

92.8%

100%

93.25%

99.19%

95.23%

Woodland Ward

100 - GENERAL SURGERY

84.99%

100%

91.4%

91.94%

87.41%

95.97%

90.28%

92.48%

94.3%

94.5%

93.83%

93.16%

94.13%

93.54%

Total

Commentary The Trust has delivered planned versus actual staffing profile for August. The continued variance on Burstow Ward is due to staffing shortfalls in the maternity service and has been actively managed by the matrons with no adverse outcomes in relation to clinical care. The Delivery Suite has experienced staffing pressures this month in addition to increased activity in month. There has been a successful recruitment campaign and the division is over recruiting against base establishments to manage predicted shortfalls in the autumn. Nursing Agency Spend Rules Further information has now been received and is tabled as a separate board paper. Nursing Recruitment National and international nursing recruitment continues. The Filipino recruitment is continuing but remains protracted with the first recruits expected in low numbers in November with higher volumes anticipated in February, March and April 2016. European recruitment is expected to supply 42 registered nurses in total. 6 nurses are in post with a further 23 expected on 5 October with the remainder expected in November. Further interviews are planned. A local recruitment event is being held on 26 September at the Trust. PLACE assessment Patient-Led Assessments of the Care Environment (PLACE) results for 2015 were published in August with the scores as follows: Criteria

SASH %

Cleanliness Food Privacy, dignity and wellbeing Condition, appearance and maintenance Dementia

97.98 85.56 79.27 86.67 56.18

National Average % 97.57 88.49 86.03 90.11 74.51

The dementia criteria is new for 2015 and in response to the scores for the Trust in this area, a Dementia Steering Group has been formed to explore the assessment outcomes of the PLACE assessment, common themes, current dementia work streams and identification of short and long term interventions.

4 An Associated University Hospital of Brighton and Sussex Medical School

A number of interventions have already been implemented through the work of the Consultant Nurse for Dementia and further areas for consideration will be explored in conjunction with the identification of care environment needs of other patient groups such as learning disabilities.

Medical Director Report Chiefs away day The clinical chiefs, including the Chief Nurse and Director of Medical Education spent two days discussing how they could lead and better contribute to the challenge of moving sash from good to outstanding. The conclusion reached, and agreed by all, was that chiefs needed to spend more time as chiefs to enable better input to strategy and in order to be held accountable for the performance of their division. Achieving these outputs would then enable better performance as individuals within the exec, and better leadership of the Clinical Leads, who would also be expected to work in a different way, as commenced within the GE work, but not seen through to a standardised and time enabled pattern of leadership, development and work. Ideas to Innovation Factory In partnership with Induct this work has now been launched. In the first week 149 people have registered as users, and 50 ideas have been submitted. We also have more than 40 people from across all divisions who have expressed an interest to work as Innovation Agents, to help screen, develop and progress ideas. Anyone with a sash email address can join and this will enable them to see the ideas that are being proposed. Consultant appointments Dr Matyas Andorka has been appointed as a consultant in Intensive Care Medicine

Recommendation

The Board is asked to note the report and associated actions.

Fiona Allsop Chief Nurse September 2015

Des Holden Medical Director

5 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD IN PUBLIC

Date: 24th September 2015

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

Agenda Item: 2.3 Quality Governance Assurance Framework – Refreshed Action Plan with Monitor Feedback Des Holden Fiona Allsop Medical Director Chief Nurse Gillian Francis-Musanu Director of Corporate Affairs ECQR – August 15 Board Seminar – August 2015

Action Required: Approval ()

Discussion ()

Assurance (√)

Purpose of Report: To review the feedback from Monitor on the Quality Governance Assurance Framework (QGAF) and the actions required to further reduce the overall score and improve quality governance processes. Summary of key issues This refreshed Action plan has been developed following Monitor feedback on the Quality Governance Memorandum & QGAF with an overall score of 3.5. The refreshed Action & Delivery plan should take the Trusts overall score to at least 2.0 by the end of this calendar year. This is an essential requirement of the Trusts FT application journey. Recommendation: The Board are asked to review the action and delivery plan. The action will be regularly reviewed by the Executive Committee for Quality & Risk and the Trust Board. 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 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

A regulatory requirement for all aspirant Foundation Trusts

Financial impact

Particularly linked to the CIP and QIA process

Patient Experience/Engagement

Relevant to the QGAF

Risk & Performance Management

Relevant to the QGAF

NHS Constitution/Equality &

Relevant to the QGAF

Diversity/Communication Attachment: Refreshed QGAF Action & Delivery Plan v0.2

2 An Associated University Hospital of Brighton and Sussex Medical School

REFRESHED QUALITY GOVERNANCE ASSURANCE FRAMEWORK ACTION & DELIVERY PLAN – v0.2 – 16TH Sept 2015 QGAF Question Strategy: 1B Is the Board sufficiently aware of potential risks to quality?

Processes & Structures: 3A Are there clear roles and accountabilities in relation to quality governance?

Monitor Commentary

Monitor Provisional Score

CIP process missing elements of good practice, relying on strong executive involvement rather than processes. Adequate for CIP programme for 2015/16 but would need to be improved for higher risk schemes in future. A/G score is dependent on the view that the Board is capable of strengthening current processes and making improvements in the future as they are required.

A/G

Board to review QIAs for 2015/16

0.5

Board approved initial 2016/17 CIP plan

The Trust has some missing good practice. The quality of SQC papers are variable, in particularly the quality report and the timing of the 5 quality sub-groups means that on occasion the latest quality information is not reported to SQC. This impacts the ability of the sub-committee to provide assurance to the Board on quality mitigated to some extent by other mechanisms through which the SQC has oversight of quality issues and the strength of

Trust Action

Board to review 2014/15 QIA PIR

A/G 0.5

Trust Evidence of compliance & Timescale

Lead

RAG & Residual Score

Completed – May 2015 – Board report and minutes Completed – June 2015 – board report and minutes Complete – August 2015 – board report and minutes

A/G

0.5

FA/DH

Moving to Green (0.0)

when all actions complete

Completion of 2016/17 CIP plan, schemes & QIAs

Due – @ Board - Dec 2015

Twice yearly review of 2015/16 CIPs & with a focus on Quality Impact

Due – @ Board - Nov 2015 & April 2016

Review of CIP process & mechanisms – outcome reported to Board.

Due – @ Board - Nov 2015

Content of Quality Report & Integrated Performance Report to be signed-off by Directors with review of narrative

Ensure completed monthly

BE/CP

Review sub-committee reporting to ensure timely escalation & timing of 5 quality subcommittees, impact and reporting to SQC in order to improve assurance to SQC and Board

BY 31.8.15 & meeting monthly timescales - Initial work complete, reviewing output

FA/DH

A/G 0.5

Moving to Green (0.0) when all actions complete

1 Refreshed QGAF Action Plan v0.2. – 16.09.15/gfm

clinical and executive management.

There is no forum for holding divisions to account for performance as a whole; although executives are satisfied they have oversight of divisional performance as a whole though executive committee meetings. Processes & Structures: 3B Are there clearly defined, well understood processes for escalating & resolving issues & managing quality performance?

Measurement: 4A Is appropriate quality information be analysed

There are some elements of good practice but some areas of weakness. The Trust is aware of weaknesses in incident reporting, clinical audit and complaints; plans to address these are at an early stage (particularly for the latter two areas). A number of escalation processes are not well documented or clear (such as the risk management policy, QIAs and reporting through sub-committees) and there is currently no clear plan to improve in these areas.

The Trust has some missing good practice, with no speciality/ward level dashboards, although the Trust has plans to introduce ward/speciality level dashboards. The Trust also has plans to introduce metrics to allow

A/R 1.0

Executive Committee to review & document processes for holding divisions to account & recommend a refreshed process which is document & implemented

Complete - divisional performance reviews reinstated

ECQR

Divisional “hot- spots” triangulated into a monthly report for ECQR & SQC

BE/CP

Risk management policy to be revised & updated to include role of sub-committees in reviewing & escalating risks

Completed

KH/FA

Quality sub- committee ToR to be updated to include responsibility for reviewing & escalating risks

Completed

Complaints reporting to be included in Quality Scorecard, IPR and reported to SQC

A/G 0.5

Completed

CP/GFM

KH/FA

Clinical Audit plan for 2015/16 to be reflective of required changes

Completed

JP/DH

Clinical Audit progress report to be reported to SQC

Due – for SQC Nov 2015

JP/DH

6 monthly report to the Board on complaints, incidents, clinical audit etc. on progress, themes etc.,

Due for Board in October 2015

JP/KH

Ward/speciality dashboards currently being piloted. A clear reporting implementation plan in place.

Implementation plan on target with input from frontline staff- due for completion - end September 2015

Moving to Green (0.0) when all actions complete

A/G - 0.5 BE/PB

Moving to Green (0.0) when all

2 Refreshed QGAF Action Plan v0.2. – 16.09.15/gfm

and challenged?

monitoring of performance against specific quality goals and strategic risks.

Measurement: 4B

The Trust has some significant areas of missing good practice, including no individual owners signing off data quality prior to inclusion in reports (although draft dashboards are circulated to divisions prior to reporting), and a lack of clearly documented controls and processes for data quality. The Board has no oversight of the quality of data reported, although the Trust has plans to introduce kite marks. The Trusts Quality Accounts were qualified in both 2012/13 and 2013/14.

Is the Board assured of the robustness of the quality information?

actions complete

A/R 1.0

A/R

Report to SQC – Oct 2015

BE/AS

Moving to A/G when actions completed

To be agreed – Oct 2015

BE/AS

Process In place – Oct 2015

Review of implementation of data quality strategy, including introduction of quality kite mark Process in place to enable Board to have clear data quality oversight.

External Audit on 2014/15 Quality Account Unqualified

Process to be put in place to ensure oversight of all other “Green” QGAF rating for sustainability – CP/GFM

TOTAL SCORES

BE/AS

Clear process for data quality sign-off which is consistently implemented for IPR & Quality Report

Achieved – June 2015 On-going

DH/GFM/LW CP/GFM

3.5

3 Refreshed QGAF Action Plan v0.2. – 16.09.15/gfm

Integrated Performance Report M05 â&#x20AC;&#x201C; August 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 – August 2015 Patient Safety • There was one SI related to missed diagnosis declared in August 2015 and no Never Events declared. • Patient safety indicators continue to show expected levels of performance. • The Trust had no MRSA bloodstream infections and three Trust acquired C-Diff cases in August 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 96.1% in August 2015. • All Cancer Access Standards were achieved except the 62 Day Referral to Treatment Standards. • The Trust continues to deliver against incomplete pathways which measures % of patients still waiting at the end of each month. Patient Experience • In August 2015 the Inpatient FFT increased from 95.1% to 95.3%. The ED FFT increased from 91.4% to 95.8% 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 – August 2015 Finance • The Trust is adverse to plan by £1.9m at month 5 with a (£2.6)m deficit. 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, Cancelled and / or delayed elective operations and Care of Adolescent patients with mental health conditions.

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

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

Regulation:

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

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

An Associated University Hospital of Brighton and Sussex Medical School 3

Patient Safety Patient Safety Indicator Description

Aug-14 Sep-14

Oct-14 Nov-14 Dec-14

Jan-15

Feb-15 Mar-15 Apr-15 May-15 Jun-15

Jul-15

Aug-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)

92.5%

92.0%

95.0%

93.0%

92.0%

91.3%

93.5%

92.0%

95.0%

92.2%

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

96.1%

94.5%

98.0%

96.0%

97.0%

96.0%

95.0%

96.0%

95.9%

97.3%

95.2%

97.7%

94.8%

95%

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

Percentage of Patient Safety Incidents causing Severe harm or Death

0.6%

1.1%

0.7%

0.2%

0.6%

0.7%

0.6%

0.2%

0.6%

0.5%

0.0%

0.2%

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 August 2015. • Safety Thermometer – the % of patients with harm free care (new harm) is lower than the threshold of 95%. The number of patients reported as having sustained a fall, a catheter & UTI or a VTE are all higher than normal. The combined effect is lower percentage than expected. • One SI was declared in August 2015 which is described overleaf.

An Associated University Hospital of Brighton and Sussex Medical School 4

Patient Safety • Missed diagnosis. In 1992 the patient was diagnosed with melanoma (5mm Breslow depth). In 2008 patient had a pigmented lesion removed which was reported as benign compound naevus. In August 2015 the patient presented with acute ascites, core biopsies taken from the peritoneum have led to a diagnosis of metastatic malignant melanoma. In view of a possible misdiagnosis in 2008, the previous skin histology has been sent for review, a formal report of the review is awaited. • A new Patient Safety Risk was added to the Significant Risk Register in relation to an increased in number of adolescent patients with mental health issues (attempted suicide, self harming, eating disorders and absconding) being admitted to general paediatric ward. Nursing staff on the ward are not mental health trained to provide appropriate care and support for this cohort of patients presenting a risk around appropriate care and supervision. Risk score 15 (Likelihood of 3 and consequence of 5). Infection Control Indicator Description

Aug-14 Sep-14

Oct-14 Nov-14 Dec-14

Jan-15

Feb-15 Mar-15 Apr-15 May-15 Jun-15

Jul-15

Aug-15

MRSA BSI (incidences in month)

CDiff Incidences (in month)

MSSA

E-Coli

Trend

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

An Associated University Hospital of Brighton and Sussex Medical School 5

Clinical Effectiveness Mortality and Readmissions Indicator Description

Aug-14 Sep-14

Oct-14 Nov-14 Dec-14

Jan-15

Feb-15 Mar-15 Apr-15 May-15 Jun-15

HSMR (56 Monitored diagnoses - 12 Months)

93.2

92.7

91.6

93.0

94.4

93.5

93.0

93.5

93.2

93.9

Emergency readmissions within 30 days (PBR Rules)

7.2%

6.8%

7.2%

7.1%

6.9%

6.7%

6.6%

6.4%

7.0%

7.2%

Jul-15

Aug-15

Trend

7.7%

• 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. • Whilst COPD is not a statistical outlier as confirmed by Dr Foster Intelligence, the rate is consistently above the relative risk of 100 (the national average). The committee raised the issue and will ask the speciality to carry out a review. • Readmissions within 30 days continues to remain at expected levels. Maternity Indicator Description

Aug-14 Sep-14

Oct-14 Nov-14 Dec-14

Jan-15

Feb-15 Mar-15 Apr-15 May-15 Jun-15

Jul-15

Aug-15

C Section Rate - Emergency

14%

17%

12%

14%

17%

18%

16%

17%

13%

17%

18%

14%

17%

C Section Rate - Elective

13%

12%

13%

11%

10%

11%

13%

Admissions of full term babies to neo-natal care

6.1%

8.0%

5.4%

3.8%

6.3%

6.0%

7.0%

6.2%

4.0%

5.0%

5.1%

Trend

• Maternity indicators continue to show expected performance. Clinical Audit Programme • The Clinical Effectiveness Committee is reviewing the Divisional Clinical Audit Programmes at the end of the month.

An Associated University Hospital of Brighton and Sussex Medical School 6

Access and Responsiveness Emergency Department Indicator Description

Aug-14 Sep-14

Oct-14 Nov-14 Dec-14

Jan-15

Feb-15 Mar-15 Apr-15 May-15 Jun-15

Jul-15

Aug-15

95.9%

95.4%

94.3%

95.7%

93.3%

92.0%

91.3%

95.0%

96.8%

96.0%

94.8%

94.3%

96.1%

Ambulance Turnaround - Number Over 30 mins

151

183

344

163

259

247

199

170

206

238

220

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 August 2015 with performance of 96.1% • 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 three risks are on the significant risk register: • ED Access Standard - Failure to maintain the emergency department standard due to lack of capacity in the health system – Risk score 16 (Likelihood of 4 and consequence of 4) • Patient admitted to the right bed first time – If the trust does not maintain and improve the ability to allocate the right bed first time, there is an increased risk of reduced quality of care (effectiveness, experience and safety) – Risk score 15(Likelihood of 5 and consequence of 3) • Cancelled and / or delayed elective operations - Due to on-going operational pressures and increasing demand for emergency inpatient beds, elective inpatient surgery is being cancelled and / or postponed. Longer waiting times result in poor patient experience and increase the number of formal and informal complaints. (effectiveness, experience and safety) – Risk score 15(Likelihood of 5 and consequence of 3)

An Associated University Hospital of Brighton and Sussex Medical School 7

Access and Responsiveness Cancer Aug-14 Sep-14

Oct-14 Nov-14 Dec-14

Jan-15

Feb-15 Mar-15 Apr-15 May-15 Jun-15

Jul-15

Aug-15

Cancer - TWR

93.0%

93.2%

93.8%

93.1%

93.3%

94.2%

93.1%

93.0%

Cancer - TWR Breast Symptomatic

94.4%

93.2%

93.3%

93.6%

93.5%

93.4%

96.3%

93.8%

90.6%

93.2%

93.3%

Indicator Description

Cancer - 31 Day Second or Subsequent Treatment (SURGERY)

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Cancer - 31 Day Second or Subsequent Treatment (DRUG)

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Cancer - 31 Day Diagnosis to Treatment

97.1%

99.2%

100.0%

99.1%

98.4%

97.1%

Cancer - 62 Day Referral to Treatment Standard

87.9%

78.8%

87.1%

86.3%

86.1%

85.4%

88.0%

Cancer - 62 Day Referral to Treatment Screening

100.0%

83.3%

100.0% 100.0%

92.3%

100.0%

98.2%

97.0%

96.2%

98.3%

99.1%

83.7%

86.4%

83.9%

86.5%

80.7%

81.3%

92.3%

84.6%

92.3%

100.0%

87.5%

83.3%

100.0% 100.0%

Trend

• All Cancer Access Standards were achieved in July 2015 except for the 62 day standards. • On the 62 Day Pathway, 15 patients breached the 62 day standard (6 shared breaches with tertiary providers). 8 patients were Urology with the upper and lower GI pathways having 4 breaches, the remainder were across a variety of pathways. • On the 62 Screening Pathway, 1 patient breached. The patient was treated at 64 days following referral from the screening centre at day 42. • The Trust is progressing with the “8 High Impact Changes” instigated by the Tripartite and expects to have all in place by the end of October. As part of this work, an investment of 2.6WTE in the cancer tracking team has been agreed and significant development of the tracking system has been made.

An Associated University Hospital of Brighton and Sussex Medical School 8

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

Aug-14 Sep-14

Oct-14 Nov-14 Dec-14

Jan-15

Feb-15 Mar-15 Apr-15 May-15 Jun-15

Jul-15

Aug-15

93.9%

93.8%

93.5%

93.3%

92.2%

92.1%

94.0%

93.7%

93.6%

93.5%

92.6%

92.2%

92.0%

RTT Admitted - 90% treated within 18 weeks

90.4%

90.7%

88.1%

81.4%

91.1%

90.2%

82.1%

88.4%

91.6%

90.1%

92.0%

84.0%

81.5%

RTT Non Admitted - 95% treated within 18 weeks

95.8%

93.2%

93.9%

92.8%

95.0%

91.7%

91.0%

93.5%

93.6%

95.3%

93.4%

89.4%

89.1%

Percentage of patients w aiting 6 weeks or more for diagnostic

0.1%

0.0%

0.4%

0.1%

0.9%

0.7%

1.4%

1.0%

0.2%

0.8%

1.0%

0.1%

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

0.0%

1.0%

1.6%

0.0%

2.2%

0.0%

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

Trend

• The Trust continues to deliver against incomplete pathways standard which measures % of patients waiting less than 18 weeks at the end of each month. • A number of newly recruited consultants will increase capacity in key specialties, Cardiology, General Surgery and T&O, and support reduction in patients over 18 weeks. • Although previous admitted and non admitted standards were not achieved against the old standard of ‘patients actually treated’. This is due to prioritisation of patients who have been waiting the longest. • 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.

An Associated University Hospital of Brighton and Sussex Medical School 9

Patient Experience Patient Voice Indicator Description

Aug-14 Sep-14

Oct-14 Nov-14 Dec-14

Jan-15

Feb-15 Mar-15 Apr-15 May-15 Jun-15

Jul-15

Aug-15

Inpatient FFT - % positive responses

98.0%

96.0%

97.0%

95.0%

95.7%

96.9%

94.2%

94.4%

95.1%

94.7%

95.1%

95.3%

Emergency Department FFT - % positive responses

98.0%

95.0%

96.0%

93.0%

95.8%

97.1%

94.7%

95.4%

95.3%

93.7%

91.4%

95.8%

Maternity FFT - Antenatal - % positive responses

99.0%

96.0%

97.0%

95.0%

90.0%

97.6%

97.1%

97.0%

96.3%

100.0%

83.3%

94.1%

98.8%

Maternity FFT - Delivery - % positive responses

98.0%

95.0%

93.0%

100.0%

95.5%

97.2%

100.0%

94.7%

97.0%

94.9%

93.8%

87.9%

Maternity FFT - Postnatal Ward - % positive responses

93.0%

90.0%

92.0%

96.0%

85.9%

91.0%

97.3%

86.7%

91.0%

86.5%

90.0%

87.7%

100.0% 100.0%

94.0%

100.0%

85.0%

100.0% 100.0% 100.0% 100.0%

77.8%

Maternity FFT - Postnatal Community Care - % positive responses Mixed Sex Breaches Complaints (rate per 10,000 occupied bed days)

Trend

100.0% 100.0% 100.0%

• Inpatients - The August Friends and Family Test (FFT) score for inpatients remains very stable at 95.3%. There has been a marked increase in the FFT response rate to 40%, the highest for seven months •

Emergency Department – The FFT score for ED has improved, up from 91.4% in July to 95.8% in August. There has also been an increase in the response rate, from 10% in July to 14% in August

• Maternity - The FFT scores for the antenatal touchpoint has increased for a second month to 98.8% (from 94.0% in July). However both the delivery and postnatal ward FFT scores have dropped (to 87.9% and 87.1% respectively). These are both based on a lower than usual response rate of 9% • National FFT comparisons July • Inpatients – The national average FFT score for inpatients in July was 95.6%. SASH scored very slightly below this at 95.1%. • ED - Our combined adult and paediatric ED Friends and Family Test score for July was 91.4%, well above the national average of 88.2%.

An Associated University Hospital of Brighton and Sussex Medical School 10

Workforce Workforce Aug-14 Sep-14

Oct-14 Nov-14 Dec-14

Jan-15

Feb-15 Mar-15 Apr-15 May-15 Jun-15

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

95.7%

95.4%

96.4%

97.1%

95.1%

94.8%

95.9%

96.5%

96.8%

95.7%

Average fill rate – care staff (%) - Day

97.5%

96.4%

95.3%

95.0%

93.1%

92.6%

93.8%

94.5%

96.1%

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

97.2%

98.1%

99.2%

99.4%

97.3%

97.2%

97.7%

96.7%

Average fill rate – care staff (%) - Night

97.5%

96.7%

97.4%

95.3%

93.7%

93.3%

94.9%

Overall Sickness Rate

3.2%

4.0%

4.4%

4.0%

4.5%

4.3%

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

75%

74%

72%

69%

72%

15.8%

15.6%

15.3%

15.6%

Indicator Description

Staff Turnover rate

Jul-15

Aug-15

96.9%

93.3%

92.5%

93.8%

93.5%

94.3%

94.5%

96.5%

97.1%

94.1%

95.2%

94.3%

94.9%

95.2%

95.9%

94.9%

94.4%

93.8%

4.4%

4.2%

4.3%

4.1%

3.9%

3.7%

67%

68%

73%

71%

68%

58%

56%

57%

15.7%

15.2%

15.5%

15.9%

15.6%

15.2%

Trend

• Sickness absence decreased to 3.7% in August 2015. It is too early to say whether this is a falling trend as the actions identified in the sickness audit are unlikely to have taken effect. • Increasing Sickness Absence Levels with impact 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 • Staff Turnover fell slightly to 15.2% in August 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 11

Finance Indicator Description

Aug-14 Sep-14

Oct-14 Nov-14 Dec-14

Jan-15

Feb-15 Mar-15 Apr-15 May-15 Jun-15

Jul-15

Aug-15

Outturn £m Surplus / (Deficit) - Plan

2.3

1.6

Outturn £m Surplus / (Deficit) - Forecast

2.3

(2.5)

(2.4)

1.6

YTD £m Surplus / (Deficit) - Plan

(1.5)

(1.3)

0.1

0.4

1.0

1.9

1.4

2.3

(0.8)

(1.2)

(2.0)

(1.1)

(0.7)

YTD £m Surplus / (Deficit) - Actual

(1.5)

(1.3)

0.1

0.5

1.0

1.9

(2.9)

(2.4)

(0.8)

(1.1)

(2.0)

(1.3)

(2.6)

Outturn UNDERLYING £m Surplus / (Deficit) - Plan

3.4

3.8

Outturn UNDERLYING £m Surplus / (Deficit) - Actual

3.4

1.0

(0.7)

(5.2)

3.8

3.3

YTD Savings £m - Actual

2.8

3.8

5.0

6.2

7.4

8.6

9.8

11.0

0.3

0.5

0.8

1.3

1.9

(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

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

3.1

3.0

3.8

2.8

4.8

3.8

2.6

3.2

2.9

2.6

2.5

3.0

(17.0)

(10.0)

(7.0)

(4.0)

(8.0)

(18.0)

(21.0)

(20.0)

(21.0)

(23.0)

(22.0)

(25.0)

YTD BPPC (overall) volume £m

94%

90%

85%

88%

87%

86%

82%

62%

75%

78%

76%

YTD BPPC (overall) value £m

88%

87%

92%

78%

84%

83%

81%

65%

73%

75%

74%

Outturn Capital spend Fav / (Adv) - forecast

19.4

19.3

17.1

OT Risk £m Surplus / (Deficit) - Assessment

YTD Liquid ratio - days

Trend

• The Trust is adverse to plan by £1.9m at month 5 with a (£2.6)m deficit. • The position is mainly due to the phasing of and reduction in the income plans and the unsustainability of covering it with reserves, plus overspending above forecast in Divisions. Emergency activity continues to drive operational pressure and agency usage remains high. • The underlying position at the end of June is £(3.1)m deficit, reflecting the non recurrent contingency savings. • The outturn forecast remains a £1.6m and the resubmitted plan to the TDA this month reflects this position. The Board will be reviewing the forecast at M06. • Risks to the 2015/16 financial plan remain at £5.8m and are all mitigated.

An Associated University Hospital of Brighton and Sussex Medical School 12

Finance • The cash balance at the end of August 2015 was £3.0m. This is adverse to the TDA plan which assumed the £18m liquidity loan would have been received. Cash is very tight (with delays in the receipt of the £4.4m capital loan and from over-performance monies from CCG’s). The plan is to draw down £6.0m of the temporary working capital facility in September. • The capital spend forecast this year is £17.1m. However, pressure is being exerted to restrict this.

An Associated University Hospital of Brighton and Sussex Medical School 13

TRUST BOARD IN PUBLIC

Date: 24th September 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 – 01/09/15

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 noted the review of the Board Assurance Framework and requested updates to reflect the Trust’s current strategic position (Foundation trust Journey) The Chair of the Finance and Workforce Committee introduced management’s review of workforce controls. The Committee took assurance from the planned mitigations and actions already taken. The Committee took assurance from Internal Audits review of Trust the workforce strategy and RTT data quality audit. Recommendation: The Board is asked to note this report. Relationship to Trust Strategic Objectives & Assurance Framework: SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment: The AAC reviews assurance in respect of all Trust systems of control which includes reporting and compliance with all statutes applied to an NHS Trust. Legal and regulatory impact Financial performance is subject to Schedule 5 of the NHS Act 2006 which provides the “breakeven duty”.

The AAC reviews assurance in respect of all Trust systems of control which includes reporting and compliance with all regulation applied to an NHS Trust. The main regulators, however are as follows: - External audit (the Audit Commission for this Trust) give an opinion on the Trustâ&#x20AC;&#x2122;s compliance with International Financial Reporting Standards and with NHS accounting conventions â&#x20AC;&#x201C; this is not purely financial and deals with procurement, fraud, transparency and legal duties. It also gives a Value for Money Conclusion on the Trustâ&#x20AC;&#x2122;s ability to put in place arrangements to deliver economy, efficiency and effectiveness in its use of resources. The Care Quality Commission registers the Trust according to its compliance with regulations concerning the safety and quality of services. Financial impact

Committee review of Trust financial position

Patient Experience/Engagement

No relevant aspects

Risk & Performance Management

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

NHS Constitution/Equality & Diversity/Communication

No relevant aspects

Attachment: N/A

2 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT – 24/09/2015 Audit & Assurance Committee Chair Update The Audit and Assurance committee met on the 01/09/2015; it was quorate. The key points from this meeting were as follows: 1) Board Assurance Framework The Committee discussed the board assurance framework prior to the September public board. The Committee focussed on strategic issues that could be updated to reflect mitigations such as inclusion of details of the transitional care ward and plans for future IT developments. The Committee asked specifically that the strategic risk relating to the Trust’s foundation trust application be reviewed to reflect current status. The Committee then discussed the four main financial risks in detail and took assurance from managements comments on use of bank and agency and Internal Audits 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. 2) Internal Controls The Chair of the Finance and Workforce committee presented management’s review of internal controls relating to the Trust’s workforce systems. The assessment includes one red and five amber rated controls; temporary staffing (red), recruitment, training, achievement review, payroll and nurses and midwife revalidation. The Committee noted 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 noted 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. 3) Internal Audit Internal Audit gave its regular update to the Committee on activity and audit completion. The Committee discussed the recent Workforce Strategy audit which had focussed on recruitment and management’s actions to improve performance. Internal Audits review of RTT data had highlighted no significant concerns and the Committee was assured by commentary on closure of open actions. 4) AOB The Committee Chair asked for assurance that recent guidance on processes to ensure that consultancy contracts in excess of £50k are supported by a business case and that management is taking action to meet the new 3% agency target. Management 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.

3 An Associated University Hospital of Brighton and Sussex Medical School

Date: 24th September 2015 TRUST BOARD IN PUBLIC Agenda Item: 4.1 Serious Incident Report for August 2015 Fiona Allsop Chief Nurse Katharine Horner Patient Safety & Risk Lead

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

n/a

Action Required: Approval ( )

Discussion ()

Assurance ()

Purpose of Report: This paper provides the Board of Directors with a report on the serious incidents declared in August and an update on the overall position with regard to the management of serious incidents within the Trust. Summary of key issues • The Trust reported one serious incident in August 2015; the incident occurred in 2008 and was identified for further investigation in August 2015. • Falls and clinical diagnosis remain the two key categories of serious incident. • As at 17th August 2015 the Trust has eight serious incidents open with the CCG, of which four have been submitted for closure. • There are no SI’s overdue for submission; the backlog has now been cleared. Recommendation: The Board is asked to note the contents of this 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

Corporate Impact Assessment: Legal and regulatory impact Financial impact Patient Experience/Engagement Risk & Performance Management NHS Constitution/Equality & Diversity/Communication

Compliance with CQC, MHRA and Audit Commission Serious incidents often become claims Included in the report Reporting, investigation and learning from serious incidents informs risk management Complies with the NHS Constitution

Attachment:

Page 1 of 4

TRUST BOARD REPORT – 24th September 2015 Serious Incident Report – period: August 2015 1.

Introduction

1.1

A report on Serious Incidents (SI) is produced each month to provide assurance that they are being managed, investigated and acted upon appropriately and that action plans are developed from the Root Cause Analysis investigations.

1.2

This paper looks specifically at those incidents that are considered as SIs following the guidance from the NHS England’s ‘Serious Incident Framework” published March 2015.

1.3

A summary of open SIs is published weekly and circulated to Execs.

1.4

SI reports are reviewed by the Sussex Scrutiny Group. The Patient Safety and Risk Lead presents the reports to the panel and provides feedback to the Trust Serious Incident Review Group.

Patient Safety Incidents in August 2015

2.1

There were a total of 655 incidents reported on Datixweb in August 2015 of which 530 (81%) were clinical/patient safety incidents. These incidents breakdown as follows:

2.2

The incident categories are shown for those incidents categorised as moderate harm, severe harm or death. One of the severe harm incidents was considered to meet the criteria of a serious incident. The other is being investigated as an amber incident. Both categorised as clinical diagnosis.

Serious Incidents declared in August 2015

3.1

The Trust declared one serious incident in August 2015 which relates to a possible misdiagnosis of a skin melanoma in 2008.

3.2

SI themes over the last 12 months The serious incidents are shown by the month in which they occurred, not the month in which they were declared. The date of knowledge and therefore declaration may be different. Patient falls and clinical diagnosis are the two main themes of serious incidents over the last twelve months.

Weekly overview A weekly open SIs overview summary is sent to the Patient Safety and Risk Lead and the Chief Nurse which indicates overall Trust and Divisional performance in completing SI investigations within the National timeframe. The Serious Incident Review Group closely monitors the investigation and submission process. The backlog of overdue SIs from 2014 has now been completed and submitted. The Divisions are asked to include an update on RCA reports to the Patient Safety and Clinical Risk Sub-Committee. This is the latest reported Trust position at 16th September 2015.

Page 3 of 4

Serious Incident investigations closed by the CCG in August 2015

The CCG closed nine investigations during August; the patients involved in these incidents have received feedback from the Trust under Duty of Candour. 6. Recommendation The Trust Board are asked to discuss the report and take assurance regarding the management of SIs and the on-going work to improve performance on completing SI investigations within the National timeframe.

Fiona Allsop Chief Nurse September 2015

Page 4 of 4

TRUST BOARD IN PUBLIC

Date: 24 September 2015 Agenda Item: 4.2

REPORT TITLE:

Agency nursing ceiling plan to TDA/Monitor

EXECUTIVE SPONSOR:

Fiona Allsop (Chief Nurse)

REPORT AUTHOR:

Paul Simpson (Chief Financial Officer)

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

Executive Comittee

Action Required: Approval



Discussion

Assurance

Summary of Key Issues •

Monitor & TDA issued rules on managing agency nursing costs and required all TDA trusts to submit a plan describing how they will reach the target “ceiling” spend. by 14 September. These plans have been signed off by the Trust’s CFO and Chief Nurse, endorsed by the Executive Team and require approval by the Board.

•

Monitor, TDA and the Chief Nursing Officer for England emphasise the importance of trusts and commissioners fulfilling their responsibilities for safe staffing as described in the NICE and National Quality Board (NQB) guidance (including the 10 expectations published in November 2013).

•

TDA rules have specifically quantified the nursing costs to be applied as a denominator (registered nurses, so excluding nursing assistants). Using that measure Trust spend on agency was 20% of registered nurse pay spend in M05. The Trust’s target in 2015/16 is 12%.

•

This target can be achieved by the end of Q4 2015/16 (the second milestone), but cannot be achieved by the first milestone (Q3). Therefore a formal “application for adjustment to the ceiling trajectory” has been submitted.

•

TDA will monitor delivery through their monthly Delivery meetings, and noncompliance sees escalation through a series of steps, including intensive support team input.

•

The rules also require the Trust to only use agencies on frameworks notified by TDA: that notification will follow.

Action: The Board are asked to approve the plan. Relationship to Trust Strategic Objectives & Assurance Framework: SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO4: Responsive – Become the secondary care provider and employer of choice for the catchment populations of Surrey & Sussex SO5: Well - led Corporate Impact Assessment:

The main regulators, are as follows: •

Legal and regulatory implications

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

•

Financial implications

The Care Quality Commission registers the Trust according to its compliance with regulations concerning the safety and quality of services The plan enclosed sees a reduction in spend on agency nursing in line with targets set by TDA..

Patient Experience/Engagement

No adverse impact is expected

Risk & Performance Management

A performance management process is in place in the Trust, including to ensure no adverse impact on quality or safety.

NHS Constitution/Equality & Diversity/Communication

No material issues

Attachments: Report paper with appendices

TRUST BOARD REPORT – 24th September 2015 AGENCY NURSING CEILING PLAN FOR SUBMISSION TO THE TRUST DEVELOPMENT AUTHORITY Summary •

•

TDA rules have specifically quantified the nursing costs to be applied as a denominator (registered nurses only). Using that measure the Trust spend on agency was 20% of registered nurse pay spend in M05. The Trust’s target in 2015/16 is 12%.

•

Achievement of the plan has been calculated based on measures already being introduced: o

international recruitment;

the pilot scheme for new bank rates for theatre staff (with agreed agency reduction);

an assumption on the new agency price cap (5%);

agreed changes to Godstone/Chaldon templates;

the impact of the recovery plan ED nursing business case;

the non-payment of breaks (notified to agencies in August).

•

The plan is challenging but realistic, and includes a contingency.

•

The Finance & Workforce Committee is receiving reports on agency management, and the Trust has a hierarchy of performance meetings that will monitor delivery. Formal reporting will be through month end financial reports.

•

TDA will monitor delivery through their monthly Delivery meetings, and noncompliance sees escalation through a series of steps, including intensive support team input. These escalations are described at Appendix 1.

•

The rules also require the Trust to only use agencies on frameworks notified by TDA: that notification will follow.

Action: The Board are asked to approve the plan.

Fiona Allsop Chief Nurse September 2015

The Plan Plan

Monthly actual values

Nursing Employee Benefits

Month ending 30-Apr-15

Month ending 31-May-15

Month ending 30-Jun-15

Month ending 31-Jul-15

Month ending 31-Aug-15

Month ending 30-Sep-15

£'000

Nursing - Total Agency costs (excluding outsourced bank) Nursing - Total Gross Employee Benefits (including agency) Nursing agency costs as % of total nursing costs

915

883

987

1,174

972

961

4,829

4,835

4,764

5,013

4,795

4,933

18.95%

18.26%

20.72%

23.42%

20.27%

19.48%

Monthly revised plan values

Nursing Employee Benefits

Month Ending 31-Oct-15

Month Ending 30-Nov-15

Month Ending 31-Dec-15

Month Ending 31-Jan-16

Month Ending 29-Feb-16

Month Ending 31-Mar-16

£'000

Nursing - Total Agency costs (excluding outsourced bank) Nursing - Total Gross Employee Benefits (including agency) Nursing agency costs as % of total nursing costs

868

795

754

612

591

606

4,966

4,943

4,940

4,825

4,926

5,048

17.48%

16.08%

15.26%

12.68%

12.00%

The workings behind the Plan are below: Nursing Employee Benefits

Nursing - Total Agency costs (excluding outsourced bank) Nursing - Total Gross Employee Benefits (including agency) Nursing agency costs as % of total nursing costs

Month ending 31-Aug15 £'000

Month ending 30-Sep15 £'000

972 4,795

961 4,933

20.3%

19.5%

Month Ending 31-Oct15 £'000

Month Ending 30-Nov15 £'000

Month Ending 31-Dec15 £'000

Month Ending 31-Jan16 £'000

Month Ending 29-Feb16 £'000

Month Ending 31-Mar16 £'000

868 4,966

795 4,943

754 4,940

612 4,825

592 4,926

604 5,048

17.5%

16.1%

15.3%

12.7%

12.0%

ngs: £'000 gency Costs Baseline (MTh 1 - 5 above) Less: Philippines Recruitment European Recruitment Theatre Bank - 30% Conversion New Rates - new Contract - assumed 5% ED - Nursing - 50% Godstone Chaldon Improved Rosta Control Non Payment of Breaks (0.5 hours per shift) Contingency against pressures

£'000

972

£'000

986

-14 -11

-53 -43 -33 -14 -11

-49 -53 -40 -33 -14 -11

-10 -185 -53 -38 -33 -14 -11

-49 -219 -53 -31 -33 -14 -11

-63 -219 -53 -30 -33 -14 -11

-40

-36

-33

-31

961

868

795

754

612

-25 40 592

-25 65 604

-25

-118

-191

-233

-374

-394

-382

-14 -11

Reduction in Agency Cost compared to average (MTh 1- 5)

£'000

986

-53

972

£'000

Attached appendices: Appendix 1 : TDA response to non compliance Appendix 2: general expectations of trusts and their Boards Appendix 3: application to adjust ceiling trajectory Appendix 4: letter to CEO dated 1 September

Appendix 1 Response to non compliance (Table 4 in Section 6.4)

Response to non compliance (continued - Section 6.5)

Appendix 2

Appendix 3 Application for adjustment to ceiling trajectory [AS SUBMITTED TO TDA] To be completed by NHS Trusts and NHS Foundation Trusts, signed off by a Finance Director or Board member. Applications will be approved in exceptional circumstances Please respond to agencyrules@monitor.gov.uk by 14 September 2015 Name of Trust

Surrey and Sussex Healthcare NHS Trust

Completed by

Fiona Allsop

Job title

Chief Nurse

Telephone number

01737 7687511 ext 1825

Email address

Fiona.Allsop@sash.nhs.uk

Date completed

14th September 2015

Name of Board member and position

Fiona Allsop - Chief Nurse

1) Why are you applying for this adjustment? (Maximum 500 words) As at the end of August 2015 the Trust’s YTD spend on qualified agency averaged 20% of total spend on qualified nurses. The Trust is fully signed up to the absolute necessity of reducing agency expenditure, and has a robust plan for doing so. The Trust’s plan brings the percentage of agency expenditure down to 12% by Jan 2016 and then down to 10% from 1st April 2016. The Trust has thoroughly reviewed whether this plan could be accelerated even further, but has come to the conclusion that to do so would have significant patient safety implications due to high vacancy rates particularly at Band 5 level nursing and the difficulties in attracting suitably qualified staff locally and nationally with the inherent delays being experienced. . 2) For what period of time are you applying for an adjustment? The Trust only requires an adjustment for Quarter 3 2015/16. Within Q3 the Trust’s expenditure is planned to reduce from 20% to 16%. In Q4 it then reduces to an average of 12% 3) What is your proposed annual trajectory of nursing agency spend? Total 2015/16 planned spend = £10,118K Q1 = £2,785K Q2 = £3,107K Q3 = £2,417K Q4 = £1,809K

Please reflect this proposal in your monthly plan for Q3 and Q4 2015/16, submitted to Monitor/TDA. If this adjustment is not approved, you will need to submit a revised monthly plan to Monitor/TDA. 4) What are your existing measures for controlling agency spend (e.g. rostering)? • Leaving vacant shifts unfilled where safe to do so • Re-deploying existing nursing staff from alternate areas where safe to do so • Overseas recruitment - Philippines circa 145 (spread between Nov 2015 and April 2016) • European recruitment - Span and Romania, circa 50 (spread between Sep 2015 and Nov 2016). • Theatres staff bank rate enhancement • Non-payment of concessionary breaks to agency staff • E-rostering upgrade to facilitate direct booking and improved fill rates - anticipated launch in December 2015 • National reduction of agency rates • Analysis of rostered patterns of ward managers • Proposal to enhance bank rates for substantive staff in the rest of the organisation.

5) Please confirm that this application has been discussed with, and approved by, the Nurse Director. Application completed by Fiona Allsop - Chief Nurse

Appendix 4

Letter issued to CEO

[END]

Date: 24th September 2015

TRUST BOARD IN PUBLIC

Agenda Item: 4.3 Equality Delivery System and Workforce Race Equality Scheme Briefing Yvonne Parker Director of HR Nathaniel Johnston, Workforce Services Manager Janet Miller Deputy Director of HR

REPORT TITLE: EXECUTIVE SPONSOR:

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

ECQR – Workforce Committee 14th May 2015

Action Required: Approval (√)

Discussion (√)

Assurance (√)

Purpose of Report: To update the Board on two new requirements which support our obligations under the Public Sector Equality Duties. These are the Equality Delivery System (EDS2) and Workforce Race Equality Standard (WRES). Summary of key issues From April 2015 EDS2 implementation and WRES reporting by NHS provider organisations became a mandatory requirement in the NHS standard contract. In addition EDS2 implementation is explicitly cited within the CCG Assurance Framework and embedded within the CQC inspection regime for hospitals within the “Well Led” domain. EDS2 is a toolkit which has been designed to help NHS organisations meet the requirements of the Public Sector Equality Duty and support the identification of areas for improvement for patients and staff. Recommendation: The Board are asked to:• • •

note the use of EDS2 and WRES and champion the principles that underpin them within the Trust Approve the EDS2 and WRES assessment process and development of revised Equality Objectives for 2016/17 note the baseline data for WRES submitted to Department of Health on 1 July 2015 and resultant actions

Relationship to Trust Strategic Objectives & Assurance Framework: Use of EDS2 and WRES supports all of the Trust objectives 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 The use and promotion of EDS2 and WRES within the Trust also underpins the Trust values and behaviours and supports a culture where patients and staff feel they are valued and treated as individuals. Corporate Impact Assessment: Legal and regulatory impact Financial impact Patient Experience/Engagement Risk & Performance Management NHS Constitution/Equality & Diversity/Communication

Supports Public Sector Equality Duty, CQC Hospital Inspection, CCG Assurance Framework Failure to comply may lead to penalties being imposed under the NSH standard contract The process of assessment under EDS2 will involve patients and any objectives agreed will lead to improvements in patient experience Better understanding of patients and staff’s requirements has the potential to Direct impact on our ability to deliver the requirements of NHS Constitution and Equality and Diversity obligations

Attachment: Equality Delivery System and Workforce Race Equality Standard Briefing document. Appendix 1 – Goals and Outcomes of EDS2 Appendix 2 – Overview of Steps for Implementing EDS2 Appendix 3 – Trust WRES submission to NHS England July 2015

2 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT – 24th SEPTEMBER 2015 EQUALITY DELIVERY SYSTEM AND WORKFORCE RACE EQUALITY STANDARD 1.

Introduction

Equality Delivery System. A revised NHS Equality Delivery System (EDS2) was launched in November 2013 and became made mandatory in the NHS Standard Contract from 1st April 2015. The aim of the EDS2 is to promote the commitment by the NHS to ensuring the NHS is fair and inclusive for patients, staff and the public. The EDS2 is not a self-assessment tool and the organisations performance should be assessed and graded in discussion with local stakeholders, patients and health bodies. The EDS2 toolkit includes 18 outcomes and is structured around 4 Goals:Goal 1 Goal 2 Goal 3 Goal 4

Better health outcomes for all Improved patient access and experience Empowered, engaged and included staff Inclusive leadership at all levels

All NHS organisations will be asked to grade themselves against. These outcomes are aligned to the NHS Constitution and the Care Quality Commissions key inspection questions (Appendix 1). Workforce Race Equality Standard. In order to respond to national challenges around race diversity in the NHS, NHS England has introduced the Workforce Race Equality Standard (WRES). From 1st April 2015 the WRES is mandated for all NHS organisations in the NHS Standard Contract. As a Trust we will be asked to gather data across nine indicators which will examine the likelihood of someone from a BAME background being recruited, receiving training or being disciplined when compared to white staff. It will also ask us to report on the results of questions in our staff survey including whether staff feel they have been bullied or harassed, if they feel they have equal opportunity for progression and whether staff feel they have been discriminated against (Appendix 3). 2.

Implementation

Both the EDS and the WRES require board level support and engagement. NHS England guidance advocates an “informed and selective approach” to undertaking the EDS2, suggesting flexibility, where there is a local need, to focus on the services that are reviewed and the characteristics that are examined. It is advised that a comprehensive implementation of EDS2 is undertaken over three to five years through the use of informed

3 An Associated University Hospital of Brighton and Sussex Medical School

choices at any one time. The Trust will follow the structure to implementing the EDS2 as set out in Appendix 2. Local stakeholders will be involved in the EDS2 to help us determine our equality objectives and EDS2 priorities. Identifying local stakeholders is a piece of work that the Patient Experience Team, along with SaSH culture champions will be starting through 2015-16. In line with WRES requirements the Trust has submitted benchmark data to NHS England. The Trust will be required to report against this benchmark data and actions on an annual basis. Progress against the actions is being monitored by the Executive Committee for Risk and Clinical Care – Workforce Committee. 3.

Recommendation

The Board are asked to • note the use of EDS2 and WRES and champion the principles that underpin them within the Trust as per Stage 1 of the EDS Implementation (appendix 2) • Approve the EDS2 and WRES assessment process and development of revised Equality Objectives for 2016/17 • note the baseline data for WRES submitted to Department of Health on 1 July 2015 and resultant actions Yvonne Parker Director of Human Resources September 2015

4 An Associated University Hospital of Brighton and Sussex Medical School

Appendix 1

5 An Associated University Hospital of Brighton and Sussex Medical School

Appendix 2

6 An Associated University Hospital of Brighton and Sussex Medical School

Appendix 3

7 An Associated University Hospital of Brighton and Sussex Medical School

AUDIT & ASSURANCE COMMITTEE Meeting held on Tuesday 17th July 2015, 9:30 to 12:00 Venue: Room AD77, Trust HQ, East Surrey Hospital Present: Paul Biddle Richard Shaw

PB RS

Committee Chair / Non-Executive Director Non Executive Director

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

PS GFM FA DE MW NA SP CP

Chief Finance Officer Director of Corporate Affairs Chief Nurse Head of Financial Accounts Grant Thornton (External Audit) Baker Tilly (Internal Audit) Local Counter Fraud Specialist Corporate Governance Manager

Action by 1

1.0

Welcome and Apologies for absence PB welcomed members to the meeting. Richard Durbanâ&#x20AC;&#x2122;s apologies for absence were noted.

1.1

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

1.2

Actions from previous meetings: PB introduced the action log, noting that each item was due to be discussed during the meeting and, as such, are recorded as closed.

2.1

Board Assurance Framework GFM introduced the Board Assurance Framework paper.

The Committee discussed the board assurance framework, focussing on individual controls and assurances recorded in finance and quality related risks specifically asking for updates relating to due actions.

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PB queried what level of review was carried out at SQC focussing on the patient safety risks. The committee noted that this specific risk had limited content on gaps in control and asked that this was reviewed. Action FA to review patient safety risk on BAF and include narrative on significant gaps in control. PB and PS discussed the detail of activity planning included in the financial BAF risks. PS noted that Sussex had signed plans but there was still work to do to agree and sign plans with Surrey CCG. PS assured the committee that the matter was being managed appropriately, with positive comments on price analysis and indicative plans. PS went on to highlight issues relating to marginal rate agreement and the general understanding that the 70% emergency activity tariff would revert to 30% in the new financial year. The Committee asked whether there should be more detail in the BAF risk relating to failure to deliver income plan. PS highlighted the records in the Trust risk register which provide greater detail to the management of the issue and its mitigation. The Committee noted that BAF risks relating to finance and foundation trust journey would need to be updated throughout July and August following Board conversations. RS asked how assured management was on issues relating to effectiveness and clinical benchmarking. PS highlighted the Trustâ&#x20AC;&#x2122;s internal benchmarking reports, Dr Foster data and work of Effectiveness subcommittee and SQC. The Committee noted the assurances that the BAF risk drew from. The Committee discussed proposals to develop assurance processes to support its work reviewing the BAF and agreed that efforts to increase management assurance of the actions and structures that supported the BAF would be welcomed. 2.2

Significant Risk Register GFM introduced the significant risk register noting conversations that had occurred earlier in the meeting.

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the

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The Committee had no further comments and duly noted the draft SRR. 3

3.1

Legal Obligations

GFM presented the review of internal controls relating to legal requirements, highlighting changes to Health and Safety, Fire Safety and Sustainability. GFM noted that significant assurance can now be taken from capital plan requirements that ensure all new build and refurbishment work are energy neutral. NA commented on the useful nature of the format and the assurances recorded in the report. RS reminded the committee that previously all elements of the internal controls had been assigned to committees of the Board and that this was a useful tool to aid the assessment of assurance. Action CP to ensure future reports detail which subcommittees are responsible for gaining assurance for elements of internal controls. The Committee asked for assurance that appropriate procurement processes are in place. PS stated that he was assured that procurement processes are in place and that the Trust was alive to the national picture and changes in regulations. NA agreed with the assurances given. The Committee took assurance from both the review and comments from Internal Audit. 3.2

Temporary Staffing Audit

FA introduced the temporary staff audit and actions that had been taken following the completion of the report. The Committee discussed the issue in significant detail, noting the linkages to the BAF and efforts to recruit and retain staff. FA highlighted that the actions detailed in the report are all long term and linked to changes in service and IT improvements. FA went on to highlight the weekly and monthly meetings that are in place to manage agency spend and assurances that short term actions are being taken. The Committee discussed efforts to align staff records with ledgers and the need to ensure that the agreed 22% uplift had been taken Audit & Assurance Committee th Minutes 27 May 2015

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into account. The committee took assurance from the actions, management had taken to date to mitigate against the issues raised by the audit. Noting continuing concerns over the effectiveness of the Temporary Staffing Bureau. The Committee asked that the Finance and Workforce Committee continued to seek assurances over effectiveness of controls, their effect on agency spend and forecasting. The Committee asked for specific assurance that the issue was being managed at an Executive level. Both FA and PS stated that the management of temporary staffing issues had significant Executive oversight. The Committee noted that the Trust is considering options for the management of TSB including potential outsourcing. PB thanked management for its update. 3.3

Annual Gifts & Hospitality Report

GFM presented the annual report which included a redacted version of the register, provided for assurance. GFM went on to note that current systems are described in the standards of business conduct. The committee noted that visibility of the register is rare and as such itâ&#x20AC;&#x2122;s difficult to benchmark the record against like sized Trusts. GFM noted that, as with most systems relying on self-declaration there would be gaps in staff understanding of what should be declared. However there was assurance from the wide range of entries recorded and how up to date the record was. GFM highlighted that this was included in MAST training for clinical staff. The committee noted the report for assurance. PB asked if the Trust was assured that directorâ&#x20AC;&#x2122;s expenses are recorded and declared appropriately, DE stated that appropriate records are kept and form part of annual report.

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4.1.a

Internal Audit Annual Report

NA introduced the Internal Audit annual report, highlighting activity, assurances provided and the delivery of the plan. Audits are based on a risk-based plan of work, agreed with management and approved by the Audit Committee. The committee agreed that it was a good and useful report and that the service provided good value. 4.1.b

Internal Audit Strategy

NA presented the draft Internal Audit strategy and plan for audit activity. The plan takes its guide from strategic risks, external pressures and national themes and has been reviewed by PS and the Executive Team. FA was keen to stress that the temporary staffing audit should not just focus on nurse management. NA noted the request and stated that the scope would include all relevant elements of temporary staff management. The Committee noted the robust process that had been taken to develop the plans and the focus on significant risks, key controls and strategic intention. The Committee agreed the plan. 4.1.c

Internal Audit Progress report

NA presented the Internal Audit progress report, highlighting the audits that had been carried out and actions that had been resolved since the last meeting. The Committee noted that, as audits from the plan had been delayed this activity would be carried forward into the next annual cycle. The Committee discussed issues relating to RTT data quality and was assured that minor issues identified did not change the overall Trust performance of the specific target. The Committee were assured that stronger controls had been put in place to support cash management systems in facilities and noted the audit issues highlighted in the payments to staff audit. Taking assurance that there is an active system in place to claw back overpayment errors but there is work to do to reduce the incidence. Audit & Assurance Committee th Minutes 27 May 2015

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The Committee took significant assurance from both the Quality Account audit and the clinical governance audit. However it noted ongoing issues relating to the delivery of the clinical audit program which is monitored by SQC and the need to ensure that actions from the ‘Francis report’ action plan are duly closed. NA went on to discuss the action tracker detailing audit recommendations and managements actions. The Committee noted the actions that remain outstanding. PB thanked NA for his report and ongoing assurances provided by the service. 4.2.1

External Audit Review of Quality Account

JB introduced the audit on the Trust’s Quality account. This provided an unqualified opinion. The Trust's Quality Account was consistent with regulations and Trust staff had made recommended changes before completion. The committee took assurance from the report, noting that it was a limited assurance audit. 4.2.2

External Audit; Annual Audit Letter

JB presented the annual audit letter which summarised its findings for the three key audits had carried out, including the Quality Account. The annual accounts audit had provided an unqualified opinion on the Trust’s accounts, income and expenditure for the year. External audit had provided a qualified conclusion on the Trust’s value for money, linked to the Trust end of year deficit of £2.4 million in 2014/15. The Committee noted the strong assurances that this provided and agreed that the £2.4 million deficit was recognised and that financial controls had been sound. GFM

Action GFM to share the letter with the Board.

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4.3

LCFS Report

SP introduced the report which provided an update on NHS Protects assessment of the Trust’s systems which is due to take place in August. This will focus on strategic counter fraud governance and the ‘hold to account’ standard. SP went on to highlight that the Trust’s assessment was a random selection rather than a risk based review. PB asked for an opinion on the level of timesheet fraud. SP stated that fraud levels continues to rise year on years and that this is linked to financial situation and increased awareness and reporting. PS went on to state that the Trust continued to learn from identified cases of fraud and regularly updated systems to mitigate against risk. The committee discussed recent issues surrounding doctors carrying out private work on Trust time and were assured that appropriate controls had been identified. RS noted issues relating to medical staff working outside of their qualification and asked what assurances management had that efforts to implement national counter terrorism initiatives are in place. CP highlighted that the Trust had an active counter terrorism lead with strong linkages to local support, noting the activity in higher risk areas and focused training that has been delivered. PB thanked SR for the report. 5

5.1

AOB PB brought the meeting to a close. There was no other business.

5.2

Date of Next Meeting: 1st September, 09:30 pre-meet, 10:00 meeting start.

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