January 2015 Board Papers by Surrey and Sussex Healthcare NHS Trust

Trust Board Meeting – IN PUBLIC Thursday 29th January 2015 - 10:00 to 12:30 PGEC Room 7/8, East Surrey Hospital, Canada Avenue, Redhill, RH1 5RH

AGENDA 1

10:00

10:30

11:15

GENERAL BUSINESS 1.1

Welcome and apologies for absence

A McCarthy

Verbal

1.2

Declarations of Interests

A McCarthy

Verbal

1.3

Minutes of the last meeting held on 18th December 2014 - For approval

A McCarthy

Paper

1.4

Action tracker

A McCarthy

Verbal

1.5

Chairman’s Report For assurance

A McCarthy

Verbal

1.6

Chief Executive’s Report For assurance

M Wilson

Paper

1.7

Board Assurance Framework, & Significant Risk Register - For approval and assurance

G FrancisMusanu

Paper

SAFETY, QUALITY AND PATIENT EXPERIENCE 2.1

Patient’s Story For assurance

D Holden

Paper

2.2

Chief Nurse & Medical Director’s Report For assurance

D Holden/ F Allsop

Paper

2.3

Safety & Quality Committee Update For assurance

R Shaw

Paper

OPERATIONAL PERFORMANCE 3.1

3.2

Paper

Integrated Performance Report (M9) For assurance 3.1.1

Operational & Quality Key Performance Indicators

P Bostock/ D Holden

3.1.2

Workforce Key Performance Indicators

F Allsop

3.1.3

Finance Key Performance Indicators

P Simpson

Finance & Workforce Committee Update For assurance

R Durban

Paper

3.3

3.4

11:55

12:25

Audit & Assurance Committee Update For assurance Audit & Assurance Committee Annual Report For approval

P Biddle

Paper

P Biddle

Paper

RISK, REGULATORY AND STRATEGY ITEMS 4.1

Care Quality Commission Action Plan Update For assurance

S Jenkins

Paper

4.2

Serious Incident’s Report For assurance

F Allsop

Paper

4.3

Corporate Governance Manual Update (Standing Orders and Standing Financial Instructions) For approval

P Simpson

Paper

4.4

The Care Act 2014 – Safeguarding Regulations For approval

F Allsop

Paper

OTHER ITEMS 5.1

Minutes from Board Committees to receive & note

All

5.1.1

Finance and Workforce Committee

Paper

5.1.2

Safety & Quality Committee

Paper

5.1.3

Audit & Assurance Committee

Paper

5.2

ANY OTHER BUSINESS

5.3

QUESTIONS FROM THE PUBLIC

A McCarthy

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

A McCarthy

5.4

DATE OF NEXT MEETING 27th February 2015 at 10.00am

Minutes of Trust Board meeting held in Public Thursday 18th December 2014 from 10:00 to 13:00 Room 7/8, PGEC East Surrey Hospital Present (AM) Alan McCarthy (MW) Michael Wilson (YR) Yvette Robbins (PS) Paul Simpson (PBo) Paul Bostock (DH) Des Holden (FA) Fiona Allsop (PBi) Paul Biddle (PL) Pauline Lambert (RD) Richard Durban (RS) Richard Shaw (AH) Alan Hall

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

In Attendance (GFM) Gillian Francis-Musanu (SJ) Sue Jenkins (Item 4.1) (SMB) Sacha Beeby 1.

Director of Corporate Affairs Director of Strategy 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 to the final meeting of the Board for 2014. No apologies for absence were noted.

1.2

Declarations of Interest The Chairman asked if the Board members had any declarations of interest. No interests were recorded.

1.3

Minutes of the last meeting â&#x20AC;&#x201C; 27th November 2014 The minutes of the meeting held on the 27th November 2014 were agreed as a true and accurate record.

1.4

Action Tracker The outstanding actions were completed and now closed.

1.5

Chairmanâ&#x20AC;&#x2122;s Report for Assurance The Chairman shared some reflections from the NHS Provider meeting (previously known as the Foundation Trust Network) held in December. The meeting emphasised the level of pressure the health system faced at the current time and Page 1 of 10

focused on the Five Year Forward View and Dalton Review for medium-long term solutions. The Board will be asked to discuss this in more detail in the Seminar to be held later in the day. The Chairman’s verbal update was duly noted by the Board. 1.6

Chief Executives Report for Assurance The Board received and noted the Chief Executive’s report in advance of the meeting. MW presented the report and highlighted the following; In February 2014 the Secretary of State asked Sir David Dalton to lead a Review to examine options and opportunities for providers of NHS care. This culminated in a report to the Secretary of State for Health which was published on 5th December 2014. The Dalton Report complements the ‘Five Year Forward View’ and provides the means by which new care models can be delivered through a range of organisational forms. The Trust is pleased to announce that following a recent recruitment and selection process Dr Bruce Stewart, Consultant Medical Microbiologist & Chief of Service for Clinical Support Services (CSS) has been appointed as the Pathology Joint Venture Clinical Director. Internally, Dr Julian Webb will take over as Clinical Chief of CSS and Dr Ed Cetti has also been appointed as Clinical Chief of Cancer Services. The launch of the SaSH Charity took place on 11th December and was very well received. The Board thanked the Communications team for their hard work in planning the launch event. The new Capel Anex ward has been opened. This is a fantastic facility for ensuring patients receive the right care, by the right person, at the right time. MW reported that the new non-slip, dementia-friendly flooring is proving problematic due to difficulties in keeping its appearance clean. This is despite increased efforts by the cleaning team. Discussions are taking place to resolve this issue. Finally, MW concluded that the hospital was very busy and experiencing similar winter pressures felt locally and nationally across the health system. Escalation remains open as demand increases. The continued hard work of staff was noted and their efforts very much appreciated by the Board. The report was duly noted by the Board.

1.7

Board Assurance Framework and Significant Risk Register for Approval and Assurance GFM introduced the BAF and SRR for discussion and approval by the Board. GFM highlighted that the BAF presents 5 red risks, 12 amber risks and 2 green risks. Following review by the Executive Committee, the changes made reflect conversations at the November Public Board, Audit & Assurance Committee and those identified through reports to the Executive Committee. It is proposed that the current ratings for “Failure to deliver income plan” (5A1) and “Failure to stop divisional overspending against budget” (5A2) are both increased from 15 to 16 to reflect the current financial position. Page 2 of 10

With apologies for not being present at the Finance & Workforce Committee meeting, PB questioned the increase noting the improved financial position at month 8. PS confirmed that the changes reflect a correction to the likelihood versus impact and is not an increase in risk. It is considered appropriate because the Trust continues to carry a ÂŁ3.6m risk despite performing well in other aspects. YR challenged the fall in severity relating to divisional overspending. PS commented that this is what the Board agreed and was appropriate for the current position. . The narrative in BAF 1A has been updated to include specific falls management controls. A new risk has been identified to reflect the risk relating to gastro viral outbreak during the winter period. DH added that the Trust has now experienced its first outbreak which resulted in ward closures. However, this has now been recovered and beds re-opened with the outbreak confirmed as Norovirus. The Chairman praised the management of risks and the challenges made by the Board. The Board resolved to approve the report. 2.

Safety, Quality and Patient Experience 2.1 Chief Nurse and Medical Directorâ&#x20AC;&#x2122;s Report for Assurance The Board received and noted the report in advance of the meeting. FA presented the first half of the report focusing on safer staffing compliance and presentations received by the Executive Team during a Learning Disability Afternoon Tea with patients and carers. The Board noted the Trustâ&#x20AC;&#x2122;s overall score for staffing compliance increased to 93.97% during the month of November, with Registered Nurse compliance at 94.89% during the day and 98.01% at night. This provides assurance that out-ofhours compliance remains a priority to ensure safety, with wards gaining access to a much increased senior nursing team during the day. PL requested some assurance that Paediatric services were safe, noting the recent increase in demand and staffing challenges. FA confirmed that matrons are visible on every ward and when necessary, nursing staff are being transferred from CAU to appropriately meet demand and patient mix. DH further added that the current acuity levels could not be explained, however focus remains on Paediatric resource in order to manage current activity levels. FA further highlighted that the Executive Team recently attended a presentation for the Learning Disability Afternoon Tea, meeting patients with learning disabilities, their carers and some of the community and Trust support services to hear about their experiences. Patients reported very positive experiences in general, with small areas of learning for the Trust. PL was pleased to see such positive reviews from this event. DH continued to present the second half of the report focusing on developments in Pharmacy education and senior medical staffing appointments. Training for Pharmacists is overseen by Health England Kent, Surrey & Sussex Page 3 of 10

(HEKSS). The Trust has been notified that for 2015/16 we have been exempt from a quality visit because of the internal high standards we have achieved. It was noted that to date, only three Trusts across Kent, Surrey and Sussex, Hampshire and the Isle of Wight have achieved this exemption through excellence. Such quality visits would focus on the release of staff to undertake their training, the quality of training provided and opportunities and delivery. DH added that the Trust has appointed two consultant Obstetricians and a consultant Radiologist since the last Board meeting. DH further added that, following recent changes to junior doctors’ workloads, the Trust would expect to see improved performance in Patient Opinion feedback comments, direct feedback from the doctors, GMC surveys and discharge enabling abilities which are currently too impacted by ward moves. It is likely that these results will not be seen until January / February 2015. The Board duly noted and took assurance from the report. 2.2

Quality, Assurance and Escalation Framework for Assurance The Board received and noted the report in advance of the meeting. DH presented an assessment of the effectiveness of changes at Board level to composition and reporting structures. It also provides an assessment of the effect of delegating elements of quality governance and resources to divisional level and describes the current escalation framework for the Trust. The report provides evidence to Monitor of the Board’s discussions relating to the impact on quality governance. The Board was asked to discuss the effectiveness of changes at Board-level and at divisional-level and to consider whether the escalation framework was appropriate and demonstrates the ability to review current practices. In relation to Appendix 1, the Board agreed that the FWC not only ‘Affects strategy and gains assurance, but also affects ‘High impact governance and assurance’. PL added that the clinical non-Executive role should receive formal valuation, and commented positively on the visibility of Executive and non-Executive Directors to staff. The Board acknowledged ongoing development with Service Managers in owning their Agenda and ensuring the appropriate level of clinical discussion. PS requested inclusion of the Quality Assurance Group in recognition of CCG comments and the formalisation of the PMO role. RD commented that the Workforce sub-Committee are looking at improving interaction with other sub-Committees. AM corrected that in relation to 3.1, performance reviews for non-Executive Directors would take place at the end of March, not February. SMB will provide dates during January. Consideration should be made for those Clinicians and Directors receiving the same information from reports presented at multiple committee meetings. DH accepted that repetition was inevitable however, the quality of discussions differed in each forum. Page 4 of 10

RS commented that the Executive Committee for Quality & Risk has enabled the Safety & Quality Committee to be selective of its discussions. It also provides the Committee with some assurance. It was accepted that structures for escalation were in place. However, culture often determined the use of those structures. Commitment and drive to improve standards was dependent on the individual. The Board duly noted the report for assurance. 2.3

15-Step Challenge Report for Assurance The Board received and noted the report in advance of the meeting. FA presented the first report to the Board which shares the outcomes of the 15step challenge reviews which have been undertaken at the Trust. The 15-steps challenge is a tool to help staff, patients and others to work together to identify improvements that can be made to enhance the patient experience. The challenge takes place in the ward environment and can help the Trust to understand and identify the key components of high quality care that are important to patients and carers from their first contact with a ward. General feedback has been positive and staff have found it to be a useful and helpful process. Areas for improvement have been identified in reports and the programme will continue during 2015. The Board noted thanks to all those engaged in the process. AM challenged the ability to address all of the issues raised by staff and the areas identified for improvement, noting that some of those may require longer-term improvement plans. FA added that some of the smaller issues raised would be managed locally by the nursing team. The Trust should be able to promptly respond to those staff raising concerns or specific issues, as well as manage expectations. MW added that the Trust was currently considering a Ward Accreditation Scheme, which accredits the ward teams and demonstrates the expectations from that team. Staff have a responsibility of their own to notify the Estates Department of any issues relating to the fabric of the building as and when it is a concern. The 15-step challenge should not be solely relied upon for raising such issues. FA added that the Ward Improvement Group continues to meet regularly and a progress report will be shared with the Board in 6 months. The Board duly noted the report for assurance.

2.4

Safety & Quality Committee Update The Board received and noted the report in advance of the meeting. The report summarised some of the key discussion points of the last committee meeting held on 4th December 2014. The committee received reports from the November Executive Committee for Page 5 of 10

Quality & Risk and meetings of the CQRM. It also reviewed the Quality Dash Board and CQC Intelligence Monitoring reports. The committee noted the actions planned to reduce the number of open SI reports, the recent review into elective deaths which has not found underlying concerns and the monitoring of formal complaints to understand if the recent increase is a trend. The committee also noted the discussions in CQRM about the management of operational pressures and the CCG actions that arise from the CQC Quality Summit and action plan. It is hoped that there will be CCG representation at the next SCQ meeting to provide an update on this. The Trust has asked CCGs to ensure that the CQC action plan is a regular item for discussion at future meetings, to ensure responsibilities are owned. RS highlighted that the most recent CQC Intelligence Monitoring report confirms the Trust’s risk rating remains at Band 6 (the lowest risk level) and that only one of the four areas of concern in the previous quarter’s report remains highlighted. The remaining elevated risk relates to the proportion of patients whose operation was cancelled in the period April-June 2014. The Board duly noted the report for assurance. 3.

Operational Performance 3.1.

Operational and Quality Key Performance Indicators The Board received the Integrated Performance report in advance of the meeting. PB highlighted some of the key themes in relation to operational performance and activity pressures. The Board noted that the performance data available was limited due to the meeting being held earlier in month. PB summarised that the month of November was successful in terms of performance, despite the continued increase in emergency activity. The ED standard was delivered with 95.7% of patients being admitted or discharged within 4 hours with no 12 hour trolley wait breaches. The Trust is working with CCGs to better understand this high level of emergency activity and mitigate the risk as we move into winter to ensure the Trust can remain resilient throughout those months. In light of the on-going operational pressures, the following risks have been added to the significant risk register;  ED Access Standard – Failure to maintain the Emergency Department standard due to lack of capacity in the health system to manage winter pressures  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. The incomplete RTT standard continued to be achieved at aggregate Trust level, while the Admitted and Non-Admitted standards were not achieved. There were a number of specialty failures as work is undertaken to reduce the number of patients waiting over 18 weeks for treatment. As part of a national drive by the TDA, the Trust has been encouraged to deliberately sacrifice the RTT standard in order to reduce the number of patients on incomplete pathways over 18 weeks (“the Page 6 of 10

backlog”). All Cancer Access standards were achieved and the number of cancelled operations reduced by approximately half since October. There were four cases of Trust acquired C.Diff, taking the total to 15 YTD against a trajectory of 19 YTD and 22 cases for the same period last year. A recent outbreak of viral gastroenteritis on a single ward is likely to be as a result of cross-infection with no learning evident from the RCA. In light of this outbreak, a risk has been added to the Trust’s significant risk register. Two Serious Incidents (SI’s) were declared in November. One relating to a fall resulting in a fractured neck of femur and one relating to incorrect input of data into the Pathology system, resulting in the mother not receiving antenatal anti-D prophylaxis which could affect the management and outcome of future pregnancies. PB added that the month of December had seen high levels of activity. Escalation remains open in order to manage the number of admissions and ambulance attendances. This will result in the delivery of quarter 3 performance being compromised. A Christmas Operational Plan has been developed to provide a robust plan for service provision and staffing during the Christmas period. Activity levels are expected to remain high. Despite considerable investments made, the challenge remains the ability to return patients to community support services. 7-day working will now be a key consideration as activity levels remain high throughout the weekend. The site team now distribute data and information from the daily Bed Board meeting to the Executive Team. This data looks at A&E activity and ambulance attendances amongst others and allows the Trust to respond quickly to peaks in activity levels. CCGs and GPs are also experiencing high levels of demand for community services as patients lose confidence in the 111 operator system. In order to manage this activity, the Trust is forced to increase it’s spend on additional therapy and consultant support for ward rounds and escalation. However, this should demonstrate the need for additional funding to support the winter pressures going forward. The Trust noted that a dip in performance in relation to staff appraisals was likely to be reflective of the pressures within the hospital and were not a cause for concern at this stage. 3.2

Finance PS highlighted that the Trust remains on plan at month 8, with a £0.5m surplus year to date. The year to date position includes an accrual in respect of challenge to CCGs over the level of emergency activity and the withheld marginal rate budget, 4/8th of the 1st tranche winter resilience funding, 4/8th of the 2nd tranche winter resilience funding, as well as the use of contingency from the balance sheet. PS made the following correction from the report; the YTD liquid ratio days was -9, not -4. The forecast year end position is £2.3m surplus. However, risks to this position have been estimated at £6.3m, a reduction in the risk from last month reflecting the Page 7 of 10

mitigations in the month 8 position. The cost improvement plan year to date target is £6.2m and at month 8 this has been achieved. The underlying position at the end of November is £1.3m deficit; this is a worsening position due to additional non recurrent income and one-off balance sheet flexibilities supporting the position. The cash balance at the end of November was £2.75m, below the planned position due to the delay in receiving contract over performance money from CCGs. The cash position will become more challenging as expenditure continues adverse to plan with delays to payments possible from commissioners. The capital forecast spend is £19.4m, reflecting the additional funding for chemo prescribing. PS noted his concern for the month 9 forecast position and the impact of operational pressures. If the Trust does not achieve elective activity and escalation remains open this will impact the position significantly. The Executive Team continue to manage divisional finance performance through PMO meetings, whilst not compromising safety and quality of patients. The CFO noted his assurance that CSS were now managing Radiology department budgets and the maternity pathway position had improved. AM added that a meeting with David Flory (Chief Executive, TDA) has been scheduled for the first week in January and this will include a discussion about the Trust’s underlying financial position. 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 some of the key points of discussion from the FWC meeting held on 16th December 2014. The committee received the month 8 finance, workforce, capital and IT performance reports for discussion and noted that the Trust was performing on plan with a surplus of £0.5m. This includes non-recurrent items and an accrual in respect of income challenge. The Trust continues to forecast a £2.3m surplus, with £6.3m of risk. The CIP update was discussed with the Committee noting that, as in the previous year, underspends were being used to mitigate overspends in other areas. The committee accepted the management report on the PACS/RIS Post Evaluation and took assurance that learning had been taken and was being applied. In particular, clinical engagement in IT is very much more visible. The committee was advised that the Trust had applied for £1.1m of Nursing Technology Funding directly with the Department of Health to enable the implementation of equipment that automatically alerts clinical staff on vital sign statistics. If awarded, Executives will decide on whether to proceed with Page 8 of 10

implementation. The committee discussed detail of action around Quality Impact Assessments in respect of savings. The committee was assured that robust processes were in place in relation to QIAs. RD noted the following correction to the report: the staff survey return was at 46% this year, compared to 58% last year. The committee noted that Electronic Patient Record (EPR) transfer would commence mid-June 2015. The Board duly noted the report. 4.

Risk, Regulatory and Strategy Items

4.1

Care Quality Commission Action Plan Update for Assurance The Board received and noted the report and action plan in advance of the meeting. Sue Jenkins, Director of Strategy presented the CQC Action Plan which was developed following a visit by the Chief Inspector of Hospitals in May 2014 and in response to their findings in relation to service improvement. The Board receives monthly updates on progress against the action plan. SJ agreed to present a summary of discussions from the Outpatient Focus Group meetings to the Trust Board in January 2015. KPIs were now presented graphically. Improvement was noted on â&#x20AC;&#x153;clinics cancelled with less than 6 weeks-noticeâ&#x20AC;? however, the Board accepted that this is likely to peak during December due to operational pressures. Improvements in the number of ad-hoc clinics is not likely to be recognised until March-April 2015 and the Quality Summit actions await CCG response. The Board duly noted the report.

Other Items 5.1 5.1.1

Minutes of Board Committees to receive and note Finance and Workforce to receive and note

5.1.2

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

5.2

The minutes of the committee were noted with no questions raised. Any Other Business

5.2.1

MW informed the Board that HEKSS have approached SaSH to lead on the development of a School for Physician Associates for the KSS region. As SaSH has historically been very successful with meeting the educational requirements of PA students on placement, HEKSS would like us to use our in-house expertise along Page 9 of 10

with a dedicated resource to build a PA training programme in the region. SaSH will work with four universities: Brighton, Canterbury, Kent and Surrey and with St Georges Medical School with regards to the purchase of their established Physician Associate 2 year educational programme. SaSH will recruit a Programme/Project Manager to lead on this 12 month project. Alongside working with the Universities, they will work with the Trust in the region who are interested in having PA on placement with them, with the outcome that they will permanently recruit them when qualified. 5.2.2

On behalf of the Board, AM congratulated Michael Wilson for being named ‘Inspirational Leader of the Year’ at the NHS Kent, Surrey and Sussex Leadership Collaborative’s annual awards ceremony and summit in November.

5.2.3

FA introduced the Board to the newly appointed Nurse Consultant for Falls & Patient Safety, Francis Fernandez who was present in the audience and will be leading on the improvements for patient falls.

5.2.4

Finally, AM agreed to circulate to the Board a copy of the letter received by Bob Alexander (Director of Finance at the TDA) summarising the feedback from the Trust’s Board-to-Board meeting with the TDA on 20th November 2014 No further business was discussed by the Board.

5.3

Questions from the Public There were no questions raised from members of the public.

5.4

Date of the next meeting Thursday 29th January 2015 at 10.00am in Room 7/8, Post Graduate Education Centre, East Surrey Hospital

Note: This is a public document and therefore will be placed into the public domain via the Trust’s website in the interests of openness and transparency under Freedom of Information Act 2000 legislation.

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

Date:

Page 10 of 10

TRUST BOARD ACTION TRACKER Action Ref

Forum

Subject

Action

Date Open

Date Due

Date Closed

Status

ACTIONS FROM LAST BOARD MEETING

TBPU‐03

TB Public

15‐Steps Challenge

TBPU‐04

TB Public

Finance

FA added that the Ward Improvement Group continues to meet regularly to review actions in relation to maintenance and a progress Fiona Allsop report will be shared with the Board in 6 months. AM agreed to circulate to the Board a copy of the letter received by Bob Alexander (Director of Finance at the TDA) summarising the feedback from the Trust’s Board‐to‐Board meeting with the TDA on 20th November 2014 Alan McCarthy

18/12/2014

25/06/2015

OPEN

TRUST BOARD IN PUBLIC

Date: 29th January 2015 Agenda Item: 1.6

REPORT TITLE:

CHIEF EXECUTIVE’S REPORT

EXECUTIVE SPONSOR:

Michael Wilson Chief Executive Gillian Francis-Musanu Director of Corporate Affairs

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

Discussion (√)

Assurance (√)

Purpose of Report: To ensure the Board are aware of current and new requirements from a national and local perspective and to discuss any impact on the Trusts strategic direction. Summary of key issues National Issues:  The Care Act 2014 and implementation in April 2015  The Forward View Into Action - NHS England Planning Guidance 2015/16  Delivering in a challenging environment – Trust Development Authority – Refreshed Plans for 15/16 for NHS Trust Boards Local Issues:  Mutual Pathfinder Programme Update  Hot Topic Event – Emergency Department  Industrial Action Recommendation: The Board is asked to note the report and consider any impacts on the trusts strategic direction. Relationship to Trust Strategic Objectives & Assurance Framework: SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment: Legal and regulatory impact

Ensures the Board are aware of current and new requirements.

Financial impact

N/A

Patient Experience/Engagement

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

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

Legislation Attachment: N/A

2 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT – 29th January 2015 CHIEF EXECUTIVE’S REPORT 1.

National Issues

1.1

The Care Act 2014 and implementation in April 2015

The Care Act 2014 comes into being on 1 April 2015. It builds on recent reviews and reforms and replaces numerous pieces of previous legislation. It sets out new duties for Local Authorities and partners and new rights for service users and carers. The Act aims to achieve clearer, fairer care and support, physical mental and emotional wellbeing support for the person needing care and their carer, prevention and delay of the need for care and support, personal control of care. Details about the Care Act can be found at www.gov/uk/government/publications/care-act2014-part-1-factsheets The main implications of the Care Act for SaSH are detailed as follows  An increase in the number of people requiring assessment. For Sussex alone this is anticipated at 40%. This may have an impact on the number of people requiring assessment once they are medically fit for discharge although this is being mitigated by local authorities taking a proactive approach in the completion of assessments prior to hospitalisation where possible.  Safeguarding which includes Safeguarding Adult Boards and Serious Case Reviews will be on a legal footing meaning that there will be a duty on all local authorities, in partnership with others, to undertake safeguarding enquiries. The Trust will continue to remain core members of the Safeguarding Boards.  A change to some of the paperwork and processes surrounding discharges from hospital which will require training and education for staff.  A responsibility to work with others to ensure that care needs are prevented or delayed by taking a proactive and preventative approach to the physical, mental health and emotional wellbeing of people. This will include providing access to information and advice on services that are available. A system wide project Board is being established to support the implications of the Care Act and SaSH will be core members and work with partners to ensure that an integrated approach to implementation is agreed.

1.2

The Forward View Into Action - NHS England Planning Guidance 2015/16

In December 2014 leaders of the NHS in England published planning guidance for the NHS, setting out the steps to be taken during 2015/16 to start delivering the NHS Five Year Forward View. NHS England, Monitor, the NHS Trust Development Authority, the Care Quality Commission, Public Health England and Health Education England came together to issue the joint guidance coordinating and establishing a firm foundation for longer term transformation of the NHS. The guidance was backed by the recently-announced £1.98 billion of additional funding, with specific financial allocations for healthcare commissioners also announced. The coordinated guidance includes a new support package for GPs, plans for a radical upgrade in prevention of illness, and new access and treatment standards for mental health services.

3 An Associated University Hospital of Brighton and Sussex Medical School

The planning guidance requires leaders of local and national health and care services to take action on five fronts; namely:  seven approaches to a radical upgrade in prevention of illness with England becoming the first country to implement a national evidence-based diabetes prevention programme  explain how £480 million of the £1.98 billion additional investment will be used to support transformation in primary care, mental health and local health economies;  makes clear the local NHS must work together to ensure patients receive the standards guaranteed by the NHS Constitution;  underlines the NHS’s commitment to giving doctors, nurses and carers access to all the data, information and knowledge they need to deliver the best possible care;  details how the NHS will accelerate innovation to become a world-leader in genomic and genetic testing, medicine optimisation and testing and evaluating new ideas and techniques. In addition to The Forward View into action: planning for 2015/16, NHS England has published a technical annex and range of supporting materials. Monitor and the NHS Trust Development Authority have also published respective technical guidance documents and supporting materials for commissioners and providers. The key milestones for 2015/16 planning are:

4 An Associated University Hospital of Brighton and Sussex Medical School

The full document is available at http://www.england.nhs.uk/ourwork/forward-view/

1.3

Delivering in a challenging environment – Trust Development Authority – Refreshed Plans for 15/16 for NHS Trust Boards

Published at the end of December 2014, “Delivering in a Challenging Environment”: refreshed plans for 2015/16 aims to support NHS Trust Boards to provide a refreshed and updated plan for the year ahead, which, while building on their five year projections and plans, will take into account changes that have occurred either locally or nationally during the year. The document sets out the new requirements on providers that have been devised either by commissioners or regulators since the previous plans were submitted. The guidance should be read in conjunction with The Forward View into Action, which, for the first time since the NHS reforms, sets out in one place the joint high-level ambitions and system priorities for commissioners and providers. The proposed business rules for 2015/16, as set out in Monitor and NHS England’s national tariff consultation and NHS England’s standard contract consultation, have the potential to make balancing quality, delivery and finance tougher for providers in 2015/16 than it has been in the year gone by. This demonstrates the pressures facing decisionmakers both nationally and locally and that there are no easy choices in the current environment. Proposals that NHS Trust Boards will need to be particularly mindful of when agreeing their plan include:  The introduction of a default 50:50 gain and loss sharing price setting rule for acute prescribed  specialist services activity above 2014/15 planned levels;

5 An Associated University Hospital of Brighton and Sussex Medical School

  

Changes to the standard contract which introduce higher penalties for non-delivery of NHS Constitutional standards and information reporting failures together with a shift to make all sanctions automatic in future; The ambition of making significant progress toward implementing 24/7 working in the absence of further investment; and Delivering further efficiency gains of 3.8% after the sustained period of a 4% efficiency factor.

As with all provider organisations we will need to ensure that our forward plans for 2015/16 take account of the requirements included in the planning guidance. The full report is available at: http://www.ntda.nhs.uk/wp-content/uploads/2014/12/tda_planning_2014_final_web.pdf

Local Issues

2.1

Mutual Pathfinder Programme Update

In December 2014 the Trust heard that Bolt partners had been allocated as the technical, legal and consultancy partners to support us in the pathfinder mutual programme which runs from January to March 2015. The background to this Pathfinder programme is that the Mutual Model (where an organisation is owned by its staff) can improve clinical outcomes, patient experience as well as staff engagement, satisfaction and motivation. There are a number of public sector organisations including libraries, social care, community service and youth service providers where the mutual model has been successfully implemented and staff engagement and satisfaction levels have been significantly improved. So far Mutual organisations in the public sector have only been for relatively small organisations but this Pathfinder programme is offering the opportunity for both NHS Trusts and Foundation Trusts to be part of a national work stream to explore whether the mutual model can work in much bigger organisations. This is a great opportunity for us in terms of being part of something that is new and exciting, testing out how it fits with our Foundation Trust application and for the reputation of the Trust as a whole. Designed to help Trusts to consider the potential advantages of the public service mutual model, it will enable us to understand what mutualisation could mean for us, the potential benefits, including increasing staff engagement across our organisation, and identifying solutions to practical barriers regarding implementation. As part of our participation in the Pathfinder programme we will explore with staff: how the role of staff governors can further be enhanced once we have become a Foundation Trust  how a staff council can influence the decisions made by the Trust and how we ensure that it is valued by staff, clinicians, managers and the Trust Board  what rewards and incentive schemes would support and encourage a greater sense of ownership by staff  whether a Mutual Model will support us in moving towards delivering “outstanding” care and services to patients To date a kick off meeting has been held with Bolt partners and a small steering group, a project Board is being established and four workshops in which the work will be progressed are in the process of being established.

6 An Associated University Hospital of Brighton and Sussex Medical School

As an organisation I am particularly proud of the high levels of patient satisfaction, motivation and engagement that the Trust currently has and we see this as an opportunity of taking this to the next level. We will continue to keep the Board updated on progress over the next few months.

2.2

Hot Topic Event – Emergency Department

On 14th January 2015 the Trust held our latest Hot Topic event showcasing our emergency department (ED). Our ED team delivered a superb presentation and it was very encouraging to see the lecture theatre full of people from our local community, GPs and CCG colleagues, other health partners and Foundation Trust members. This event highlighted the excellent work of our ED team at a time when emergency departments across the country, and the NHS generally, are in the media’s spotlight, our ED team continues to shine, working tirelessly and valiantly to care for our patients. Our ED has worked around the clock over the winter period, a time that has traditionally been challenging for hospitals and this winter has been particularly busy. Their ability to swiftly respond to this and other challenging situations is underpinned by a solid foundation of infrastructure, robust forward planning and strong clinical leadership. With our proximity to Gatwick Airport, we are regularly called to “stand by” for incidents and the team, together with members of the local, regional and even national health economy, are ready, equipped and on hand to handle whatever incident occurs.

2.3

Industrial Action

Some of the trade unions will be calling on their NHS members in England to take strike action on the 29th January and 25th February. We have now received notification from those trade unions involved and we do not anticipate severe disruption to our services. The Trust’s overriding statutory obligation is to provide high quality and safe services to patients and Trust management will need to implement contingency plans if necessary.

Recommendation

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

Michael Wilson Chief Executive January 2015

7 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 2014/15 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.A.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, supported by robust monitoring mechanisms. (Falls management is a specific focus and therefore highlighted)

Director responsible

Chief Nurse

Initial Risk Current rating

S4 x L3 = 12 S4 x L3 = 12

Target risk score

S3 x L2 = 6

Linked to Risk

1055 and 1545

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 and Maternity Strategy and 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

1) Lack of system to differentiate between Trust and community acquired cases of VTE

Specific Falls management controls 1) Falls management policy in place 2) Training undertaken for clinical staff in the assessment and management of patients at risk of falls 3) Falls pathway developed and operational for assessment of patient fall risk and those at risk of falling line in with NICE guidance June 2013 4) Patient falls strategic group meet monthly and report KPIs to the patient safety and clinical risk committee. 5) Falls Operational Board meet weekly to share investigation and learning from all complex, major and moderate falls. 6) Audit of falls policy and falls process undertaken and results and actions escalated to the appropriate operational and governance groups 7) Monthly reporting at Executive committee for Quality enabling improved understanding of falls and any gaps in falls management strategies 8) Divisional reporting, oversight and ownership of falls 9) Equipment audit and review undertaken 10) Falls and patient safety consultant nurse appointed, start date 1 December 11) Datix incident reporting in place and all serious falls investigated using SI methodology Page 2

Specific gaps in Falls management controls 1) ED Falls pathway â&#x20AC;&#x201C; under development 2) Consistency of joint working with community falls teams

12) Lead trust in south area falls network Potential Sources of Assurance (documented evidence of controls effectiveness)

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

1) Patient safety related KPI agreed and monitored at Board and Divisional Level 2)Meeting minutes and action plans, evidence of presentations and board discussion 3) External reports and visits both scheduled and unscheduled (including new CCG quality visits) 4) CQC intelligent monitoring rating 5) Patient tracking and analysis (Whiteboard project) 6) 15 Steps quality program

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 Negative (-) Never events incidence low (1 in last 12 Months, low harm) (-) NRLS reporting

Specific Falls management sources of assurance 1) 2) 3) 4) 5)

Datix incident reporting and analysis Monthly trust wide reporting using national benchmarking Training data Annual Falls Report 13/14 Clinical Nurse Consultant for Falls and Patient Safety commenced 4 December 2014

Specific assurances regarding Falls management Positive (+) Annual Falls report 2013/14 reduction in falls with harm in year (+) Resource focus on patient safety and falls (+) Evidence of improved SI investigation management and closures (+) Improved reporting of patient falls has enabled the Trust to understand fall profile and identify gaps in the falls management strategies available

Gaps in assurance

Assurance Level gained: RAG

Ability to benchmark in real time National Safety Dashboard to be implemented once produced

Mitigating actions underway

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

1) Establish links with falls team within community 2) Develop Emergency Department falls pathway

Update by

Page 3

FA 12/01/15

1) 2)

Date discussed at board

February 2015 January 2015

To be discussed at January 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 2014/15 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.A.1 Failure to maintain systems to control rates of HCAI will effect 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). This presentation is done in departmental meetings with IC doctor and Nurse attendance. This increases learning in the clinical team when compared to consultant attendance at IC meeting. 7) Prevalence studies and Enhanced surveillance of catheter-associated UTI part of annual programme. 8) 3 ICE-POD units in place â&#x20AC;&#x201C; ED, HDU and Hazelwood. 9) Developed a system where site team and matrons during the weekend are responsible in checking wards that have received positive results (See 4 above) 10)Focus on risk and mitigation of VHF involving ED/Micro/ITU/PHE 11)Antibiotic Stewardship group revitalized 12)Decontamination group informing development of strategy for IPCAS

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

Gaps in assurance Page 4

Director responsible

Medical Director

Initial Risk

S4 x L3 = 12

Current rating

S4 x L3 = 12

S5 x L2 = 10 Target risk score 1049 and 1050 Linked to Risk 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 (+)No C. diff outbreaks declared in year 2013/14 (+)CQC visit Feb 2013 found no immediate concerns (+)Antimicrobial prescribing audit compliance (+)Actions taken as part of annual program (+) Recent CQC inspection highlighted improvements in MRSA screening (+)TDA visit inspecting controls and procedures (+)PHE and NHSE walkthrough ED for VHF risk provides good assurance (+)Data quality indicated in Internal Audit of Quality Account (2013/14) (+)First seasonal outbreak of Norovirus 2014/15 was contained to one area (+)Incidence of CDI 2013/14, 10 to date 2014/15 Negative (-)3xMRSA BSI case during 2013/14, 0 to date 2014/15 (-)Period of increased incidence of CDI Godstone ward, typing suggests cross infection

Assurance Level gained: RAG

Extensive auditing and monitoring in place. Trust position known Mitigating actions underway 1) Roll out of Urinary catheter Passport 2) Full list of actions in IPCAS Annual Programme of work 3) Ongoing discussion with commissioners about penalties applying only to cases with poor/inadequate care. This conversation is nationally mandated DH 22/01/15 Update by Date discussed at Board

Page 5

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Embedding 2) 2014/15 3) Ongoing To be discussed at January Board

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

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

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

2.A.1 There is a risk that patient outcomes will not continue to improve if monitoring and benchmarking outcomes are not utilised and implemented appropriately across divisions and specialties

Director responsible

Chief Nurse / Clinical Leads

Initial Risk Current rating

S3 x L3 = 9 S3 x L2 = 6

Target risk score

S2 x L2 = 4

Linked to Risk

844

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 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/outcomes

Potential Sources of Assurance (documented evidence of controls effectiveness) 1. Regular data collection 2. PROMS 3. Minutes of divisional meetings including M & M 4. Minutes of Clinical Effectiveness and Patient Safety and Risk subcommittees 5. Patient tracking and analysis (whiteboard project) 6. Datix reporting and analysis 7. Clinical Nurse Consultant for Patient Safety and Falls commenced 02/12/14

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 (+) 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 low (1 in last 12 Months, low harm) (-) NRLS reporting Assurance Level gained: RAG

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

FA 12/01/15

Date discussed at Board

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Start date 12/01/2015 To be discussed at January Board

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

Key Action for 2014/15 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.B.1 There is a risk of a loss of elective business to outside provider if we do not align our activity to local commissioning priorities

Director responsible

Chief Operating Officer

Initial Risk Current rating

S4 x L3 = 12 S4 x L3 = 12

Target risk score

S4 x L1 = 4

Linked to Risk

No specific risk recorded on the operational risk register

Controls in place (to manage the risk) 1) Local Transformation Board 2) 3x3 meetings 3) CEO strategic meetings 4) Partnership boards

Gaps in Control 1) Pathway redesign needs to ensure its appropriate and fit for purpose 2) Still to agree 15/16 contract with BICS

Potential Sources of Assurance (documented evidence of controls effectiveness) 1)Letters of intent 2)Contracts 3)Meeting minutes

Actual Assurances: Positive (+) or Negative (-) Positive (+) Commitment from all parties, initial plans and agreements good (+) Consultant engagement in pathway redesign (+) Recent experiences and management of Dermatology services (+) Current referral flows likely to remain until Q1 2015/16 (+) Contract 14/15 signed with BICS Negative (-) Other services provided could be effected by the outcome of this model

Gaps in assurance Contract to be agreed with BICS, undefined staff model (TUPE) and activity undefined

Assurance Level gained: RAG

Mitigating actions underway

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

1)Appropriate pathways to be determined and developed 2)Currently Negotiating 15/16 contract with BICS

1)Q4 2014/15 2)Q4 2014/15

Update by

Page 7

PB 20/01/15

Date discussed at Board

To be discussed at January Board

Objective 3 - Caring – 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 2013/14 objectives and description of any potential significant risk to this priority

3.B.1 Failure to recruit and retain clinical staff may result in excessive usage of agency and may impact negatively on Trust’s quality of care provided to patients.

Director responsible

Chief Nurse and Medical Director

Initial Risk Current rating

S3 x L3 = 9 S3 x L4 = 12

Target risk score Linked to Risk

S3 x L2 = 6 1416

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. 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 3. Recruitment process reviewed, KPIs under development to provide assurance 4. Bank workstream developed and bank recruitment in progress to reduce use of agency nursing staff 5. Review of MAST and induction processes to be undertaken to ensure they meet operational requirements 6. Marketing plan in development 7. Weekly PMO focusing on agency usage 8. SASH funded by HEKSS to develop and lead on physician associate training and recruitment for SEC 9. SNCT data presented and approved at November Board 10. Foundation doctors workloads re-modelled such that 95% of time is spent with no more than 14 patients.

Gaps in Control 1) E-Roster system is not updated out of hours 2) Unfilled agency shifts 3) Staffing Ratios in some areas of the Trust at night are under review 4) The Trust still carries a volume of vacancies specifically within ITU and theatres 5) Imperfect induction for short notice, short term medical locums 6) Aiming for full recruitment (influenced by HEKSS)

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. Incident reporting via Datix demonstrating patient or staff harm 3. Staff absence reports 4. % of vacant shifts filled by Trust and agency staff 5. Number /severity of issues escalated to relevant agency 6. Daily Nursing review “planned vs actual” 7. References from other local employers 8. Revalidation (GMC) for locums 9. SOP developed for the management of nursing staffing Gaps in assurance Trust position known - no identified gaps in assurance

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

Mitigating actions underway Page 8

Positive (+)SNCT data (+)Further recruitment planned has been undertaken Negative (-)Benchmarked high proportion of agency staff usage against other Trust’s (-)Vacancy rates and turnover rates

Assurance Level gained: RAG

Progress against mitigation (including dates, notes

1)Continue to monitor recruitment drives 2)Implement latest version of E-Roster (better utilisation of bank staff) 3)7 day working plans for medical staff under development across the Trust FA 12/01/15 and Update by Date discussed at Board DH 22/01/15

Page 9

on slippage or controls/ assurance failing. 1) Underway and ongoing 2) Being implemented 3) Embedding and under review To be discussed at January Board

Objective 3 - Caring – Ensure patients are cared for and feel cared about Priority ID and reference Key Action for 2013/14 objectives and description of any potential significant risk to this priority

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

3.B.2 If the Trust does not put into place systems to assess, monitor and evaluate nursing staffing levels there may be negative impact on Trust’s quality of care provided to patients. Controls in place (to manage the risk) 1. Ward staffing templates monitored daily by Matrons and escalated to the Divisional Chief Nurses to ensure safe levels to meet patient needs. 2. Planned versus actual staffing levels on a shift by shift basis and evidence actions taken 3. Procurement of updated e roster system. 4. SNCT tool 5. Agency staff sourced from agencies known to and contracted by Trust. Issues regarding agency staff practice are subject to formal arrangements between the agency and the Trust any unresolved concerns are escalated and managed by Deputy Chief Nurse. 6. Robust recruitment process to both substantive and bank staff posts including overseas recruitment 7. Monitoring of Safety Thermometer, patient experience and staff turnover, sickness at ward level 8. Matron for workforce recruited Potential Sources of Assurance (documented evidence of controls effectiveness) 1. Daily ward staffing review and reporting 2. Incident reporting via Datix demonstrating patient or staff harm 3. Staff absence reports 4. % of vacant shifts filled by Trust and agency staff 5. Number /severity of issues escalated to relevant agency 6. SNCT data presented at November Board 7. Increased reporting of positive patient experience in relation to staffing/high quality care and compassion reported 8. Gap analysis against ‘Right Staffing’ report and current ward staffing levels undertaken 9. Gaps filled by using staff flexibly across the Divisions with bank staff used in priority to agency. 10. Review of maternity staff ratio undertaken 11. Monthly reporting of nursing staffing levels with actions taken to mitigate to Trust Board Gaps in assurance Trust position known no identified gaps in assurance

Page 10

Director responsible

Chief Nurse

Initial Risk Current rating

S3 x L4 = 12 S3 x L3 = 9

Target risk score Linked to Risk

S3 x L1 = 3 1447

Gaps in Control 1. E-Roster system is not updated out of hours 2. Trust does not currently have the latest version of E-Roster that is more effective at accessing and utilizing Bank Staff 3. Unfilled agency shifts 4. Staffing Ratios in some areas of the Trust at night are under review 5. The Trust still carries a volume of vacancies specifically within ITU and theatres

Actual Assurances: Positive (+) or Negative (-) Positive (+) CQC Chief Inspector of Hospitals Report (+) Daily ward staffing review (+) Reports regarding reducing vacancy rates, sickness, absence (+) Incident reporting via Datix (+) Patient experience data by ward or unit Negative (-)Benchmarked high proportion of agency staff usage against other Trust’s (-)Vacancy rates and turnover rates

Assurance Level gained: RAG

Mitigating actions underway 1. 2.

Implement e-roster upgrade and utilize core functionality (bank and messaging) Implement plans to manage staffing issues in ITU and Theatres

Update by

Page 11

FA 12/01/15

Date discussed at Board

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) March 2015 2) TBA To be discussed at January Board

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

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

3.D Treat patients and their families with dignity, respect and compassion

Director responsible

Chief Nurse / Director of HR

Initial Risk

S2 x L4 = 8

3.D.1 There is a risk that the Trust may not deliver continuous improvement to patient experience if the wider care and compassion strategy, vision and values are not embedded and sustained with all members of staff.

Current rating

S2 x L3 = 6

Target risk score

S2 x L1 = 2

Linked to Risk

No specific risk recorded on the operational risk register, 20 risk monitored by the Executive patient experience committee

Controls in place (to manage the risk)

Gaps in Control

1) Trust values embedded and disseminated across organization 2) Nursing and Midwifery Strategy implemented including 6 Câ&#x20AC;&#x2122;s 3) Values based recruitment integral to nursing and midwifery recruitment and performance management/appraisal 4) Customer care training undertaken with OPD and ED front line staff 5) YCM and F&FT feedback shared with clinical and non-clinical staff. Actions plans developed in response 6) Work underway to ensure staff are treated with respect by patients & other staff

1) Evidence of shared learning across divisions and clinical units 2) Standarised appraisal and performance management process 3) Ability to roll out customer care training across organisation

Potential Sources of Assurance (documented evidence of controls effectiveness)

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

1) Work in progress to develop and roll out GE leadership development including values and organisational development (SASH Plus) 2) YCM and FFT 3) Datix and patient compliments and complaints

Positive (+) CQC Chief Inspector of Hospitals Report (+) Staff survey (+) YCM and FFT score (above average for inpatients) (+)The August FFT score for ED was +81, the highest score to date. Since December 2013, the (+)ED FFT score has been between +75 and +81, well above the National average. (+) The Inpatient score has risen by 2 points this month to +84, the inpatient FFT scores have been between +80 and +84 since March2014. (+) Incident reporting (+) pilot of 8a and above appraisal process incorporating assessment against behaviours Negative (-) Complaints received relating to patient experience (-) FFT response rates variable (-) Appraisal rates recorded

Gaps in assurance Trust position known no identified gaps in assurance

Assurance Level gained: RAG

Mitigating actions underway

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

1)Customer care training pilot 2)Evaluate effect of pilot and consider wider role out 3)Role out Behavioural Anchors developed through SASH Plus and embed values in staff appraisal 4)Output of pilot of new Achievement Review process (which includes appraisal of behaviours) being worked through

1)Complete 2)Sep 2014 3)Dec 2014

Update by Page 12

FA 12/01/15 and JM 19/01/15

Date discussed at Board

To be discussed at January Board

4 - Responsive to people’s needs – Become the secondary care provider of choice for the catchment population Priority ID and reference

4.A.1 Deliver access standards

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

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) Extra 10 surgical beds for 3 months (Dec –Feb) to support elective flow and reduced cancellations 10) Capel Annex opened 1/12 (20 beds) 11) AMU Annex opened 29/12 (12 beds until 28/2) 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

Gaps in assurance Winter plans and local health economy position going into winter months Mitigating actions underway

Director responsible

Chief Operating Officer

Initial Risk Current rating

S3 x L4 = 12 S4 x L4 = 16

Target risk score

S3 x L3 = 9

Linked to Risk

1220 and 1491

Gaps in Control 1)Identified on a rolling basis as part of weekly review 2)It is difficult for the Trust to influence the output of decision making across the local health economy 3)Ambulatory pathways yet to imbed

Actual Assurances: Positive (+) or Negative (-) Positive (+) ED Standard delivered Q1 and Q2 narrowly missed Q3 (+) 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 Negative (-) 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 (-) Increase in no of medically fit for discharge patients Christmas New Year period Assurance Level gained: RAG

1) Rolling bed capacity plans being reviewed Update by Page 13

PB 20/01/15

Date discussed at Board

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

Objective 4 - Responsive to people’s needs – Become the secondary care provider of choice for the catchment population Priority ID and reference

4.A.2 Deliver access standards

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

4.A.2 As readmission rates are an indicator of high quality care, failure to improve the Trust’s rate poses a risk to this objective

Controls in place (to manage the risk) 1) Discharge processes in place, Medical and MDT fit 2) Dr Foster report re-admission monthly (monitored by clinical effectiveness and ECQR) 3) Data review for pathway specific re-admissions 4) Change of some patient episodes to reflect out-patient contact rather than readmission 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) KPIs 2) Dr Foster alerts 3) Regular audit review of readmissions at service level 4) Joint Audit with Clinical Commissioning Groups 5) Triangulation with other data sets (e.g. VTE)

Director responsible

Medical Director

Initial Risk Current rating

S3 x L3 = 9 S3 x L3 = 9

Target risk score

S3 x L2 = 6

Linked to Risk

No specific risk recorded on the operational risk register, 20 risk monitored by the Executive patient experience committee

Gaps in Control 1) Temporary notes makes clinical coding more difficult , but are reducing in numbers 2) Not all elements of pathway under central oversight

Actual Assurances: Positive (+) or Negative (-) Positive (+) Re-admission data no longer flags on “Dr Foster” reports (+) Re-admission data work by local physicians (+) Internal audit of readmission figures provides positive assurance (+) Feedback following initial work on discharge process 2013/14 (+) RCA on areas highlighted by Dr Foster

Negative (-) Readmission data quality Gaps in assurance 1)Exact definition of re-admission required Mitigating actions underway

Assurance Level gained: RAG

1) Safer discharge practices agreed by local healthcare providers, discharge to access pilot 2) Data quality coding 3) OPAL Service linked to GP 4) Review storage of medical records to reduce need for temporary notes 5) Work to improve coding at ward level on clear signaling of planned readmission (TWOC) Update by Page 14

DH 22/01/15

Date discussed at Board

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Under review 2) Underway 3) Underway 4) Tendering at present 5) Underway To be discussed at December Board

Objective 4 - Responsive to peopleâ&#x20AC;&#x2122;s needs â&#x20AC;&#x201C; Become the secondary care provider of choice for the catchment population 4.D Develop local services as appropriate at East Surrey Hospital, other Trust sites and in the community Key Action for 2014/15 objectives 4.D There is a risk that the Trust may not realise the benefits of and description of any potential service development opportunities significant risk to this priority which are fully appropriate for the local community unless partnership working and links between strategic partners are improved Controls in place (to manage the risk) 1) Local Transformation Board 2) 3x3 meetings 3) CEO strategic meetings 4) Partnership boards

Director responsible

Chief Operating Officer

Initial Risk

S4 x L3 = 12

Current rating

S4 x L3 = 12

Target risk score

S4 x L2 = 8

Linked to Risk

1501, 1270, 1491, 1164, 1332

Potential Sources of Assurance (documented evidence of controls effectiveness) 1)Letters of intent 2)Contracts 3)Meeting minutes

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

Priority ID and reference

Gaps in Control 1)Length of stay needs to reduce 2)Repatriation of tertiary services effected and influenced by external factors

Positive (+) Joint working with Royal Surrey County ( Chemeo and Radiotherapy) (+) Pathology joint venture BSUH (+) Bowel screening (+) BOC respiratory unit (+) Initial work on repatriating Cardiology Lab (8 wk pause to support winter pressures) (+) Winter beds initiative 2013/14 (+) Business case new surgical ward and additional theatre

Gaps in assurance Trust position known no identified gaps in assurance

Assurance Level gained: RAG

Mitigating actions underway

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1)Q4 2014/15

1)Decant ward

Update by

Date discussed at Board PB 20/01/15

Page 15

To be discussed at December Board

Objective 4 - Responsive to people’s needs – Become the secondary care provider of choice for the catchment population Priority ID and reference

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

4.E Develop local services as appropriate at East Surrey Hospital, other Trust sites and in the community 4.E There is a risk that recruitment and retention strategies are not effective in attracting and retaining staff which will impact on our ability to develop and maintain services.

Director responsible

Director of Human Resources

Initial Risk

S3 x L4 = 12

Current rating

S3 x L4 = 12

Target risk score

S3 x L2 = 6

Linked to Risk

1580

Controls in place (to manage the risk)

Gaps in Control

1) Workforce & OD Strategy with vision to be “Employer of Choice” 2) Key Theme of W&OD Strategy is Recruitment and Retention with key objectives for short, medium and long term 3) Finance and Workforce Committee receives monthly updates on key themes 4)Executive Committee for Quality & Risk through Workforce Sub-group considers workforce metrics and risks. 5)Workforce metrics – turnover and vacancy rate reported at Divisional and Trust level. 6)Specific Nursing Recruitment & Retention workstream Chaired by Chief Nurse reports into Workforce Committee via Deputy Chief Nurse

1) Nature of workforce skills means that “Employer of Choice” must not be restricted to catchment populations of Surrey & Sussex. The Trust must be free to recruit for the skills required as these may not be present in the locality. The benefits of employment on population health and life expectancy mean that the Trust should where appropriate recruit from the locality.

Potential Sources of Assurance (documented evidence of controls effectiveness)

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

1) Performance reports and minutes of committee meetings 2) Progress on Workforce Strategy

Positive (+) Trust vacancy rate (+) Hospital Intelligent Monitoring report for July 2014 – no elevated risks flagged for workforce Negative (-) Trust Turnover rate (-)Draft Hospital Intelligent Monitoring report for Oct 2014 – indicates low risk relating to nursing turnover benchmark

Gaps in assurance Assurance Level gained: RAG 1) Subjective factors in employee motivation and long lead in time mean it is difficult to monitor ‘cause and effect” for R&R initiatives 2) Performance reporting is not currently configured to report at Service Line level Mitigating actions underway Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Monthly reporting of metrics 2) Task & finish group with key deliverables

Update by

Date discussed at Board JM 19/01/15

Page 16

1) Ongoing

To be discussed at January Board

Objective 5 – Well Led Priority ID and reference

5.A Live within our means to remain financially sustainable

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

5.A.1 Failure to deliver income plan

Director responsible

Chief Finance Officer

Initial Risk Current rating

S5 x L3 = 15 S4 x L4 = 16

Target risk score Linked to Risk

S4 x L2 = 8 1479,1480,1601,1648,1649

Controls in place (to manage the risk) 1) Business Plans and budgets (activity and financial) savings / transformation plans. 2) Signed contracts with both main sets of commissioners (NHSE and CCGs). 3) Contract management process in place - clearer and better structure than last year. 4) Financial reporting, including forecast scenarios presented to Board Please note that the linked SRR risks refer to shortfall in elective income (1601), maternity pathway risk (1645) and (a non –finance risk) the level of emergency demand (1491) Potential Sources of Assurance (documented evidence of controls effectiveness) 1) Financial performance and contractual reporting to Exec Committee, Finance & Workforce Management Board 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 group) 5) Output of Contract Management Process - including the output from Activity Query Notice process.

Gaps in Control 1) A Chief Officer meeting has replaced the LTB but it is still establishing its structures – these are anticipated to be in place soon, but there is a question over the effectiveness of health system forums to manage emergency activity actions (this is subject to discussion on 26 Jan at Chief Officer Mtg) 2) No agreement over repayment of withheld marginal rate emergency tariff or completion of activity query process (action in train) 3) CCG plans make significant assumptions on activity reductions that are not being adjusted by them in response to actual outturn and there is a widening gap between their plan and actuals – this is impacting elective activity as well as driving cost and providing the “wrong” income. (Activity Query Notice in train).

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

Positive (+) 2013/14 activity and income met the Plan (+) Reconciliation process working with CCGs at the moment (avoiding delay to disputes) - that continues to be the case at M07 (+) settlement of 13/14 Surrey income dispute, also settlement of first 2014/15 dispute with NHS England. Negative (-) At M09 there continues to be adverse variance against plan in several areas – this includes the maternity pathway, radiology (both areas now improving) and elective activity – however, income is better than expected at M09 (-) From July to date emergency activity is higher than it has ever been, putting pressure on elective income, costs and providing the “wrong” income. (-) Too much non elective activity, not enough elective. Gaps in assurance Assurance Level gained: Amber None as yet, but adverse variances within the actual value of income collected leaves this as amber. Mitigating actions underway 1) Regular Contract monitoring meetings in place and working – payments are now having to be chased with CCGs; 2) Ongoing internal review actions operating – income variances being tracked and fed into PMO discussions – specific detail being followed up in adverse areas (e.g.: radiology, maternity) 3) Trust is bringing action to a conclusion in respect of the 30% marginal rate tariff payment. PS 21/01/2015 Update by Date discussed at Board

Page 17

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. Actions proceeding to timetable – M09 shows additional income but also additional over spending.

To be discussed at January Board

Objective 5 – Well Led Priority ID and reference

5.A Live within our means to remain financially sustainable

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

5.A.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 agreed & signed off 3) Internal Performance Review (PMO) process and CEO review 4) Forecast scenarios presented to Board 5) M06 forecast process sees all Divisions working to clear targets Potential Sources of Assurance (documented evidence of controls effectiveness) 1) Financial performance and contractual reporting to Exec Committee, Finance & Workforce Management Board 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 in financial reporting describes improvement and risk mitigation. 5) Agency PMO.

Director responsible

Chief Finance Officer

Initial Risk Current rating

S5 x L3 = 15 S4 x L4 = 16

S3 x L2 = 6 Target risk score 1602, 1663 Linked to Risk Gaps in Control 1) There are some areas in the Trust where variance from budget is significant and reduction of spend is not appropriate – these budgets need to be reviewed (and that will form part of 2015/16 budget setting)

Actual Assurances: Positive (+) or Negative (-) Positive (+) Corporate budgets within tolerance. (+) budgets corrected for undeliverable savings and contingency found. (+) forecasts have been reviewed and nominal permission to overspend goiven where appropriate, with action in other areas. Negative (-) Emergency activity pressures are greater than expected (-) YTD all Divisions are overspent (please note comments on control through forecast process). (-) Overall agency cost remains high. (-) M09 variance from forecast is adverse although income is favourable. Overall risk for BAF “red” – assurance rating also “red” noting position on overspend action planning.

Gaps in assurance

Assurance Level gained: Red

Please note comments above – budgets are overspent, but overspending levels have been agreed (nb: not as final control totals yet) and action is being linked to that work. The assurance level remains red, as some of the stretch actions present risk. Mitigating actions underway 1) PMO/Performance structure continues - M09 PMOs now complete 2) Controls are being exercised in divisions and centrally (vacancies are passed through Execs, procurement management etc.) 3) Contingency action around emergency and elective activity is now being implemented with the opening of additional capacity. PS 21/01/2015 Update by Date discussed at Board

Page 18

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

To be discussed at January Board

Objective 5 – Well Led Priority ID and reference

5.A Live within our means to remain financially sustainable

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

5.A.3 Unable to provide realistic medium term financial plan

Controls in place (to manage the risk) 1) Items referred to in 5.A.1 and 5.A.2 above 2) V5.0 long term financial model and integrated business plan completed (submitted to TDA in September 2014) 3) TDA Plan to be submitted January 2015, draft paper to FWC in December 4) Board to Board held with the TDA in November 2014.

Potential Sources of Assurance (documented evidence of controls effectiveness) 1) Delivery of current year financial plans 2) Delivery of long term financial model and integrated business plan documentation, and delivery against them

Director responsible

Chief Finance Officer

Initial Risk Current rating

S5 x L3 = 15 S4 x L3 = 12

S4 x L2 = 8 Target risk score 1603 Linked to Risk Gaps in Control 1) Items listed above (5.A.1, and 5.A.2) are applicable here 2) Elements of 2014/15 planning cannot yet be incorporated in Trust financial planning (e.g.: Better Care Fund implications) because of lack of detail. 3) Lack of alignment between CCG activity plans and actual performance. 4) Reliance on centrally determined rules for PbR, Better Care Fund and the wider NHS finance regime.

Actual Assurances: Positive (+) or Negative (-) Positive (+) Delivery of performance in 2013/14 (+) 5 versions of LTFM submitted – each has passed muster with TDA high level review although it has not been subject to full challenge and scrutiny. (+) LTFM submitted describes viable position (+) TDA have provided positive feedback following Board to Board. Likely next stage is a Monitor “preassessment” review Negative (-) Performance in 2014/15 provides risk (-) alignment with CCG plans is not clear. There are significant differences between actual performance on activity and CCG plans. (-) Lack of clarity on significant changes from Better Care Fund.

Overall, on basis of current assumptions and delivery of LTFM, RAG reduced to amber. Assurance RAG amber. Gaps in assurance Assurance Level gained: Amber Revised LTFM (long term financial model) and IBP (Integrated Business Plan) currently being prepared but not yet complete Mitigating actions underway

1) Next material action is likely Monitor “pre-assessment” review, and, if that is OK, a revised LTFM will be prepared. Update by

Page 19

PS 21/01/2015

Date discussed at Board

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. Progress is on timetable To be discussed at January Board

Objective 5 – Well Led Priority ID and reference

5.A Live within our means to remain financially sustainable

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

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

Director responsible

Chief Finance Officer

Initial Risk Current rating

S5 x L3 = 15 S5 x L3 = 15

Target risk score

S4 x L3 = 12

Linked to Risk

1604

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

Gaps in Control 1) Problems with Commissioners delivering to agreed cash flow dates.

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 and Trust Board

Actual Assurances: Positive (+) or Negative (-) Positive (+) Positive cash flow reported for 2013/14 - temporary borrowing needed in 2013/14, but reasons for that were delays in agreements (CCG and TDA) – temporary borrowing repaid in full by 31 March 2013 (+) Liquid ratio has followed expectations (+) Cash remains on plan in M09 2014/15 Negative (-) no confirmed additional cash to resolve underlying liquidity problem – likely to be resolved in FT application process – potentially through a working capital loan (-) cash flow dependent on financial outturn described in 5.A.1 and 5.A.2 above. (-) remedial action has had to be taken at M09 to secure cash from Commissioners. 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: Amber 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. PS 21/01/2015 To be discussed at January Board Update by Date discussed at Board

Page 20

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

5.B We are an organisation that is clinically led and managerially enabled 5.B There is a risk that Clinical leadership efforts will not embed if staff do not feel empowered and supported in order to make positive changes regarding care pathways within specialties and directorates

Director responsible

Medical Director

Initial Risk

S4 x L2 = 8

Current rating

Proposed score S4 x L1 = 4

Target risk score

S4 x L1 = 4

Linked to Risk

No specific risk recorded on the operational risk register, 14 risk monitored by the Executive patient experience committee

Controls in place (to manage the risk) 1)JD and appointments to reflect importance of Chiefs and clinical leads 2)Joint work with Clinical leads and Exec Team undertaking the opportunity to work with GE 3)Work of Clinical leaders in many significant projects draws on and underlines the value of clinicians as leaders 4)Implementation of Trial appraisal using â&#x20AC;&#x153;talent mappingâ&#x20AC;? methodology to promote succession planning 5)Clinical Leads meeting frequency increased to twice monthly

Gaps in Control 1)Variation in priorities of clinical leads 2) Some departments are small with no appropriate interest in clinical management.

Potential Sources of Assurance (documented evidence of controls effectiveness) 1) 1:1 training 2) Board presentations SQC, Prescribing committee 3) HEKSS established dentistry school

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

4) GMC survey highlights no safety concerns (for the first time) 5) Talent review and achievement review at appraisal 6) Increased interest in clinicians wanting to lead and manage

Gaps in assurance Trust position known no identified gaps in assurance

Positive (+) CQC report and feedback (+) GE updates (+) Increasing buy in from clinical leads to leadership agenda (+) Overall staff survey (+) Deanery reports Negative (-) GMC survey training results , some areas report undermining Assurance Level gained: RAG

Mitigating actions underway 1)Ongoing work to embed Clinical Leads in activities to support strategic objectives 2)Delivery of outputs of SASH Plus (Appraisals)

Update by

Date discussed at Board DH 22/01/15

Page 21

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1)Next phase commencing August 2014 2)February 15

To be discussed at January Board

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

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

5.E Have appropriately qualified and competent staff always working to the highest standards of professionalism and ethics 5.E.1 There is a risk that staff do not take up opportunities to participate in developmental programmes which could further impact upon staff development and missed opportunities to improve quality of care

Director responsible

Director of Human Resources

Initial Risk

S3 x L3 = 9

Current rating

S3 x L3 = 9

Target risk score

S3 x L2 = 6

Linked to Risk

1170

Controls in place (to manage the risk)

Gaps in Control

1) Personal Development Plans as part of Appraisal identify development needs 2) Training Need’s Analysis at Divisional level extrapolated to Trust level inform strategic planning of development priorities. 3) Analysis of education and training activity 4) Make available e learning packages as an alternate to face to face training implement new delivery model on yearly cycle (elearning one year face to face the next) 5) Pilot elearning and roll out across Trust 6) OLM configured to capture locally delivered MAST programmes

1) Reporting of development that is undertaken within Divisions

Potential Sources of Assurance (documented evidence of controls effectiveness)

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

1) PDP’s 2) Training needs analysis update to August 2014 Finance Investment and Workforce Committee 3) Monthly reporting against 10 Core Mandatory Training subjects at Divisional and Trust level at Finance Investment and Workforce Committee through ECQR&CC – Workforce Committee.

Positive (+)Trust utilises HEKSS central funding (+)TNA update to August 2014 Finance Investment and Workforce Committee

Negative (-) Bursary funding being restructured under national ‘costings’ exercise (-) Compliance rates for MAST programme

Gaps in assurance

Assurance Level gained: RAG

Reporting of development that is undertaken within Divisions

Mitigating actions underway

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

1) Reporting structure in ESR being reconfigured

1) Ongoing

Update by

Page 22

JM 19/01/15

Date discussed at Board

To be discussed at January Board

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

5.G.2 We are a well governed organisation

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

5.G.2 If the Trust does not progress and deliver its Foundation Trust plans it is unlikely to be able to successfully authorised. This could leave the Trust without local autonomy and could lead to an alternative organisational form being imposed on the Trust. Which could reduce choice and focus on local health provision

Controls in place (to manage the risk) 1)BGAF assessment carried out and action plan in place 2)Corporate governance framework in place 3)Foundation Trust project board meeting 6 weekly 4) FT Task & Finish Group meeting monthly 5)Timeline agreed with TDA 6)QGAF assessment carried out and action plan in place Potential Sources of Assurance (documented evidence of controls effectiveness) 1)BGAF action plan and self-assessment completed 2)LTFM agreed by the Board 3)FT Project board 4)FT Project plan 5)Integrated Business Plan 6)Public Consultation completed with positive outcome 7)QGAF External assessment completed with implementation of action plan 8)Speciality deep dives to inform Trust on readiness for assessments 9) TDA Readiness Review completed 10) Chief Inspector of Hospitals Inspection 11) Elections to Shadow Council of Governors due following TDA approval 12) TDA Board to Board completed 13) Implementation of Board Development Programme

Gaps in assurance Historical Due Diligence to be confirmed by TDA & Monitor Mitigating actions underway

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 (+) Active FT Project Board (+) Draft IBP submitted to TDA 20.6.04 - updated & submitted 20.10.14 (+) LTFM submitted to TDA – 20.06.14 - updated & submitted 20.10.14 (+) FT membership strategy revised and being implemented – achieved 70% of target (+) External review of BGAF & QGAF undertaken (+) BGAF action plan being implemented - Amber/Green (+) Refresh of QGAF by Deloitte’s – complete – score 3.5 action plan in place (+) Readiness Review held with TDA – March 14 (+) FT Timeline agreed with TDA (+) Mock board to board undertaken – Sept 14 (+) Board to Board with TDA took place on 20.11.14 – formal outcome awaited (+) Positive outcome of public and staff consultation (+) Patient & Public membership increasing with engagement of MES (+) Governor Awareness Sessions taking place with +70 expressions of interest (+) Engagement of ERS for Governor Election Services – Draft election timetable agreed Assurance Level gained: RAG

1) Membership Strategy implementation with positive increase in membership 2) Re-fresh of QGAF external assessment - score of 3.5. Action plan in place GFM 21/01/15 Update by Date discussed at Board Page 23

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Ongoing 2) Plans are on track To be discussed at January 15 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 2013/14 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. F. 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) IT Strategy aligned with Clinical Strategy and IBP and reviewed Oct 14 2) Clinical Informatics Group 3) Clinical IT leads 4) EPR User Group now well established 5) Various project group (EPMA etc.) 6) Internal Audit 7) EPR costs identified in LTM 8) CCIO and CNIO roles being implemented – greater clinical buy-in 9) EPR Contract now signed and implementation underway with datacenter transfer scheduled for Mid-June 2015 Potential Sources of Assurance (documented evidence of controls effectiveness) Efficiencies being delivered through IT enabled change

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

Director responsible

Director of Information and Facilities

Initial Risk

S5 x L3 = 15

Current rating

S5 x L3 = 15

Target risk score

S5 x L2 = 10

Linked to Risk

1605

Gaps in Control 1) Investment in Infrastructure needs to keep pace with organization requirements 2) Insufficient focus on change benefits realization due to financial constraints 3) Lack of operational involvement in identifying and delivering benefits 4) Insufficient focus on staff training 5) Need for increased operational manager buy-in

Actual Assurances: Positive (+) or Negative (-) Positive (+) Improving infrastructure (e.g. Wi-Fi) (+) Development of existing EPR platform (e.g. EPMA) (+) EPR Contract signed (+) Successful EPMA upgrade Negative (-) Major IT transition approaching – 2015 (-) Technical issues resulting in organizational disruption from a recent major IT implementation, has led to concerns over future implementations Assurance Level gained: RAG

Mitigating actions underway 1. Procurement of replacement EPR as national contract ending November 2015 - preferred supplier now reached and OBC agreed by Board and TDA 2. Establishment of Clinical Lead IT Role 3. Clinical Cerner User Group now in place with strong leadership 4. Greater focus on IT in Capital Plan for 2014/15 and future years 5. Introduction of Business Continuity System for EPR (7/24) Update by Page 24

IM 12/01/15

Date discussed at Board

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

TRUST BOARD IN PUBLIC

Date: 29th January 2015

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

Agenda Item: 1.7 Board Assurance Framework & Significant Risk Register Gillian Francis-Musanu Director of Corporate Affairs Colin Pink Corporate Governance Manager AAC 13th January 2015, Executive Team 21st January 2015

Action Required: Approval (√)

Discussion (√)

Assurance (√)

Purpose of Report: The BAF highlights potential risks to the Trust’s strategic objectives and mitigating actions, and the implementation of its programme of objectives for year one 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 19 risks to the trusts strategic objectives, 5 of which are recorded as key strategic risks and red rated (Section 4). It is proposed that the current rating for risk that Clinical leadership efforts will not be embedded (5.B) is reduced to 4 to reflect the current engagement and activity in leadership activities. There are 10 significant risks recorded on the Trust significant risk register. Recommendation: The Board is asked to discuss and approve the report and consider the following:  Review the BAF and its alignment to strategic objectives  Does the Board agree with the recorded controls and assurances  Approve the proposed revised score to risk 5.B 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

The report is a requirement for all NHS organisations. 1

An Associated University Hospital of Brighton and Sussex Medical School

Financial impact Patient Experience/Engagement

As discussed in sections 5 (Income generation linked to activity referred to throughout the document) Patient experience and engagement is one of the Trusts strategic objectives. .

Risk & Performance Management

These are highlighted throughout the report.

NHS Constitution/Equality & Diversity/Communication

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

Attachment: January 2015 BAF and the current SRR

An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT – 29th January 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 2014/15: 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 Executive team reviewed the existing BAF throughout January 2015 and have updated risks accordingly. The changes made reflect conversations at the December public Board, January Audit and Assurance Committee and changes identified through reports reviews of assurances and actions considered by the Executive Team. It is proposed that the current rating for “There is a risk that Clinical leadership efforts will not be embedded” (5.B) is reduced from 8 to 4 to reflect the current engagement and activity in leadership activities.

An Associated University Hospital of Brighton and Sussex Medical School

The 14/15 BAF (attached) details a total of 19 risks to the 5 Trust strategic objectives which are scored as follows: Objective 1.Deliver safe services and be in the top 20% against our peers 2.Deliver effective and sustainable clinical services within the local health economy 3.Ensure patients are cared for and feel cared about 4.Responsive - Become the secondary care provider and employer of choice for the catchment populations of Surrey & Sussex 5. Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Total

Red (15-25)

Amber (8-12)

Green (1-6)

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).The tables below highlight the predicted swing in risk rating. Table 1: Current BAF Risk Profile

An Associated University Hospital of Brighton and Sussex Medical School

Table 2: Target BAF Risk Profile

3.1 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

Current Risk Rating: Severity x Likelihood

Target Risk Score

1.A.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, supported by robust monitoring mechanisms (Page 2)

S4 x L3 = 12

S3 x L2 = 6

1.A.1 Failure to maintain systems to control rates of HCAI will effect patient safety and quality of care (Page 4)

S4 x L3 = 12

S5 x L2 = 10

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

Initial Risk Rating: Severity x Likelihood

2.A.1 There is a risk that patient outcomes will not continue to improve if monitoring and benchmarking outcomes are not utilised and implemented appropriately across divisions and specialties (Page 6) 2.B.1 There is a risk of a loss of elective business to outside provider if we do not align our activity to local commissioning priorities (Page 8)

Current Risk Rating: Severity x Likelihood

Target Risk Score

S3 x L3 = 9

S3 x L2 = 6

S2 x L2 = 4

S4 x L3 = 12

S4 x L1 = 4

An Associated University Hospital of Brighton and Sussex Medical School

Objective 3 - Caring – Ensure patients are Initial Risk cared for and feel cared about Rating: Severity x Likelihood 3.B.1 Failure to recruit and retain clinical staff may result in excessive usage of agency and may impact negatively on Trust’s quality of care provided to patients (Page 9) 3.B.2 If the Trust does not put into place systems to assess, monitor and evaluate nursing staffing levels there may be negative impact on Trust’s quality of care provided to patients (Page 10) 3.D.1 There is a Risk that the Trust may not deliver continuous improvement to patient experience if the wider care and compassion strategy, vision and values are not embedded and sustained with all members of staff (Page 12)

Objective 4 – Responsiveness – Become the secondary care provider for the catchment population

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

S3 x L4 = 12

S3 x L2 = 6

S3 x L4 = 12

S3 x L3 = 9

S3 x L1 = 3

S2 x L4 = 8

S2 x L3 =6

S2 x L1 = 2

Current Risk Rating: Severity x Likelihood

Target Risk Score

S3 x L4 = 12

S4 x L4 = 16

S3 x L3 = 9

S3 x L2 = 6

S4 x L3 = 12

S4 x L2 = 8

S3 x L4 = 12

S3 x L2 = 6

Initial Risk Rating: Severity x Likelihood

5.A.1 Failure to deliver income plan (Page 17) 5.A.2 Failure to stop divisional overspending against budget (Page 18) 5.A.3 Unable to provide realistic medium term financial plan (Page 19) 5.A.4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position (Page 20) 5.B There is a risk that Clinical leadership efforts will not be embedded if staff do not feel empowered and supported in order to make positive changes regarding care pathways within specialties and directorates (Page 21)

Target Risk Score

S3 x L3 = 9

Initial Risk Rating: Severity x Likelihood

4.A Failure to maintain Emergency Department performance because of lack of capacity in health system to manage winter pressures has a significant impact on the Trust's ability to deliver high quality care (Page 13) 4.A.2 As readmission rates are an indicator of high quality care, failure to improve the Trust’s rate poses a risk to this objective (Page 14) 4.D There is a risk that the Trust may not realise the benefits of service development opportunities which are fully appropriate for the local community unless partnership working and links between strategic partners are improved (Page 15) 4.E There is a risk that if That recruitment and retention strategies are not effective in attracting and retaining staff which will impact on our ability to develop and maintain services (Page 16)

Current Risk Rating: Severity x Likelihood

Target Risk Score

S5 x L3 = 15

S4 x L4 = 16

S4 x L2 = 8

S5 x L3 = 15

S4 x L4 = 16

S3 x L2 = 6

S5 x L3 = 15

S4 x L3 = 12

S4 x L2 = 8

S5 x L3 = 15

S4 x L3 = 12

S4 x L2 = 8

Proposed Score S4 x L1 = 4

S4 x L1 = 4

An Associated University Hospital of Brighton and Sussex Medical School

Objective 5 â&#x20AC;&#x201C; Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model

Initial Risk Rating: Severity x Likelihood

5.E.1 There is a risk that staff do not take up opportunities to participate in developmental programmes which could further impact upon staff development and missed opportunities to improve quality of care (Page 22) 5.G.2 If the Trust does not progress and deliver its Foundation Trust plans it is unlikely to be able to successfully authorised. This could leave the Trust without local autonomy and could lead to an alternative organisational form being imposed on the Trust. Which could reduce choice and focus on local health provision (Page 23) 5.F. There is a risk that the Trust will not fully realise the benefits available from well embedded IT systems (Page 24)

Current Risk Rating: Severity x Likelihood

Target Risk Score

S3 x L3 = 9

S3 x L2 = 6

S4 x L2 = 8

S4 x L1 = 4

S5 x L3 = 15

S5 x L2 = 10

Key risks Strategic risks Identified

The BAF highlights the following 5 key red risks to the Trust objectives that have been identified at time of updating the framework. These are: Risk description

Current rating

4.A Failure to maintain Emergency Department performance because of lack of capacity in health system to manage winter pressures has a significant impact on the Trust's ability to deliver high quality care 5.A.1 Failure to deliver income plan 5.A.2 Failure to stop divisional overspending against budget 5.A.4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position 5.F. There is a risk that the Trust will not fully realise the benefits available from well embedded IT systems

S4 x L4 = 16

Target risk score

Page

S3 x L3 = 9

P12.

S4 x L2 = 8

P16

S3 x L2 = 6

P17

S5 x L3 = 15

S4 x L3 = 12

P19

S5 x L3 = 15

S5 x L2 = 10

P23

S4 x L4 = 16 S4 x L4 = 16

5. Significant Risk Register On the 21st January the Executive Committee reviewed and agreed the content of the significant risk register. There are 10 risks on the Trust significant risk register. Each is in date and has mitigating actions to reduce the level of risk to an acceptable level.

An Associated University Hospital of Brighton and Sussex Medical School

5.1 SRR Breakdown ID

1401

1480

1491

1501

1601

1602

1604

1605

1645

1652

Title Risk of outbreak of viral gastroenteritis Risk that non elective activity does not reduce and no payment in respect of marginal tariff Failure to maintain Emergency Department performance 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) Risk that demand growth activity does not deliver the plan and elective income reduces Failure to stop divisional overspending against budget Liquidity: inability to pay creditors/staff resulting from insufficient cash due to poor liquid position There is a risk that the Trust will not fully realise the benefits available from well embedded IT systems Loss of income and unnecessary expenditure as a result of the complexities associate with the maternity pathway The current local availability of qualified nurses and pressures on temporary staffing costs is effecting the Trust's ability to achieve optimum workforce management

Initial Rating

Current Rating

Residual Rating

Next Review

01/02/2015

31/03/2015

31/01/2015

31/03/2015

27/02/2015

31/03/2015

An Associated University Hospital of Brighton and Sussex Medical School

6. 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 proposed revised score to risk 5.B

Gillian Francis-Musanu Director of Corporate Affairs January 2015

Colin Pink Corporate Governance Manager

An Associated University Hospital of Brighton and Sussex Medical School

Appendix 1: Risk Appetite for 2014/15 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. 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 endeavour to meet those expectations within a framework of prudent controls, balancing the prospect of risk reduction and elimination against pragmatic operational imperatives. 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. Target: Amber/Green

An Associated University Hospital of Brighton and Sussex Medical School

18/11/2014

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

i) Follow up notification to CCGs and agree payment from the 70% (ongoing)

16 4

16 Robust plan required to manage elective activity 30/05/2014 As describded on the BAF 31/03/2015

Involvement of Service Users

Failure to maintain Emergency Department performance

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

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

20 4

16 As decribded on the board assurance framework

31/03/2015

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

15 As describded on BAF

31/03/2015

If non elective activity does not reduce there will be constraints i) Ring fence elective beds after new capacity has opened and monitor delivery. Risk that demand growth on capacity to deliver the demand plan. activity does not deliver the Subset of BAF 5.A.1 plan

16 4

16 As described on BAF

31/03/2015

Faliure to stop Risk of overspending from operational pressures. divisional overspending against budget

i) Divisions to implement action plans and contingencies to control/or recover overspending. Specific action is required in all Divisions. iii) Agency PMO to deliver outputs in respect of reduced agency usage following recruitment. The October milestone was not achieved in the face of the increased capacity required. Position being reviewed (Nov).

16 4

16 As described on the BAF

31/03/2015

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

15 5

15 As described on the BAF

31/03/2015

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

31/03/2015

31/01/2015

31/03/2015

Financial Management

Risk that the Trust may not achieve its breakeven plan as a result of non elective activity no reducing as planned and no payment recieved in respect of the marginal tariff. Subset of BAF 5.A.1

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 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

Next Review

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

Residual Rating

Current Rating

Due date 31/03/2013 30/06/2013 01/04/2013 02/09/2013 31/03/2014 31/03/2013 20/03/2015 01/03/2016 22/09/2014 31/03/2014 30/03/2013 25/09/2013 31/01/2013

Involvement of Service Users

Treatment Plan 15 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

01/02/2015

16 3

Current Likelihood

Current Consequence

Initial Rating

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

Patient Safety

Risk Type

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

Risk that non elective does not reduce and no payment in respect of marginal tariff

Financial Management

Risk Owner Des Holden Paul Simpson Paul Bostock Paul Bostock Paul Simpson Paul Simpson Paul Simpson

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

Directorate CORP CORP CORP CORP CORP CORP CORP

Open Date 23/01/2013 23/07/2013 29/08/2013 19/09/2013 18/06/2014 18/06/2014 18/06/2014

Monitoring Committee Safety Executive Committee Responsiveness Responsiveness Executive Committee Executive Committee Executive Committee

ID 1401 1480 1491 1501 1601 1602 1604

Title Risk of outbreak of viral gastroenteritis

Done date

Next Review

Due date 31/03/2015

Residual Rating

Treatment Plan 15 As described on the BAF

10 31/03/2015

15 5

Current Rating

Current Likelihood

Current Consequence

Existing controls 1.IT Strategy aligned with Clinical Strategy and IBP 2.Clinical Informatics Group 3.Clinical IT leads 4.EPR User Group 5.Various project group (EPMA etc) 6.Internal Audit 7.EPR costs identified in LTM

Initial Rating

Loss of income owing to other organisations submitting erroneous invoices Difficulties capturing accurate activity across multiple organisations greater impacted by women's right to choose place of care delivery and movement between care providers at different points in the maternity pathway Data collection reliant on a convoluted paper process which lends itself to error

Robust process for monitoring receipt of PBR forms agaist activity introduced Staff training / administrative support Multiple invoices validated by the Head of Midwifery and ADO.

16 4

16 Review the management of the maternity pathway

31/03/2015

The current local availability of qualified nurses and pressures on temporary staffing costs is effecting the Trust's ability to

The Trusts current vacancy rates, turnover and reliance on agency is leading to increased resource time being spent on ensuring existing clinical areas are safely staffed. The acute presentation of these issues is felt in the management of escalation areas and plans to staff the decant ward.

As decribeded on the BAF

16 4

16 As describded on the BAF

31/03/2015

27/02/2015

Loss of income and unnecessary expenditure as a result of the complexities associated with the maternity pathway

31/03/2015

Risk Type ICT Infrastructure Financial Management Staffing - general

Risk Owner Ian Mackenzie Bill Kilvington Fiona Allsop

Bus. Int. - Information & Specialty Data Quality Obstetrics Operations

Directorate CORP WACH CORP

Open Date 18/06/2014 09/10/2014 23/10/2014

Monitoring Committee Executive Committee Executive Committee Workforce

ID 1605 1645 1652

Title Description There is a risk As described on the BAF that the Trust will not fully realise the benefits available from well embedded IT systems

TRUST BOARD IN PUBLIC

Date: 29th January 2015

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

Agenda Item: 2.1 Patient story – Delayed treatment of bronchial carcinoma Dr Des Holden Medical Director Dr Des Holden Medical Director Relevant divisional and management boards, and reported externally

Action Required: Approval (√)

Discussion (√)

Assurance (√)

Purpose of Report: To provide an opportunity for the Board to review the story of patient care and experience at the Trust and to share an understanding of how lessons are learnt from incidents. Summary of key issues Patients attending the ED have a range of investigations performed, some of which will inevitably throw up a previously unsuspected problem. The complexity of ensuring our pathways provide a safety net for such patients is great and this case, of an unregistered, foreign national raised questions about our imaging coding Z5 safety net, the difficultly of using family as interpreters and the problems faced by patients and the trust where they are not registered with a GP.

Recommendation: The Board is asked to discuss this patient’s story and to gain assurance around the lessons learnt. 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

N/A

Financial impact

N/A

Patient Experience/Engagement

Included in the report

Risk & Performance Management

As discussed at relevant divisional and management boards, and reported externally

NHS Constitution/Equality & Diversity/Communication

N/A

Attachment:

2 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT – 29TH JANUARY 2015 PATIENT STORY 1. Introduction An elderly male patient, who was visiting his son from India, presented at ED in February 2014 with dizziness. He was seen promptly and had a thorough history and examination performed and the presumed diagnosis of labyrinthitis was made. He was discharged home with his son with an anti-vertigo medication. While in ED he had a CXR performed although the investigation has failed to show who ordered the imaging. The CXR was reported on the same day, but after the patient had been discharged, as suspicious of either chest infection or cancer, and further imaging after a short interval was recommended. The film was given a Z5 code. The ED notes are further annotated three days after the attendance by the ED consultant, who telephoned the patient’s son twice, wrote to the patient and suggested that further imaging would be needed and the patient should register with a GP. He also wrote to the son’s GP practice and sent a summary of the case and noted the need for further imaging. Three months later the patient re-attended the ED with breathlessness and an obvious bronchial carcinoma significantly larger than at initial imaging was found. At that time the patient’s son reported that his father had never registered with a GP and that the son has felt that as the dizziness had been successfully treated and there were no chest symptoms, there was no need for further imaging. The patient opted, after counselling, to return to India for treatment and has subsequently died. 2. Contributing factors There are a number of contributing factors in this patient’s story. The governance around the ordering and follow up of the CXR is confused, though the consultant took reasonable steps to try to ensure onward care was in place. While a Z5 code for most imaging prompts the safety new of MDT discussion, the volume of abnormal CXR cannot be accommodated in this way. This was not known in the ED. It is unclear exactly how good a command of English the patient and his son had and there was no use of an interpreter. The ED orders many investigations but is not in general structured to provide on-going care or recall patients for any but a small number of indications. 3. Lessons learned and changes made This case was declared an SI in the first instance and investigated as such. However the investigation showed that reasonable attempts had been made to try to ensure on-going care for the patient through advice that was not followed. There were two worrying aspects around our processes; firstly that a CXR could be ordered without our ability to know who has requested it, and that the pathway of NOT picking up all Z5 reported CXR at MDT was not known in the ED. Electronic radiology requests should have now resolved the first of these issues. A new critical results policy has been passed at the Clinical Effectiveness Committee, taking advantage of new Cerner functionality. This will run for six months and then be audited by Dr Ed Cetti, the new Chief of Cancer (and himself a respiratory physician).

3 An Associated University Hospital of Brighton and Sussex Medical School

4. Conclusion As well as the above changes the department have again reflected on the use of interpreter services to avoid over-reliance on family members. When the CCG met and discussed this case it was agreed that there had not been a lapse of care, and the incident was down-graded from SI and removed from the national data base (STEIS). Des Holden Medical Director January 2015

4 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT – (INSERT DATE)……………. (INSERT TITLE OF REPORT) 1.

Introduction (or Executive Summary)

The report should include the background, key issues from a national, regional or local perspective including the evidence base with clear options and rationale. Consider and describe how the key issues relate to the BAF or SRR or strategic objectives. 2.

Main Content of the Report

Recommendation

Outline the clear recommendation required for the Board/Committee as per the front sheet including any additional next steps.

Name of Director Title of Director Month/ 2014

5 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD IN PUBLIC

Date: 29th January 2015 Agenda Item: 2.2

REPORT TITLE:

Chief Nurse & Medical Director Report

EXECUTIVE SPONSOR:

Fiona Allsop, Chief Nurse Des Holden, Medical Director Sally Brittain, Deputy Chief Nurse Des Holden, Medical Director

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

N/A

Action Required: Approval

Discussion

Assurance (√)

Purpose of Report: An update of on-going work in relation to safe and quality patient care that sits out with the operational performance reports including Monthly Safer Staffing information and exemption report.

Summary of key issues Chief Nurse’s Report  Safe Staffing Report (January 2015)  Sign Up to Safety Medical Director’s Report  National patient safety collaborative  Virginia Mason  Interviews  Electronic prescribing update  KSS Expo  Patient Safety Executive Recommendation: The Trust Board is asked to review and gain assurance from the information within 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: Appendix 1 - Surviving Sepsis at East Surrey Hospital

2 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT – 29TH JANUARY 2015 CHIEF NURSE AND MEDICAL DIRECTORS’ REPORT 1.

Introduction

This report seeks to provide regular assurance and information to the Trust Board in response to national and local policy and care changes which impact patient safety, experience and clinical outcomes. 2.

Safe Staffing Compliance

Safe staffing data for the Trust was uploaded to unify as required and is now visible to the public via the NHS Choices and the Trust Website. The data is presented for the Trust Board within the table below. The Board will note that the Trust total score for total staffing compliance 95.09%, with RN compliance at 95.13% during the day and 97.39% at night. This provides assurance that out of hour’s compliance, especially of RN’s is a priority to ensure safety. During the day the wards have access to a much increased senior nursing team to offer support such as Matrons, Clinical Specialist Nurses and Divisional Chief Nurses for support and guidance. Staffing challenges identified and discussed in month are evidenced within the data below. 3.

Data Capture Results – Monthly (January 2015) Ward Specialty

Entries RN Day RN Night NA Day NA Night Total Day Total Night

Ove rall

430 ‐ GERIATRIC MEDICINE

98.54%

100%

96.75%

98.89%

97.61%

99.34%

98.2 9%

Acute Medical Unit

300 ‐ GENERAL MEDICINE

94.38%

96.77%

82.78%

93.5%

91.04%

95.59%

93.0 5%

Birthing Centre

501 ‐ OBSTETRICS

100%

N/A

100%

100 %

300 ‐ GENERAL MEDICINE

93.92%

93.71%

88.46%

96.58%

91.82%

95%

93.1 1%

502 ‐ GYNAECOLOGY

98.4%

100%

94.92%

98.94%

97.52%

98.3 8%

100 ‐ GENERAL SURGERY

100%

98.36%

100%

N/A

100%

98.36%

99.3 5%

101 ‐ UROLOGY

94.54%

100%

96.67%

96.45%

98.33%

97.1 4%

501 ‐ OBSTETRICS

92.74%

100%

106.19% 83.87%

95.52%

91.94%

93.9 4%

97.73%

99.47%

100%

98.48%

98.86%

98.6 2%

430 ‐ GERIATRIC MEDICINE

89.04%

90.48%

99.3%

103.57%

92.15%

95.71%

93.6 8%

300 ‐ GENERAL MEDICINE

93.7%

88.24%

95.93%

92.47%

94.64%

90.68%

93.2

Ward Abinger Ward

Bletchingley Ward Brockham Ward Brook Ward

Buckland Ward Burstow Ward

Capel Annex l Ward Capel Ward

Chaldon Ward

3 An Associated University Hospital of Brighton and Sussex Medical School

3% 301 ‐ GASTROENTEROLOGY

96.37%

96.77%

94.77%

94.12%

95.8%

95.38%

95.6 4%

301 ‐ GASTROENTEROLOGY

95.19%

100%

98.96%

100%

96.45%

100%

97.7 5%

320 ‐ CARDIOLOGY

89.13%

98.39%

232.61% 94.12%

92.18%

96.88%

94.5 5%

501 ‐ OBSTETRICS

98.92%

99.46%

80.65%

83.87%

94.35%

95.56%

94.9 6%

300 ‐ GENERAL MEDICINE

94.17%

96.3%

96.08%

96.3%

95.12%

96.3%

95.5 3%

303 ‐ CLINICAL HAEMATOLOGY

96.09%

95%

N/A

96.09%

96.67%

96.3 8%

300 ‐ GENERAL MEDICINE

92.86%

104.17%

95.01%

88.46%

93.7%

96%

94.6 7%

300 ‐ GENERAL MEDICINE

100%

70.65%

100%

88.26%

100%

93.0 9%

320 ‐ CARDIOLOGY

96.13%

100%

97.01%

100%

96.36%

100%

97.7 1%

192 ‐ CRITICAL CARE MEDICINE

95.03%

96.28%

86.07%

90.32%

93.83%

95.85%

94.7 9%

110 ‐ TRAUMA & ORTHOPAEDICS 31

97.22%

96.67%

92.05%

96.67%

95.38%

96.67%

95.7 7%

Meadvale Ward

430 ‐ GERIATRIC MEDICINE

89.18%

98.39%

96.49%

100%

93.07%

99.22%

95.2 6%

Neonatal Unit

420 ‐ PAEDIATRICS

91.14%

95%

92.13%

79.37%

91.48%

89.62%

90.5 6%

110 ‐ TRAUMA & ORTHOPAEDICS 31

96.2%

96.77%

85.64%

91.94%

91.78%

94.35%

92.6 5%

430 ‐ GERIATRIC MEDICINE

100%

97.47%

98.39%

99.06%

99.19%

99.1 %

420 ‐ PAEDIATRICS

94.14%

100.49%

77.85%

68.97%

92.56%

96.57%

94.3 3%

501 ‐ OBSTETRICS

100%

N/A

100%

100 %

100 ‐ GENERAL SURGERY

95.97%

95.16%

83.87%

93.55%

89.52%

91.7 6%

300 ‐ GENERAL MEDICINE

94.57%

100%

96.19%

98.39%

95.24%

99.19%

96.5 5%

300 ‐ GENERAL MEDICINE

95.97%

98.08%

96.87%

96.15%

96.33%

97.12%

96.5 9%

100 ‐ GENERAL SURGERY

92.45%

96.67%

81.89%

93.33%

88.52%

95%

90.6 4%

95.13%

97.37%

92.97%

93.83%

94.44%

96.04%

95.0

Charlwood Ward Copthorne Ward

Coronary Care Unit Delivery Suite

Discharge Lounge

Godstone Ward (Haem) Godstone Ward (Med) Hazelwood

Holmwood Ward ITU/HDU

Leigh Ward

Newdigate Ward Nutfield Ward

Outwood Ward Rusper Ward

Surgical Assessment Unit Tandridge Ward Tilgate Ward

Woodland Ward

Total

4 An Associated University Hospital of Brighton and Sussex Medical School

Background Sign up to Safety is a national patient safety campaign that was announced in March 2014 by the Secretary of State for Health and launched at the end of June 2014. The campaign underpins the ambition set out of halving avoidable harm in the NHS over the next 3 years, and saving 6,000 lives as a result. NHS organisations who ‘Sign up to Safety’ are expected to commit to 5 safety pledges; set out the actions they will undertake in response to the pledges; agree to publish this on their website for staff, patients and the public to see; and commit to turn their actions into a safety improvement plan (including a driver diagram) which will show how organisations intend to save lives and reduce harm for patients over the next 3 years. 4.1

The five Sign up to Safety pledges 1. Put safety first. Commit to reduce avoidable harm in the NHS by half and make public the goals and plans developed locally. 2. Continually learn. Make their organisations more resilient to risks, by acting on the feedback from patients and by constantly measuring and monitoring how safe their services are. 3. Honesty. Be transparent with people about their progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong. 4. Collaborate. Take a leading role in supporting local collaborative learning, so that improvements are made across all of the local services that patients use. 5. Support. Help people understand why things go wrong and how to put them right. Give staff the time and support to improve and celebrate the progress.

4.2

Campaign Support and Context

A National Co-ordinating and Support Group has been established, chaired by Sir David Dalton who is supported by Dr Suzette Woodward as campaign director. The following national organisations have committed to system wide support of Sign up to Safety: 



NHS England will provide expert clinical patient safety input to the development of improvement plans and framework for plan assessment. They will also play a key leadership role in the campaign and will ensure all their programmes of work are actively working to support the campaign. Monitor and the NHS Trust Development Authority will offer leadership and advice to trusts and foundation trusts who participate in Sign up to Safety and who will develop and own locally their improvement plans. They will also sign post to partner organisations for specific expertise where required. NHS Litigation Authority which indemnifies NHS organisations against the cost of claims will review trusts’ plans and if the plans are robust and will reduce claims, they will receive a financial incentive to support implementation of the plan. Any

5 An Associated University Hospital of Brighton and Sussex Medical School



4.3

savings made in this way will be redirected into frontline care. This is just one way that we can tackle some of the financial costs of poor care. The Care Quality Commission will support trusts signed up by reviewing their improvement plans for safety as part of its inspection programme. CQC will not offer a judgment on the plans themselves but consider them as a key source of evidence for Trusts to demonstrate how they are meeting the expectations of the five domains of safety and quality. The Department of Health will provide Government-level support to the campaign and work with the Sign up to Safety partners to ensure that the policy framework does all it can to support the campaign and the development of a culture of safer care. SASH Pledges

Surrey and Sussex Healthcare NHS Trust 5 safety pledges 1. Put safety first. Identify, evaluate and implement patient safety systems that look to enhance the quality of our care by increasing the chances of the initial signs of a deteriorating patient being acted on appropriately. It is believed that recent innovations in patient monitoring systems could be of value in improving patient safety related outcomes. We expect that these innovations could also affect the numbers of incidents relating to delays in treatment which are identified by our staff and recorded in our patient safety data. 2. Continually learn. Seek to improve the Trust’s systems for identifying and managing pain specifically with patients who have a diagnosis of dementia. We will look to develop a greater understanding of the effectiveness of our pain management systems, develop tools and processes that improve the quality of this element of care, develop further training for staff and then share our findings across the local health provider network. This program will allow significant numbers of staff to be appropriately trained in the assessment of pain, which we anticipate will have considerable benefits for all patients within the Trust. 3. Honesty. Ensure that the Trust is compliant with the statutory responsibility regarding Duty of Candour. The Trust follows the principles of Being Open but will improve the process to ensure compliance with the components of Regulation 20. We will develop a robust system for monitoring compliance and evidence through improved documentation of communications with ‘the relevant person’ in accordance with the regulation. We will develop training and support for staff in awareness of the duties under the regulation and the principles and how to have the open and honest conversation after an incident resulting in harm, as defined in the regulation, has occurred. 4. Collaborate. Learn from COPD EQ pilot that the Trust has committed to undertake and seek to identify and share learning across South East Coast over the 3 year period of the pilot. This collaborative approach will be extended to acute kidney injury and sepsis. 5. Support. The Trust will ensure that Divisions will; improve the visibility and accessibility of their patient safety data to all staff within the Division; empower their clinical teams to make patient safety improvements; ensure a clear link between patient safety data (incidents, mortality , outcome data) and action plans developed and implemented; ensure that improvements to patient safety are audited to ensure efficacy

6 An Associated University Hospital of Brighton and Sussex Medical School

4.4

SASH Progress and Update

The Trust has submitted its Safety Improvement Plan and awaits feedback from the NHS Litigation Authority regarding any financial incentive and NHS England approval. The Executive sponsor is the Chief Nurse and the Trust Lead is the Patient Safety and Risk Facilitator. A detailed Safety Improvement Plan Guidance document is currently being worked through and a project lead for each pledge has been identified. The detailed project implementation and communications plan to support the Safety Improvement Plan will be developed during February and March 2015. The Trust Sign up to Safety â&#x20AC;&#x201C; Safety Improvement Plan will be launched in April 2015 and run for 3 years. The Executive Committee for Quality and Risk has been identified as the monitoring committee and a quarterly report will be presented for monitoring, escalation and assurance purposes. Medical Directorâ&#x20AC;&#x2122;s Report 5.

National patient safety collaborative

The Department of Health and NHS England have launched a national safety drive for England, facilitated by the 15 AHSNs. After a collaborative approach, the programme for Kent Surrey and Sussex will include work programmes in the areas of sepsis, pressure damage (across the local health economy), falls, acute kidney injury (AKI) and handover of care between secondary and primary/ community care givers. Of note the last of these topics came from consultation with patient groups while the others are either nationally mandated, or came from consultation with providers. 6.

Virginia Mason

The Virginia Mason Hospital in Seattle is famous for having achieved game changing gains in patient safety. It has achieved this through the standardisation of many processes, eliminating needless, valueless variation within teams. It describes itself not as a hospital which has a lot of safety projects, but as a hospital with an ethos that seeks to be as safe as possible. The TDA hosted a study day for senior teams from 15-20 non-FTs with a view to fund 5 improvement programmes with 5 providers. While the central funding for this initiative is as yet not finalised, it is the current intention of SaSH to apply to be one of the 5 providers working to implement o VM model. 7.

Interviews

Since the last trust Board there has been a consultant interview for a paediatrician (0.6wte) to co-lead on safeguarding. The post will also provide support to the general paediatric service. Dr. Katy McGlone was successfully appointed to the post on 15.1.2015 and will join us after a three month notice period. 8.

Electronic prescribing update

Electronic prescribing was introduced in the second week of December on Capel annex. Given the risks around cover over the Christmas and new year periods there was extensive discussion and modeling of safeguards but the project has run smoothly to date and has increased to cover 15 beds on the ward. Unofficially, the feedback from the ward is very positive, but a formal project evaluation will take place at the beginning of February after which a decision on roll out across the organisation will be made.

7 An Associated University Hospital of Brighton and Sussex Medical School

KSS EXPO

The KSS AHSN hosted its annual Expo and awards on 13th January. Key note speeches were given by Dr. Mike Durkin (National patient safety Lead) and Sir Bruce Keogh (NHSE Medical Director) xxx. A number of awards were presented for the Enhancing Quality and Recovery Programme and SaSH did not receive one of these despite strong performance in several of the disease strands. The safety poster prize was judged by Sir Bruce and Dr. Shuab Quraishi won for his work on six steps to safety in sepsis. Sir Bruce commented that he hoped (and expected) this work to be rolled out across KSS. Dr.Quraishi has since presented his work to the Patient Safety Executive 10.

Patient safety executive

In January we commenced a Patient safety Executive. This stand up meeting is attended by the Exec, the senior corporate staff from E&F, Finance, HR, Procurement, data, and by the matrons and care centre managers. Each session will involve a short presentation on a clinical topic or patient story and the learning that has resulted. So far Dr. Quraishi has presented his sepsis 6 work, and the PII of Cdiff on Godstone ward has been presented. The presentation scheduled for 28th January is the audit of blood supply and use from SaSH blood bank to the KSS air ambulance. This initiative gives the opportunity for key non-patient facing departments and staff to build up and ground their every day work in the context of the delivery of patient care. 11.

Recommendation

The Trust Board is asked to review and gain assurance from the information within the report

Fiona Allsop Chief Nurse January/ 2015

Des Holden Medical Director

8 An Associated University Hospital of Brighton and Sussex Medical School

Surviving Sepsis at East Surrey Hospital Cathy Pye, Chris Martin, Neerajen Poonumutharai, Shuaib Quraishi, Ravi Saibaba, Guarav Agarwal

Introduction n

Sepsis is a systemic response to infection leading to severe sepsis (acute organ dysfunction secondary to documented or suspected infection) and septic shock (severe sepsis plus hypotension not reversed with fluid resuscitation).

n

Each year in the UK, it is estimated that more than 100,000 people are admitted to hospital with sepsis.

n

It is estimated that sepsis claims 36,800 UK lives annually, and it carries a 35 percent mortality.

n

Sepsis has a 10-fold greater incidence in the over-65s.

n

Rapid diagnosis and treatment are critical to survival

Surviving Sepsis Campaign n

Reliable delivery of basic aspects of care early reduces mortality significantly- absolute risk reductions reported range from 16 percent to over 50 percent.

n

In 2004 an international body formed from 18 professional bodies from Europe, North America, Australasia and Japan issued the Surviving Sepsis Campaign (SSC) Guidelines for the management of severe sepsis and septic shock.

n

These led to the development of the Sepsis Resuscitation Bundle, to be delivered within 6 hours following the onset of sepsis.

Surviving Sepsis Campaign n

TO BE COMPLETED WITHIN 3 HOURS:

n

1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L

n

TO BE COMPLETED WITHIN 6 HOURS:

n

5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥ 65 mm Hg

n

6) In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate 4 mmol/L (36 mg/dL):

n

- Measure central venous pressure (CVP)*

n

- Measure central venous oxygen saturation (ScvO2)* 7) Remeasure lactate if initial lactate was elevated*

n

*Targets for quantitative resuscitation included in the guidelines are CVP of ≥8 mm Hg, ScvO2 of 70%, and normalization of lactate.

Sepsis Six Campaign n

In 2006, a landmark paper demonstrated that each hour’s delay of administration of antibiotics to patients with septic shock was associated with a 7.6% greater risk of death

n

The Sepsis Trust has developed the concept of the ‘Sepsis Six’

n

Compliance with the Sepsis Six has been shown to reduce the relative risk of death by 46.6 %.

Sepsis Six Campaign Initiate early management of sepsis within 1 hour

The Sepsis Six

•Oxygen – 100% via mask with O2 reservoir bag •IV access, Blood cultures septic screen before antibiotics •Antibiotics – do not delay (see protocol below) •Fluids – 500ml challenges and repeat if required •Urinary catheter – aim for output >0.5ml/kg/hour •Check Lactate and Hb – transfuse if Hb < 7

Aims n  To

ensure East Surrey Hospital is following the guidance outlined in the Sepsis Six Campaign

n  To

assess compliance after intervention (raising education and awareness)

n  To

assess the impact on mortality after intervention

Methods n

Retrospective audit

n

+ve blood cultures from april – june 2013

n

12/21= 57%>75 years, 9/21= 43%<75 years, Age Range 45-102

n

31 patients identified n  n

21 of these met the criteria for severe sepsis Data collected using paper notes, online discharge summaries, laboratory results

% compliance with 1 hour targets

70%

60%

50%

40%

30%

20%

10%

0% OXYGEN

BLOOD CULTURE

ANTIBIOTICS

FLUIDS

LACTATE

CATHETER

Results 30 day MR and length of stay n  30

day Mortality Rate 38%

n  Average

length of stay = 10 days

Action Plan n

POSTERS – Guidelines & target timelines, ED & AMU

n

Distribute copies of guidelines to ED and all medical junior doctors

n

Grand round

n

Teaching for AMU Nurses

n

Teaching for ED juniors and Nurses

n

Prospective audit May 2014

n

Simulation training in sepsis initiated

Prospective Audit n

Prospective audit of patients suspected of having severe sepsis

n

54 cases (May 14)

n

21/54 = 39% <75 years, 33/54= 61% > 75 years. Age range 21-105

n

Patients identified with severe sepsis covering AE/AMU/ wards/ITU

n

Proforma used to collect data

n

Data collected on 30 day mortality

+1 Hour targets 100.00% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 1HR OXYGEN 1 HR BLOOD 1HR IV 1 HR FLUIDS 1 HR LACTATE CULTURE ANTIBIOTICS

1 HR CATHETER

1 HR OUTREACH

+ Achievement of 1 hour targets (% compliance)

100% 90% 80% 70% 60% Retrospective Audit

50%

Prospective Audit 40% 30% 20% 10% 0% OXYGEN

BLOOD CULTURE

ANTIBIOTICS

FLUIDS

LACTATE

CATHETER

Mortality and length of stay n  30

day mortality rate: 18.9%

n  Average

length of stay: 8.2 days

Average Length of stay (days) 12

Days

0 Retrospective Audit

Prospective Audit

+ 30 day Mortality (%) (Retrospective Vs Prospective Audit) 40

0 Retrospective Audit

Prospective Audit

Limitations n

Small sample size

n

Greater proportion of elderly patients in both audits – more comorbidities

n

Documentation n

Time of review not clearly written – hard to know when urine output measured from.

n

Oxygen not prescribed therefore may have been given earlier than documented in noted or recorded on observation chart

Conclusions n

Marked improvement in compliance with all parameters of the sepsis six car bundle

n

Education and training promoted early recognition and better management of patients with severe sepsis

n

50.3% relative risk reduction in mortality without added healthcare costs

n

18% relative reduction in length of hospital stay

Next Steps Further measures that may be considered prior to re-audit in 2015 are:

n

Creation of a specialized sepsis proforma with increased prominence in the ED clerking template.

n

Sustained emphasis on sepsis education

n

Detailed review of sepsis deaths as case-study-based reminders at departmental meetings

Surviving Sepsis at East Surrey Hospital Dr.$Shuaib$Quraishi,$Dr.$Cathy$Pye,$Dr.$Chris$Mar4n,$Dr.$Neerajen$Poonuthurai,$Dr.$Ravi$Saibaba,$$ Dr.$Gaurav$Agarwal$$ Department$of$Acute$Medicine,$Surrey$&$Sussex$Healthcare$NHS$Trust$

•  Society of Acute Medicine Conference Oct 14

Introduc4on$

! Each!year!in!the!UK,!it!is!es0mated!that!more! than!100,000!people!are!admi6ed!to!hospital! with!sepsis.!It!is!es0mated!that!sepsis!claims! 36,800!UK!lives!annually,!and!it!carries!a!35%$ mortality.!Rapid!diagnosis!and!treatment!are! cri0cal!to!survival.!1!! ! Early! interven0on! ensuring! basic! aspects! of! care!has!been!shown!to!!reduce!absolute!risk!of! sepsis! mortality! with! reports! ranging! from! reduc0ons!of!16%$to$50%.!1! ! In! 2006,! a! landmark! paper! demonstrated! that! each! hour’s! delay! of! administra0on! of! an0bio0cs! to! pa0ents! with! sep0c! shock! was! associated!with!a!7.6%$greater!risk!of!death!.!2! ! The!Sepsis!Trust! !has! !developed! !the! !concept!! of!!the!!‘Sepsis!!Six’!which!is!a!set!of!six!tasks!to! be! ins0tuted! within! the! ﬁrst! hour! at! the! front! line.!3!Compliance!with!the!Sepsis!Six!has!been! shown! to! reduce! the! rela0ve! risk! of! death! by! 46.6$%.!1! !

This! audit! aimed! to! assess! our! adherence! to! Sepsis!Six!and!to!assess!the!impact!of!educa0on! in! our! adherence! to! Sepsis! Six.! We! also! measured! the! impact! this! has! on! 30! day! mortality!and!length!of!hospital!stay.!

Methods$

Results$

Initiate'early'management'of'sepsis'within'1'hour

Overall!compliance!with!the!Sepsis!Six! improved!between!2013!and!2014!as! demonstrated!by!an!increase!in!all!domains.! (Fig.!1)! !

! ! !

!Figure 1: Percentage compliance with each aspect of the Sepsis Six in one hour of presentation in the retrospective

! and prospective analyses. !

Average!mortality!at!30!days!decreased! between!the!two!data!sets!from!38%!to!18.9%! following!steps!taken!to!increase!awareness!of!! Sepsis!Six!(Fig.!2)!

! !

A!retrospec0ve!audit!was!undertaken!of! compliance!with!the!Sepsis!Six!over!three! months!(AprilPJune!2013)!which!examined! adherence!to!protocol!in!21!cases!of!suspected! sepsis!and!noted!detec0on!of!posi0ve!blood! cultures.! Results!of!this!retrospec0ve!audit!ini0ated!the! following!steps:!

•  Display!of!posters!–!Guidelines!&!target! 0melines!in!ED!&!AMU! •  Distribu0on!of!guidelines!to!ED!and!medical! junior!doctors! •  Highligh0ng!Sepsis!Six!at!Medical!Grand! Round! •  Teaching!for!AMU!Nurses! •  Teaching!for!ED!juniors!and!Nurses! •  Simula0on!training!in!sepsis!for!doctors! •  Prospec0ve!audit!May!2014! ! Prospec0ve!audit!examined!54!cases!of! suspected!sepsis!in!pa0ents!aged!25P94!from! MayPJuly!2014!to!assess!adherence!to!the! Sepsis!Six!and!associated!30!day!mortality.! !

0 Retrospective Audit

Prospective Audit

2: A bar graph of the percentage mortality at 30 !Figure days during the three-month periods of the retrospective

! and prospective audit

! !

! •Oxygen'–"100%"via"mask"with"O2"reservoir"bag" •IV'access,'Blood'cultures'septic'screen"before" antibiotics" •Antibiotics'–"do"not"delay"(refer"to"protocol) •Fluids'–"500ml"challenges"and"repeat"if"required •Urinary'catheter'–"aim"for"output">0.5ml/kg/hour •Check'Lactate'and'Hb'–"transfuse"if"Hb"<"7

12!

10!

8.2!

0! Retrospec0ve!Audit!

Results!of!the!audit!demonstrate!a!50.3%$ rela0ve!risk!reduc0on!of!dying!from!sepsis!at! East!Surrey!Hospital!from!2013!to!2014! following!steps!to!increase!awareness,!and! compliance!with,!the!Sepsis!Six!guidance.!! ! In!addi0on!the!rela0ve!reduc0on!in!hospital! stay!for!those!surviving!sepsis!was!18%.!These! improvements!were!achieved!with!no! addi0onal!healthcare!costs.! ! Limita0ons!of!this!study!were!the!rela0vely! small!sample!sizes!used,!par0cularly!between! studies!(n=21!vs!n=54)!and!the!reliance!on! correct!documenta0on!such!as!the!recording!of! prescribing!or!administra0on!of!oxygen!by! medical!staﬀ!and!the!0me!of!inser0on!of!a! urinary!catheter.!! ! This!study!does!indicate,!however,!a!posi0ve! impact!of!increased!awareness!of!Sepsis!Six! protocol!in!sepsis!outcomes!at!East!Surrey! Hospital.!

Next$Steps$

Average!length!of!hospital!stay!for!those! pa0ents!surviving!to!30!days!decreased!from!10! days!to!8.2!days!(Fig.!3)!

! The!Sepsis!Six!

Discussion$ $

Days!

•  HEKSS IMRAD Conference Sep 14

Prospec0ve!Audit!

Figure 3: A bar graph of average length of hospital stay during the three-month periods of the retrospective and prospective audit.

A!downward!trend!is!noted!in!both!mortality! and!length!of!hospital!stay!when!comparing! retrospec0ve!and!prospec0ve!data.!

! Con0nued!early!recogni0on!and!interven0ons! for!suspected!sepsis!in!a!busy!district!general! hospital!have!improved!survival.!Through! further!staﬀ!educa0on!and!training!it!is!hoped! that!the!downward!trend!in!mortality!and! dura0on!of!hospital!stay!can!be!maintained.! ! Further!measures!that!may!be!considered!prior! to!rePaudit!in!2015!are:!! ! •  Crea0on!of!a!specialized!sepsis!proforma! with!increased!prominence!in!the!ED!clerking! template.! •  Sustained!emphasis!on!sepsis!educa0on! •  Detailed!review!of!sepsis!deaths!as!caseP studyPbased!reminders!at!departmental! mee0ngs! ! This!audit!data!supports!the!asser0on!that!staﬀ! educa0on!in!Surviving!Sepsis!is!essen0al!for! improving!sepsis!outcomes!at!Surrey!and! Sussex!NHS!Trust.!

References$ 1.  Factsheet:!Implementa0on!of!the!‘Sepsis!Six’!care!bundle.!NHS!England.!Feb!14.!www.england.nhs.uk/wp/content/uploads/2014/02/rm/fs/10/1.pdf.: 2.  Kumar!A,!Roberts!D,!Wood!KE!et!al.!Dura0on!of!hypotension!prior!to!ini0a0on!of!eﬀec0ve!an0microbial!therapy!is!the!cri0cal!determinant!of!survival!in!human!sep0c!shock.!Cri0cal!Care!Medicine! 2006;!34:!1589–96!! 3.  The!Sepsis!Six.!h6p://survivesepsis.org/thePsepsisPsix/.$

Please!send!all!correspondence!to!Department!of!Acute!Medicine,!Surrey!&!Sussex!Healthcare!NHS!Trust,!Canada!Avenue,!Redhill,!Surrey!RH1!5RH!!!!!!!!!!!email:!Shuaib.Quraishi@sash.nhs.uk!

References n

http://www.survivingsepsis.org/Bundles/Pages/default.aspx

n

http://survivesepsis.org/the-sepsis-six/

n

http://guidance.nice.org.uk/CG/Wave0/686/ ScopeConsultation/DraftScope/pdf/English

n

Kumar A, Roberts D, Wood KE et al. Duration of hypotension prior to initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Critical Care Medicine 2006; 34: 1589–96

n

Sepsis management as an NHS clinical priority. NHS England www.england.nhs.uk/wp-content/uploads/2013/12/sepsisbrief.pdf.

Date: 29th January 2015

TRUST BOARD IN PUBLIC

Agenda Item: 2.3 SAFETY & QUALITY COMMITTEE UPDATE

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

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

Action Required: Approval ( )

Discussion ( )

Assurance ()

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

Compliance with CQC, MHRA and Audit Commission

Financial impact

Serious incidents often become claims

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

Reporting, investigation and learning from serious incidents informs risk management

Trust Board Report - 29th January 2015 Safety and Quality Committee Chair’s Report The Safety and Quality Committee met on 8th January. It considered its standing agenda items; the report from December’s CQRM meeting and the SQC Dashboard. There was no report from ECQRM in December. Health System Actions The committee noted that the CCG intended to respond to the Chair of SQC’s recent letter about health system actions arising from the CQC action plan, potentially through a letter to the January meeting of the Trust Board. Concern was expressed about the effectiveness of system resilience groups in reducing delays in discharge and the pressure on A&E. It was reported that “2020” work had not yet started. SQC Dashboard Discussion on the Dashboard focused on winter pressures on A&E, which had been severe over the holiday period. There had been a high proportion of patients at A&E requiring admission, while the number of patients occupying beds in the hospital who were medically fit to be discharged was also high. Having a plan in place had enabled staff to cope with the pressures and the discussion provided good assurance of the Trust’s business continuity plans. SECAMB had not declared a major incident, there had been good coordination with ambulance crews, and patient feedback on their experience had been positive. Nevertheless the pressures had caused cancellations of elective surgery leading the Committee to discuss the balance of the management or risk within the local healthcare system. Now that the hospital was returning to a more normal pattern of activity, a full debriefing exercise was planned with the intention of reporting the findings to the January meeting of the Trust Board. It was emphasized that better performance on delayed discharges was essential and that this would require joint work across the health system. Presentation on Stroke Pathway The Committee received a stimulating presentation on the stroke pathway. This showed an improving trajectory, especially in therapy, and good audit compliance. More improvement was needed in getting access to a bed in the stroke unit within four hours. The main impediment to better performance lies in the pressures on hospital beds, and the Committee asked for more work to be done across the health system to support early discharge. In terms of prevention, more anti-coagulation work could be done in primary care, while measurement of outcomes will be a future focus of performance conversations and commissioning decisions. Internal Controls Assurance The Committee considered an annual report on the internal controls that support the Trust’s clinical governance systems, specifically: Clinical Audit, Incident Management, Mortality, Infection Prevention and Control, NICE Compliance and Clinical or Personal Injury Litigation and Inquests. The Committee noted the improvements in assurance introduced over the last twelve months and also the amber risk rating for Incident Management and for Litigation and Inquests. It considered the management actions to mitigate risk and added some further actions in respect of Clinical Audit, Incident Management and Clinical or Personal Injury Litigation and Inquests. These are designed to ensure learning is derived from the audits and to increase the visibility of evidence at Committee levels. The report was then referred on 13 January to Audit and Assurance Committee, which asked SQC to keep the risk rating for Clinical Audit under review when it received its next quarterly report on 5 March.

2 An Associated University Hospital of Brighton and Sussex Medical School

Falls Data The Trustâ&#x20AC;&#x2122;s focus is on reducing the number of falls with major or moderate harms, while increasing awareness of falls and reporting of minor falls and near misses. Analysis has significantly improved over the last year. The Committee had asked for data showing the trend in falls with moderate, major or extreme harm. The evidence received at this meeting indicated no significant change in the incidence of falls with harm per 1000 bed days. The Committee reflected on changing patient mix and considered whether recent falls initiatives had had a positive effect on maintaining the current of falls with harm which could have worsened if left unchecked. The data will be used to assess the effectiveness of our Falls Strategy over the coming months. Information Governance A report on Information Governance provided good assurance. The Committee welcomed a new scheme to improve the training of new staff that is being introduced from this month. Patient Survey Programme The Committee received a report setting out the timetable for the National Patient Survey Programme in 2015. A survey on A&E will report shortly. Other areas to be surveyed in the coming months are: Cancer; Emergency and Elective in-patient; Children and Young People day case and inpatients; and Maternity. The Committee asked to be routinely informed of key findings from these surveys.

Richard Shaw Safety & Quality Committee Chair January 2015

3 An Associated University Hospital of Brighton and Sussex Medical School

Integrated Performance Report M09 â&#x20AC;&#x201C; December 2014

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

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

Performance – December 2014 Care Quality Commission • The Trust is not subject to any CQC enforcement action and continues to progress the improvement plans which followed the CQC Inspection in May 2014. Patient Safety • Patient safety indicators continued to show expected levels of performance. • The Trust had no MRSA bloodstream infections and no Trust acquired C-Diff cases in December 2014. • Adult Bed occupancy remains higher than plan due to increased activity and is one of the items covered within the collaborative CQC action plan. Clinical Effectiveness • The latest HSMR data shows overall Trust mortality is lower than expected for our patient group. • Maternity indicators continue to show expected performance. Access and Responsiveness • In December 2014, 93.3% of patients were admitted or discharged within the ED standard of 4 hours with no 12 hour trolley wait breaches. The Trust did not achieve the ED 4hr standard for Q3 with performance of 94.4% • All three aggregate RTT standards were achieved in December 2014. There were a number of speciality failures as work is undertaken to reduce the number of patients waiting over 18 weeks for treatment. • All Cancer Access Standards were achieved. Patient Experience • In December 2014, ED achieved an FFT score of 93% and the inpatient score was 95% .

An Associated University Hospital of Brighton and Sussex Medical School 2

Performance – December 2014 Workforce • The Trust continues to monitor ward nursing (numbers and skill mix) on a daily basis and is assured that adequate staffing is in place. Ward staffing levels are now published on the Trust’s external website at ward level. The Trust is also continuing to monitor temporary staffing usage on a weekly basis Finance • The Trust remains on plan at M09 with a £1m surplus year to date. Key Risks • Finance – The risk to the forecast outturn is recorded as £6.3m potential adverse change. That risk is from income (emergency activity over plan / reduced elective) and divisional overspending. • Quality – The Significant Risk Register for the Trust includes four quality risks in relation to “Right bed first time”, ED Access standards , Outbreak of viral gastroenteritis and local availability of qualified nurses.

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

Dec‐13

Jan‐14

Feb‐14

Mar‐14

Apr‐14

May‐14

Jun‐14

Jul‐14

Aug‐14

Sep‐14

Oct‐14

Nov‐14

Dec‐14

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)

91.9%

90.4%

92.7%

94.2%

90.5%

92.8%

92.3%

90.8%

92.5%

92.0%

95.0%

93.0%

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

95.3%

94.2%

96.5%

97.7%

95.4%

97.0%

97.3%

95.3%

96.1%

94.5%

98.0%

96.0%

97.0%

96%

95%

96%

95%

100%

98%

100%

0.06

0.29

0.13

0.35

0.24

0.40

0.06

0.63

0.17

0.12

0.11

Percentage of patients who have a VTE risk assessment WHO Checklist Usage ‐ % Compliance Number of Sis Serious Incidents ‐ No per 1000 Bed Days Number of overdue CAS and NPSA alerts

Trend

• Patient safety indicators continue to show expected levels of performance. • There were no Never Events or medication errors causing severe harm or death in December 2014. • Safety Thermometer – achievement of both the “All Harm” and “New Harm” measures was sustained in December 2014. • VTE assessment performance was archived in December and WHO Checklist compliance returned to 100% following a marginal decrease in November 2014

An Associated University Hospital of Brighton and Sussex Medical School 4

Patient Safety • Two SIs declared were declared in December 2014. • A blood sample from a baby who had died during delivery was incorrectly transcribed into the laboratory information management system as being RhD negative. This has had adverse consequences for the subsequent care of the mother which has significantly increased her risk factors during any future pregnancies. • Unexpected death: a patient admitted to ED was transferred to CT for a booked scan to achieve a diagnosis and therefore plan of care. She was very unwell and subsequently died during the scan. The RCA is to establish whether her care was appropriate and establish whether there were any missed opportunities. • There were no overdue CAS alerts at the end of December but one did breach the deadline in month. Infection Control Indicator Description

Dec‐13

Jan‐14

Feb‐14

Mar‐14

Apr‐14

May‐14

Jun‐14

Jul‐14

Aug‐14

Sep‐14

Oct‐14

Nov‐14

Dec‐14

MRSA (incidences in month)

CDiff Incidences (in month)

MSSA

E‐Coli

Trend

• There were no cases of MRSA in December 2014, and no cases of trust acquired C.diff taking the total to 15 YTD against a trajectory of 22 YTD and 22 cases for the same period last year. • The trust continues to enforce good antimicrobial practice with on-going audit and reporting of results to clinical teams. • In light of the recent outbreaks of viral gastroenteritis, the following risk has been added to 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

Dec‐13

Jan‐14

Feb‐14

Mar‐14

Apr‐14

May‐14

Jun‐14

Jul‐14

Aug‐14

HSMR (56 Monitored diagnoses ‐ 12 Months)

95.7

96.3

97.0

95.6

94.4

92.7

92.1

92.0

90.8

Emergency readmissions within 30 days (PBR Rules)

6.8%

7.0%

6.3%

7.4%

6.7%

6.6%

7.2%

6.8%

Sep‐14

Oct‐14

Nov‐14

6.8%

7.1%

7.0%

Dec‐14

Trend

• Mortality – The latest HSMR data shows overall Trust mortality is lower than expected for our patient group when benchmarked against national comparators. • Readmissions within 30 days continues to remain at expected levels. Maternity Indicator Description

Dec‐13

Jan‐14

Feb‐14

Mar‐14

Apr‐14

May‐14

Jun‐14

Jul‐14

Aug‐14

Sep‐14

Oct‐14

Nov‐14

Dec‐14

C Section Rate ‐ Emergency

13%

19%

20%

16%

18%

15%

14%

17%

14%

17%

12%

14%

17%

C Section Rate ‐ Elective

10%

11%

10%

11%

10%

13%

12%

13%

11%

6.4%

5.2%

6.0%

6.2%

7.6%

6.7%

7.5%

8.5%

6.1%

8.0%

5.4%

3.8%

6.3%

Maternal Deaths Admissions of full term babies to neo‐natal care

Trend

• Maternity continues to show positive performance overall and quality measures remain under monitoring at the Clinical Effectiveness committee.

An Associated University Hospital of Brighton and Sussex Medical School 6

Access and Responsiveness Emergency Department Indicator Description

Dec‐13

Jan‐14

Feb‐14

Mar‐14

Apr‐14

May‐14

Jun‐14

Jul‐14

Aug‐14

Sep‐14

Oct‐14

Nov‐14

Dec‐14

96.9%

95.7%

94.7%

97.5%

96.8%

96.1%

96.6%

97.6%

95.9%

95.4%

94.3%

95.7%

93.3%

Ambulance Turnaround ‐ Number Over 30 mins

105

151

Ambulance Turnaround ‐ Number Over 60 mins

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

Trend

• In December 2014, 93.3% of patients were admitted or discharged within 4 hours with no 12 hour trolley wait breaches • As a result of the adverse performance in December, The Trust did not achieve the ED 4hr standard for Q3 with performance of 94.4%. • The delivery of the ED 4hr standard remains a challenge across the country and despite the under-performance at the Trust, we remained in the top 20% of Major Emergency Departments. • Ambulance Turnaround data is still subject to review with SECAmb. • In light of the on-going operational pressures in the Trust, the following two risks are on the significant risk register: • ED Access Standard - Failure to maintain the emergency department standard due to lack of capacity in the health system to manage winter pressures – Risk score 16 (Likelihood of 4 and consequence of 4) • Patient admitted to the right bed first time – If the trust does not maintain and improve the ability to allocate the right bed first time, there is an increased risk of reduced quality of care (effectiveness, experience and safety) – Risk score 15(Likelihood of 5 and consequence of 3)

An Associated University Hospital of Brighton and Sussex Medical School 7

Access and Responsiveness Cancer Indicator Description

Dec‐13

Jan‐14

Feb‐14

Mar‐14

Apr‐14

May‐14

Jun‐14

Jul‐14

Aug‐14

Sep‐14

Oct‐14

Nov‐14

Dec‐14

Cancer ‐ TWR

93.7%

94.5%

95.9%

96.1%

93.1%

93.6%

93.1%

93.0%

93.2%

93.8%

93.1%

Cancer ‐ TWR Breast Symptomatic

92.1%

93.3%

99.2%

98.6%

93.7%

93.5%

93.7%

93.2%

94.4%

93.2%

93.3%

93.6%

93.5%

Cancer ‐ 31 Day Second or Subsequent Treatment (SURGERY)

95.6%

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% 100.0%

97.6%

96.8%

99.0%

100.0%

98.1%

99.2%

97.1%

99.2%

100.0%

99.1%

98.4%

Cancer ‐ 62 Day Referral to Treatment Standard

100.0%

87.8%

85.0%

95.2%

89.7%

87.0%

86.9%

90.8%

87.9%

78.8%

87.1%

86.3%

86.1%

Cancer ‐ 62 Day Referral to Treatment Screening

85.0%

25.0%

50.0%

100.0%

50.0%

100.0%

83.3%

100.0% 100.0%

Cancer ‐ 31 Day Second or Subsequent Treatment (DRUG) Cancer ‐ 31 Day Diagnosis to Treatment

Trend

• All Cancer Access Standards were achieved in December 2014 and for Quarter 3 as a whole.

An Associated University Hospital of Brighton and Sussex Medical School 8

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

Dec‐13

Jan‐14

Feb‐14

Mar‐14

Apr‐14

May‐14

Jun‐14

Jul‐14

Aug‐14

Sep‐14

Oct‐14

Nov‐14

Dec‐14

RTT Admitted ‐ 90% in 18 weeks

93.8%

93.4%

92.0%

91.4%

92.9%

94.4%

94.7%

92.8%

90.4%

90.7%

88.1%

81.4%

91.1%

RTT Non Admitted ‐ 95% in 18 weeks

97.6%

98.1%

97.6%

97.4%

97.2%

96.5%

95.2%

95.8%

93.2%

93.9%

92.8%

95.0%

RTT Incomplete Pathways ‐ % under 18 weeks

96.8%

96.2%

95.9%

96.2%

96.4%

96.0%

95.2%

94.9%

93.9%

93.8%

93.5%

93.3%

92.2%

Percentage of patients w aiting 6 weeks or more for diagnostic

0.3%

0.1%

0.0%

0.3%

0.1%

0.0%

0.4%

0.1%

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

0.0%

1.3%

0.0%

1.0%

1.6%

0.0%

RTT Patients over 52 weeks on incomplete pathways

Trend

• In December 2014, all three RTT standards were achieved at aggregate level. • There were a number of speciality failures of the admitted and non-admitted standards as work is undertaken to reduce the number of patients waiting over 18 weeks for treatment. Several specialities also failed the incompletes standard. • The incompletes performance reduced from 93.3% in November to 92.2%, in large part driven by increases in the admitted “backlog” driven by cancellations. • Within Diagnostics, the quality standard for waits over 6 weeks was achieved and there were no urgent operations cancelled twice.

An Associated University Hospital of Brighton and Sussex Medical School 9

Patient Experience Patient Voice Indicator Description

Dec‐13

Jan‐14

Feb‐14

Mar‐14

Apr‐14

May‐14

Jun‐14

Jul‐14

Aug‐14

Sep‐14

Oct‐14

Nov‐14

Dec‐14

Inpatient FFT ‐ % positive responses

98%

96%

97%

95%

Emergency Department FFT ‐ % positive responses

99%

98%

95%

96%

93%

Maternity FFT ‐ Antenatal ‐ % positive responses

97%

99%

96%

97%

95%

90%

100%

98%

95%

93%

100%

Maternity FFT ‐ Postnatal Ward ‐ % positive responses

92%

93%

90%

92%

96%

Maternity FFT ‐ Postnatal Community Care ‐ % positive responses

93%

100%

94%

100%

85%

Maternity FFT ‐ Delivery ‐ % positive responses

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

Trend

National Picture for November • Under the revised calculation of the Friends and Family Test score the November FFT score for ED was 96%, well above the National average of 88%. The score ranks the ED as joint 4th in the country. • The November Inpatient FFT score is 97%, very similar to September and October, and above the National average of 94%. • The November maternity FFT scores are 95% for antenatal care, which is the same as the National average. Both the delivery touchpoint and the postnatal ward touchpoint are below the National average of 95%, at 93% and 92% respectively. The postnatal community score is 100%, against the National average of 95%. December FFT Scores • ED achieved an FFT score of 93%, a slight drop from the 96% achieved in November. The response rate was 18%, below the target of 20% but the same as November.

An Associated University Hospital of Brighton and Sussex Medical School 10

Patient Experience • At 95% the inpatient score dropped slightly compared to the 97% in November. The response rate dropped to 31% (from 36%) but was above the 30% target. • In maternity FFT scores increased for both delivery and the postnatal ward (to 100% and 96% respectively), but dropped for both the community touchpoints - to 90% for 36/40 antenatal and 85% for the postnatal community touchpoint. • There was a marked drop in response rates for the 36/40 touchpoint – down from 33% to 18%. The 19% response rate for the delivery and postnatal ward was similar to that achieved in November. • For the postnatal community touchpoint the FFT score has dropped from 100%, to 85%, based on a very low response rate of 3% • There were no Mixed Sex Breaches in December 2014.

An Associated University Hospital of Brighton and Sussex Medical School 11

Workforce Workforce Indicator Description

Dec‐13

Jan‐14

Feb‐14

Mar‐14

Apr‐14

May‐14

Jun‐14

Jul‐14

Aug‐14

Sep‐14

Oct‐14

Nov‐14

Dec‐14

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

97.3%

97.7%

97.5%

95.7%

95.4%

96.4%

97.1%

95.1%

Average fill rate – care staff (%) ‐ Day

95.6%

97.3%

95.1%

97.5%

96.4%

95.3%

95.0%

93.1%

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

97.5%

97.9%

98.2%

97.2%

98.1%

99.2%

99.4%

97.3%

Average fill rate – care staff (%) ‐ Night

96.7%

97.5%

97.2%

97.5%

96.7%

97.4%

95.3%

93.7%

Overall Sickness Rate

3.6%

3.9%

3.2%

3.0%

3.3%

3.6%

3.8%

3.2%

4.0%

4.4%

4.0%

4.5%

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

79%

83%

76%

87%

80%

82%

80%

75%

74%

72%

69%

72%

15.6%

14.5%

14.8%

14.3%

14.6%

14.5%

15.0%

15.8%

15.6%

15.3%

15.6%

Staff Turnover rate

Trend

• The Trust continues to monitor ward nursing (numbers and skill mix) on a daily basis and is assured that adequate staffing is in place. Over the Christmas and new year period, staffing was a particular challenge and additional management controls were put in place to ensure safe care across the Trust. • Staff Turnover increased marginally to 15.6% in December 2014. HR Business Partners within the divisions continue to support actions to improve recruitment and retention with a significant focus on nursing. • Sickness absence increased to 4.5% in December 2014. • Due to the on-going challenges in recruiting qualitied nurses, the following risk has been added to the Trust’s significant risk register: •

Current local availability of qualified nurses and pressures on temporary staffing is leading to increased resource time being spent on ensuring existing clinical areas are safely staffed – Risk score 16 (Likelihood of 4 and consequence of 4)

An Associated University Hospital of Brighton and Sussex Medical School 12

Finance Indicator Description

Dec‐13

Jan‐14

Feb‐14

Mar‐14

Apr‐14

May‐14

Jun‐14

Jul‐14

Aug‐14

Sep‐14

Oct‐14

Nov‐14

Dec‐14

Outturn £m Surplus / (Deficit) ‐ Plan

0.0

2.3

Outturn £m Surplus / (Deficit) ‐ Forecast

0.1

0.3

2.3

YTD £m Surplus / (Deficit) ‐ Plan

0.0

(0.9)

(1.7)

(2.8)

(2.1)

(1.5)

(1.3)

0.1

0.4

1.0

YTD £m Surplus / (Deficit) ‐ Actual

0.3

(0.9)

(1.7)

(2.8)

(2.1)

(1.5)

(1.3)

0.1

0.5

1.0

Outturn UNDERLYING £m Surplus / (Deficit) ‐ Plan

(3.5)

3.4

Outturn UNDERLYING £m Surplus / (Deficit) ‐ Actual

(3.2)

(4.3)

3.4

1.0

(0.7)

(5.2)

7.5

8.7

9.9

11.1

0.4

0.6

1.1

1.9

2.8

3.8

5.0

6.2

7.4

(5.5)

(4.3)

0.0

(8.5)

(8.0)

(8.5)

(6.3)

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

2.6

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

2.8

3.8

8.3

2.6

2.9

2.6

2.4

2.7

3.1

3.0

3.8

2.8

4.8

YTD Liquid ratio ‐ days

(6.0)

(1.0)

(13.0)

(16.0)

(15.0)

(18.0)

(17.0)

(10.0)

(7.0)

(4.0)

(8.0)

YTD BPPC (overall) volume £m

83%

84%

85%

94%

90%

85%

88%

YTD BPPC (overall) value £m

84%

85%

87%

89%

90%

87%

88%

87%

92%

78%

84%

Outturn Capital spend Fav / (Adv) ‐ forecast

17.3

16.4

19.3

19.4

19.3

YTD Savings £m ‐ Actual OT Risk £m Surplus / (Deficit) ‐ Assessment

Trend

• The Trust remains on plan at M09 with a £1m surplus year to date. • Divisional spend is still higher than budget, as expected, but offset by income. The levels of emergency activity within the Trust, as in other trusts, have been significant. December saw a notable increase in agency nursing costs and outsourcing of elective work. Income from elective day cases and inpatients is now £1.5m adverse to plan. • The year to date income continues to include an accrual in respect of challenge to CCGs over the level of emergency activity and the withheld marginal rate, as well as 2 tranches of winter resilience funding and the use of contingency from the balance sheet (which remains as at M08). There is a technical adjustment to the calculation of the accrual, which is now in twelfths rather than eighths.

An Associated University Hospital of Brighton and Sussex Medical School 13

Finance • The forecast year end position remains a £2.3m surplus. The risks to this position (mainly from the impact of emergency activity) have been estimated at £6.3m, as reported last month. • The cost improvement plan year to date target is £7.4m and at M09 this has been achieved. • The underlying position at the end of December is £3m deficit, reflecting the non-recurrent funding in the year to date position. The forecast year end underlying position has also been amended to match the Trust’s planning return and the revised start point for the next version of the LTFM. This is now £5.2m. • The cash balance at the end of December 2014 was £4.9m, slight above the planned position (correcting a dip last month). The cash position will become more challenging as expenditure continues adverse to plan. Management of cash payments from CCGs has been proactive and it is hoped that payments by CCGs will be timely in future. • The capital forecast spend adjusted to £19.3m (reduction of £100k in respect of Salix funding & expenditure as agreed with TDA).

An Associated University Hospital of Brighton and Sussex Medical School 14

TRUST BOARD IN PUBLIC

Date: 29 January 2015 Agenda Item: 3.2

REPORT TITLE:

Finance & Workforce Committee Chair Update – Part 1

EXECUTIVE SPONSOR:

Paul Simpson (Chief Financial Officer)

REPORT AUTHOR (s):

Richard Durban (Non-Executive Director and FWC Chair)

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

No – Board Update

Action Required: Approval ( )

Discussion ( )

Assurance (√)

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

The Finance and Workforce Committee met on the 27th January 2015. The key points from the meeting were as follows: Business Case Investment The Committee received and approved an Outline Business Case to re provide the Medical Records accommodation on the East Surrey site. It requested certain aspects of the proposal were expanded upon in the FBC Financial, Workforce, Capital and IT M09 performance reports M09 reports were received for Finance, Workforce and Organisational Development, Capital and IT. On Finance the Trust has performed on plan, with a surplus of £1m at M09 2014/15, but this includes non-recurrent items and accruals. The Trust continues to forecast a £2.3m surplus but this includes £6.3m of red rated risks and an underlying deficit of £5.2m. The Committee received a paper Nursing Recruitment and Retention and verbal updates on the EPMA and ERR projects. Recommendation:

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

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

Legal and regulatory impact

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

Financial impact

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

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

Patient Experience/Engagement

Indirect impact through Trust planning and workforce.

Risk & Performance Management

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

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

An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT – 29 January 2015

Finance & Workforce Committee Chair Update The Finance and Workforce Committee met on 27 January 2015 and it was quorate. points from Part 1 were as follows:

The key

Business Case Investment The Committee received an Outline Business Case (OBC) for the Medical Records Extension incorporating Maple Annex Replacement. The OBC proposes the construction of a two-storey extension of the existing Medical Records accommodation, which abuts the in-patient Pharmacy/Fracture Clinic areas at East Surrey Hospital (ESH). The development is put forward because the facilities currently available to the SaSH Medical Records function are not suitable for the delivery of an efficient service to the Trust and does not support appropriate standards of record management and governance. The capital cost is estimated at £2m, £500k above the allocation in the capital programme. The Committee asked that the following points were expanded upon and included in the Full Business Case: -

the impact on the use of space elsewhere in the Trust the relationship between the use of the external storage facility – soon to be relocated and under new management – and the redeveloped internal facility any impact of future moves to electronic records the quantification of productivity benefits clarity around the impact on the capital programme of the additional £500k. that the “do nothing” option is quantified

The Committee approved the OBC and that the scheme can progress the design, submit a planning application, progress a competitive tender process and submit the FBC for approval in March 2015. Financial, Workforce, Capital and IT M09 performance reports The month 9 Finance, Workforce and Organisational Development, Capital and IT performance reports were presented to the Committee: -

The Committee received an update on Nursing recruitment and retention. Fiona Allsop outlined the plan to recruit 150 qualified nurses from the Philippians to help fill the vacancies in permanent staff within the Trust (the business case to be reviewed by the Executive and put to the 29/1 Board). Recruitment has been successful in Midwives and Paediatric nursing but we have not yet recruited to the 1:7 during the day and 1:10 at night ratios that the Trust set for safer staffing. Currently the turnover rate amongst nursing staff is 15% per year. The Committee noted that the 15% turnover resulted in an annual recruitment target of 250 nurses and discussed actions to reduce turnover to the target of 12% or below. It also noted that current vacancies stood at 167 nurses. It also discussed the approach to international recruitment, the use of the bank and how the recruitment of appropriate nurses might be a constraint on the development of services.

The IT report was presented and noted by the Committee. David Heller gave a verbal report on the pilot EPMA project. The one ward trial had gone well both technically and in terms of user feedback. It will now undergo a project evaluation in order to determine how it is progressed. Ian Mackenzie presented an EPR update advising that the data flip will take place in June after a An Associated University Hospital of Brighton and Sussex Medical School

4 month period of testing and we would then start our move to the latest version of the EPR software in September 2015. The IT project manager role is not currently to be filled by a permanent member of staff and the budget will be used to employ specialist contractor to support the specific IT projects the Trust is undertaking. -

The Trust is on plan for M09 2014/15, with a £1m surplus year to date and a £0.5m surplus in M09. The Committee was advised that the Trust forecast remains at £2.3m surplus but the underlying deficit position has moved to £5.2m deficit, reflecting the non-recurrent emergency tariff income. The net red rated risks to this position have been estimated at £6.3m a reduction in risk from the previous months. On cash the Trust is currently experiencing delays in payments by the CCG’s for contracted over performance which may result in the Trust needing to take a loan.

The CIPs update was discussed with the Committee noting that as in the previous year central underspends and reserves were being used to mitigate overspends in other areas. It was agreed to provide greater visibility of this in future reports.

The Workforce and Organisational Development Report was received. The Committee noted that the sickness absence had worsened in the last month. This was being investigated and a report would come to the February FWC. It was also being added to the Risk Register. Other indicators were showing red and the Committee discussed overall staff morale; it noted the national context and the very high level of activity and was assured that all appropriate Trust actions were being taken eg the continued focus on good communications.

The Capital & Estates Report was presented with the Committee noting the opening of the new Capel Annex on time and on budget and the possibility of a storage room being added to the decant ward project.

An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD IN PUBLIC

Date: 29th January 2015 Agenda Item: 3.3

REPORT TITLE:

Audit & Assurance Committee Chair Update

NON EXECUTIVE SPONSOR:

Paul Biddle (Non-Executive Director and AAC Chair) Colin Pink Corporate Governance Manager

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

Audit & Assurance Committee â&#x20AC;&#x201C; 13/01/15

Action Required: Approval ()

Discussion ()

Assurance (â&#x2C6;&#x161;)

Purpose of Report: This report provides the Board with an executive summary of the January Audit and Assurance Committee. Summary of key issues The committee reviewed and accepted assessments of internal control linked to finical management and clinical governance. Noting the changes to management of revenue budgets and actions being taken to improve incident reporting and clinical audit systems. The committee received a draft annual report to board and a review of the corporate governance manual for the Trust. Both where discussed and agreed to be forwarded to the board for acceptance. Internal Audit and counter fraud teams provided update reports providing assurance on financial feeder systems, whistleblowing systems and recent significant successful legal action taken by the Trust relating to a time sheet fraud. 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:

Legal and regulatory impact

The AAC reviews assurance in respect of all Trust systems of control which includes reporting and compliance with all statutes applied to an NHS Trust. Financial performance is subject to Schedule 5 of the NHS Act 2006 which provides the

“breakeven duty”. The AAC reviews assurance in respect of all Trust systems of control which includes reporting and compliance with all regulation applied to an NHS Trust. The main regulators, however are as follows: - External audit (the Audit Commission for this Trust) give an opinion on the Trust’s compliance with International Financial Reporting Standards and with NHS accounting conventions – this is not purely financial and deals with procurement, fraud, transparency and legal duties. It also gives a Value for Money Conclusion on the Trust’s ability to put in place arrangements to deliver economy, efficiency and effectiveness in its use of resources.

Financial impact Patient Experience/Engagement Risk & Performance Management

The Care Quality Commission registers the Trust according to its compliance with regulations concerning the safety and quality of services. No material financial implications. The report provides independent assurance about BAF reporting on financial risk and counter fraud systems No relevant aspects 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 – 29th January 2014 Audit & Assurance Committee Chair Update The Audit and Assurance committee met on the 13/01/2015; it was quorate. The key points from this meeting were as follows: 1) Review of committee effectiveness and draft annual report The committee considered its effectiveness and reviewed a draft annual report to the Board. The committee agreed with the review of effectiveness and noted the initial delays in progress to review internal control systems. It reflected on the need to continue to focus on financial control as the national and local position became ever challenging. It noted the assurances that had been provided by internal and external audit throughout the year and the actions taken to complete recommendation’s that had seen significant improvements in the internal audit action tracker. The committee accepted the annual review of effectiveness and agreed the annual report to Board. 2) Internal controls and data quality review a) Financial Controls The Chief Finance Officer presented an updated review of the Trust’s financial controls. This highlighted changes to risk assessment of controls relating to assessment for revenue budget setting and cost improvement planning. These changes are based on need to adjust financial position to reflect revenue budgets and activity and are based on sound forecasting systems. Whilst acknowledging the changes proposed that would recognise significant forecast revisions to the activity assumptions used as the basis for the annual plan, it is important to maintain variance reporting against the approved plan. The Committee accepted the assessment of financial control systems. The committee noted the proposed changes and asked for further information on how this element of budget control is managed. b) Clinical Governance Controls The Chair of the Safety and Quality Committee (SQC) presented a review of controls that supported the Trust’s clinical governance systems. The committee noted the improvements that had been made in year and the level of system risk attached to incident reporting, and trust wide learning from clinical negligence and clinical audit. The committee accepted the assessment of internal controls and asked that the SQC reconsider the assessment of clinical audit system once proposed actions had been completed. 3) Corporate Governance Manual The Chief Finance Officer presented the annual review of the Corporate Governance Manual, which includes the Trust’s SFIs, defines accountability and the scheme of delegation. The committee noted that there where minor

3 An Associated University Hospital of Brighton and Sussex Medical School

changes throughout and discussed the proposed changes to modernise tendering processes which reduce administration and improve capability to audit activity. The committee accepted the review and proposed that the manual be referred to public board for acceptance. 4) Internal Audit update Internal Audit provided its regularly update on activity, highlighting the review of Trust Whistleblowing systems which had identified possible improvements in policy and recommendations on shared leaning of incidents. The committee where assured that the policy changes had already been effected and that there are plans to produce regular whistleblowing reports. Internal audit went on to highlight the financial feeder system audit which had provided strong assurance. 5) Counter Fraud The Trustâ&#x20AC;&#x2122;s Counter Fraud representative provided their update report which gives specific progress of activity to prevent and minimise the impact of Fraud on the Trust. This focused on the proactive review of systems in radiology and possible timesheet fraud. The committee noted that a proactive review of timesheets had randomly identified a fraud case which was under review and was reassured that the Trust was taking actions to mitigate against opportunist fraud. The committee was assured by the recent successful fraud investigation which had resulted in a custodial suspended sentence.

Paul Biddle Non-Executive Director Chair â&#x20AC;&#x201C; Audit & Assurance Committee January 2015 [END]

4 An Associated University Hospital of Brighton and Sussex Medical School

Date: 29th January 2015

TRUST BOARD IN PUBLIC

Agenda Item: 3.4 REPORT TITLE: NON EXECUTIVE SPONSOR: REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

Audit and Assurance Committee (AAC) Annual Report Paul Biddle, (Non-Executive Director and AAC Chair) Colin Pink Corporate Governance Manager AAC 13th January 2015

Action Required: Approval ( )

Discussion ( )

Assurance (√)

Purpose of Report:

This paper is the annual committee report to the Trust board. It provides a summary of a review of committee effectiveness, activity and areas of focus for 2015. Summary of key issues This reports highlights assurances of the committees activity focusing on the development of annual report, annual governance statement, review of internal and external assurances and controls and ongoing management of financial risk. Recommendation: The Board is asked to note the report and activity of the Audit and Assurance Committee in line with the Trust’s rules of procedure and the “Audit Committee Handbook”. 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

The AAC reviews assurance in respect of all Trust systems of control which includes reporting and compliance with all regulation applied to an NHS Trust. The main regulators, however are as follows: - External audit (the Audit Commission for this Trust) give an opinion on the Trust’s compliance with International Financial Reporting Standards and with NHS accounting conventions – this is not purely financial and deals with procurement, fraud, transparency and legal duties. It also gives a Value for Money Conclusion on the Trust’s ability to put in place arrangements to deliver economy, efficiency and effectiveness in its use of resources.

Financial impact

The Care Quality Commission registers the Trust according to its compliance with regulations concerning the safety and quality of services. The report reflects the AAC overview of financial risk management and management of the Trust’s annual accounts

Patient Experience/Engagement

No relevant aspects

Risk & Performance Management

The committee provides assurance about internal control and risk management.

NHS Constitution/Equality & Diversity/Communication

No relevant aspects

Attachment: N/A

TRUST BOARD REPORT – 29th January 2015 AUDIT & ASSURANCE COMMITTEE ANNUAL REPORT 1. Purpose The purpose of this paper is to provide assurance to the Board that the Terms of Reference of the Committee are being met, to highlight significant issues that have been raised, resolved or challenged and to describe improvements in the way the Committee works. 2. Context The purpose of the Committee is to assist the Board of Directors by providing assurance that the Trust is well managed across the whole range of their activities through: i) reviewing the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the organisation’s activities (both clinical and non-clinical); ii) ensure there is an effective internal audit function established by management, which provides appropriate independent assurance to the Audit Committee; iii) reviewing the work and findings of the External Auditor appointed by the Audit Commission and consider the implications and management’s responses to their work and; iv) reviewing the annual report and financial statements before submission to the Board. The Committee meets every other month for normal business and convenes extra meetings where necessary to support the management of annual accounts. The Agendas are split into 4 parts looking at risk management, internal controls, Audit (internal and External) and general business. The Committee’s terms of reference states that there shall not be less than three nonexecutive directors on the membership, one of whom shall be appointed as Chairman of the Committee; the quorum necessary for the transaction of business shall be three.

Yvette Robbins

Sep 14

Nov 14

√* Apologies √* Apologies √ √ √ Apologies Apologies √ √* √

Jul 14

May 14

√* √ √ √

Apr 14

Richard Congdon Richard Shaw John Power Richard Durban Paul Biddle

Mar 14

Member

Jan 14

Attendance throughout the year is has been as follows:

√ √ √* √

Apologies

√

√ √*

√ * Denotes Committee Chair

3. Sources of assurance To meet it’s terms of reference the Committee receives: ‐ The Board assurance Framework and SRR ‐ Sound management of financial risk that evidences dynamic adaption to meet local and national changes. ‐ Reports from the finance team on loses and compensation and amendments to SFIs and review of accounting policies ‐ Reports from Internal Audit and Counter Fraud services which provide assurance and through discussion benchmarking information. ‐ Reports from External Audit which provide assurance, benchmarking and emerging national themes and issues. ‐ The annual accounts, annual report and annual governance statement. 4. Committee Activity during 2014 During the 2014 the Committee has looked to develop and strengthen Board level assurance of risk management and internal controls. This was based on the foundation of sound financial controls and the first internal controls map developed throughout 2013. The main points of note are: ‐ Audit of annual accounts by external audit commented on the quality of the accounts without any recommendations. ‐ In its review of annual accounts External audit made adverse comment on value for money and the Trust’s “Quality Account” (one KPI was identified) ‐ Review and signoff of the annual governance statement and annual report (as part requirements of the annual accounts) ‐ Regular review and challenge of BAF and Significant Risks register and their process which have identified improvements to the detail and accuracy of both board papers. Review of risk management system using key lines of enquiry. ‐ Reviews of Internal Audit and CFSMS have provided assurance of Trusts controls and the support these services provide. Management and completion of Internal Audit recommendations has seen a drop of outstanding actions from 30 (January 2014) to 10 (November 2014). The committee finished its initial review of the Trust Internal controls but did not receive any of the planned reviews of internal controls that where due to be tabled. The first two topics, clinical governance controls and financial controls, where considered at the January 2015 meeting and the draft data quality strategy has been reviewed at private board. The committee received an update on planned actions to improve compliance across the Trust’s systems of controls and plans to review control systems as a standing agenda item. 5. Ways of Working The Committee’s membership has seen significant change throughout the year two members of the committee (including the chair) have left the Trust. Both these roles have been filled and there has been minimal effect on the normal duties of the committee. The committee has increased its membership to four non-executive directors who are all chairs of Board sub-committees. The Committee has changed the structure of its agenda to reflect the structure defined in the context (as described above). This has facilitated simpler agenda structures and meeting planning.

As expected the committee has relied on a healthy balance of challenge and discussion led by the membership and supported by executive leads and internal and external audit. Throughout the year the committee has requested attendance from executive and management leads to provide support and allow challenge of any issues that have been identified as a significant issue. 6. Challenges for 2015 Mindful of the possible impact on the committees and Boards function should the Trust achieve its ambition to become a foundation Trust. The Committee has identified the following as main challenges for 2015: 1. To continue to provide assurance of financial control during a period of financial pressure, uncertainty and strategic change in the national health care system. 2. Embed the process for reviewing specific elements of internal controls. 3. Provide suitable assurance to the board to support the Trustâ&#x20AC;&#x2122;s Foundation Trust Application (particularly Historical Due Diligence). 4. Complete an impact assessment of changes made to audit committee handbook and identify any gaps 7. Conclusion The Board can be assured that the Audit and Assurance Committee is meeting its terms of reference.

Paul Biddle Non-Executive Director Chair of Audit & Assurance Committee January 2015

Appendices

Audit and Assurance Committee: Terms of Reference 1.

Introduction

1.1

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

Constitution

2.1 The Board hereby resolves to establish a committee of the Board to be known as the Audit and Assurance Committee (The Committee). 2.2 The Committee is a non-executive committee of the Board and has no executive powers, other than those specifically delegated in these terms of reference.

Membership

3.1 3.2 3.3 3.4

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

Attendance

4.1

4.2

4.3 4.4

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

Frequency

5.1

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

5.2

Authority

6.1

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

7.1

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

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

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

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

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

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

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

7.1.2 In carrying out this work the Committee will primarily utilise the work of internal audit, external audit and other assurance functions (for example the Trustâ&#x20AC;&#x2122;s clinical audit function) to ensure review is external, but will not be limited to these. It will also seek reports and assurances from directors and managers as appropriate, concentrating on the overarching systems of integrated governance, risk management and internal control, together with indicators of their effectiveness.

7.1.3 In relation to the Board Assurance Framework the committee will use this to guide its work and will provide assurance that the controls and actions taken to address any gaps are robust and support the delivery of corporate objectives. 7.2 Internal Audit The Committee shall ensure there is an effective internal audit function established by management, which provides appropriate independent assurance to the Audit Committee, Chief Executive and Board and meets mandatory NHS Internal Audit Standards. This will be achieved by: -

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

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

consideration of the major findings of internal audit work (and managementâ&#x20AC;&#x2122;s response), and ensure co-ordination between the internal and external auditors to optimise audit resources

ensuring the internal audit function is adequately resourced

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

7.3 External Audit The Committee shall review the work and findings of the External Auditor appointed by the Audit Commission and consider the implications and managementâ&#x20AC;&#x2122;s responses to their work. This will be achieved by: -

consideration of the appointment and performance of the External Auditor, as far as the Audit Commissionâ&#x20AC;&#x2122;s rules permit

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

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

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

7.4 Other Assurance Functions 7.4.1 The Committee shall review the findings of other significant assurance functions, both internal and external to the organisation, and consider the implications to the governance of the organisation. These will include, but will not be limited to, any reviews by Department of Health Arms Length Bodies or Regulators/Inspectors (e.g. CQC, NHS Litigation Authority, etc.), professional bodies with responsibility for the performance of staff or functions (e.g. Royal Colleges, accreditation bodies, etc.), reports by the Trustâ&#x20AC;&#x2122;s local counter fraud specialist. 7.4.2 In addition, the Committee will review the work and function of other committees, working groups and senior responsible officers within the organisation, whose work can provide relevant assurance to the Committeeâ&#x20AC;&#x2122;s own scope of work. 7.4.3 In reviewing work of around clinical risk management, the Committee will wish to satisfy itself on the assurance that can be gained from the clinical audit function and outcome measures from the Trusts clinical benchmarking systems.

Management

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

Financial Reporting

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

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

changes in, and compliance with, accounting policies and practices

unadjusted mis-statements in the financial statements

major judgmental areas

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

10. Reporting 10.1 The minutes of the Committee meetings shall be formally recorded by the Trust Secretary and submitted to the Board. The Chair of the Committee shall draw to the attention of the Board any issues that require disclosure to the full Board, or require executive action. 10.2 The Committee will report to the Board annually on its work in support of the Statement on Internal Control, specifically commenting on the fitness for

purpose of the assurance framework, the completeness and embedding of risk management in the organisation, the integration of governance arrangements and the appropriateness of the self-assessment of provider compliance with CQC regulations.

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

Agreement of agenda with Chairman and attendees and collation of papers

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

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

Advising the Committee on pertinent matters

Audit and Assurance Committee: Standing Agenda 1

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

Risk Management Board Assurance Framework Risk Management Systems

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

Specific Duties Review annual accounts Reviews losses waivers and special payments

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

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

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

March 1.

Plan how to discharge Audit Committee duties

Self-assess Committee’s effectiveness

Review Committee’s terms of reference

Produce annual Audit Committee report

Private discussions with internal and external audit

May

July

Sept

Nov

Jan

    



Risk Management 6.

Review the Board Assurance Framework in Full

Review the Assurance Framework in sections

Review the risk management system in full

Receive the Significant Risk Register

 



 



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



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

   

16. Review risks and controls around clinical governance



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

 

Specific Duties 19. Review of other reports and policies as appropriate – for example, changes to standing orders



20. Review of audited annual accounts and financial statements



21. Review changes to standing financial instructions and changes to accounting policies



22. Review of losses and special payments

  



 

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



25. Review and approve internal audit terms of reference



26. Review the effectiveness of internal audit



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



29. Agree external audit plans and fees 30. Review the effectiveness of external audit 31. Review external audit progress reports



 

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



33. Receive the External Auditor’s annual audit letter



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

 



36. Review the organisation’s assessment against CFSMS qualitative assessments 37. Review the effectiveness of the Local Counter Fraud Specialist



 

38. Receive counter fraud annual report to AAC



Lower Ground Floor Crawley Hospital West Green Drive Crawley West Sussex RH11 7DH Richard Shaw Chairman of the Safety and Quality Committee Surrey and Sussex Healthcare NHS Trust

Tel: 01293 600300 (ext. 4255) Email: v.daley@nhs.net

23 January 2015

Dear Richard, Thank you for your letter dated 12th December 2014 regarding the SASH CQC Quality Summit 2014: Health Systems Actions. Extensive work has been undertaken by the CCG’s in this area and I am pleased to provide you with a summary of the work streams that are currently in place from the perspective of the Crawley, Horsham and Mid-Sussex Clinical Commissioning Group to support the Trust to move from ‘Good’ to ‘Outstanding’: Chief Officers Group A Chief Officers Group has now been formed in place of the Local Transformation Board with the role and responsibility for overseeing the plans for systems resilience. This forum takes a strategic view of problems and solutions for the whole system. Occupancy rate The CCG’s are part of the Systems Resilience Group (SRG) which has the function for modelling and monitoring whole system capacity including occupancy rates. The transformational programmes of work are agreed, measured and monitored at the two Systems Resilience Groups (for Surrey and Sussex). The outcomes of these groups are brought together at the Chief Officers Group on a monthly basis. Discharge to Assess This project is underway and led by the Trust under the direction of Sue Jenkins. The Rapid Safe Integrated Discharge group (RAPSID) has been formed to improve processes across the whole

Crawley Clinical Commissioning Group Horsham and Mid Sussex Clinical Commissioning Group

system. In addition, the Systems Resilience Group regularly discusses issues arising as a result of delayed discharge and how these issues may be resolved. Continuing Health Care Assessments/Decision Support Tools An agreement in principle has been made between the Local Authority and the Clinical Commissioning Groups. This has been trialled over Christmas/New Year and the recent period of increased service demand and this has resulted in the identification of a number of key areas of improvement. This work continues at pace and is discussed at the Systems Resilience Group.

I hope this summary is helpful in providing assurance to yourself and the Trust Board of the CCG’s commitment to the delivery of actions that directly affect patient care and the health systems reputation. Please do not hesitate to get in touch should you or your colleagues have any queries. Yours sincerely,

Head of Quality/Chief Nurse, Crawley and Horsham & Mid-Sussex CCG’s On behalf of: Sue Braysher - Chief Officer, Horsham and Mid-Sussex CCG/Chief Operating Officer, Crawley CCG Dr Amit Bhargava - Clinical Chief Officer, Crawley CCG Dr Minesh Patel – Chair, Horsham and Mid-Sussex CCG Debra Wheeler – Head of Delivery, Crawley, Horsham and Mid-Sussex CCG’s.

CC: Karen Devanny – Director of Quality, East Surrey CCG

Crawley Clinical Commissioning Group Horsham and Mid Sussex Clinical Commissioning Group

TRUST BOARD IN PUBLIC

Date: 29th January 2015 Agenda Item: 4.1

REPORT TITLE:

CQC Improvement Action Plan

EXECUTIVE SPONSOR:

Michael Wilson Chief Executive Sue Jenkins Director of Srategy

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

Executive Committee

Action Required: Approval ()

Discussion ()

Assurance (√)

Purpose of Report: This report provides the Board with assurance that the recommendations made following the CQC visit in May 2014 are being addressed Summary of key issues The Chief Inspector of Hospitals visited the Trust in May 2014. The Trust was rated as “good” for all domains. In terms of the 8 core services that were reviewed the Trust received a “good” rating for all services apart from Outpatients services which were rated as “requires improvement”. In response to the CQC report and summary of findings an action plan has been developed to address the areas for improvement in the outpatients service. A monthly update of progress against the action plan is provided to the Trust Board every month. An update on the system wide issues identified at the quality summit has previously been requested from the CCGs and updates have been requested. This has been followed up by the chair of the Safety and Quality Committee. Sussex CCGs have agreed to provide an update for the January SaSH Board meeting and Surrey CCGs have been asked to liaise with them. This report provides a summary of progress to date which confirm that all of the four main work streams are rated as green. Recommendation: The Board are asked to consider this report and ensure that it provides assurance around delivery of the CQC improvement plan. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about

SO4: Responsive â&#x20AC;&#x201C; Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment: Legal and regulatory implications Financial implications Patient Experience/Engagement Risk & Performance Management NHS Constitution/Equality & Diversity/Communication

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

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

2 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT –29 January 2015 CQC Improvement Plan Update - Outpatients 1.

Introduction

The Chief Inspector of Hospitals visited the Trust in May 2014. The Trust was rated as “good” for all domains. In terms of the 8 core services that were reviewed the Trust received a “good” rating for all services apart from Outpatients services which were rated as “requires improvement”. In response to the CQC report and summary of findings an action plan has been developed to address the areas for improvement in the outpatients service. A monthly update of progress against the action plan is provided to the Trust Board every month. An update on the system wide issues identified at the quality summit has previously been requested from the CCGs and updates have been requested. This has been followed up by the chair of the Safety and Quality Committee. Sussex CCGs have agreed to provide an update for the January SaSH Board meeting and Surrey CCGs have been asked to liaise with them. This report provides a summary of progress to date. 2. Outpatient update There are four key work streams that the outpatient action plan covers. They are  Environment  Workforce and leadership skills  Communications  Systems and processes The table below details the key actions that are being undertaken for each of the four areas and a RAG status is included:RAG B G A R

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

Ref

Details

1.0 1.1

Environment Minor redecoration and refurbishment in the existing department have been completed A date for the Diabetes and Endocrinology services moving off site to a GP practice in Earlswood has now been agreed. The move will take place on 2 and 3 February and new services will commence on 4 February. This move will release 3 rooms along the Chipstead corridor which will be converted to clinic rooms. IT solution being explored to support room allocation and monitoring

1.2

1.3

RAG status G B G

3 An Associated University Hospital of Brighton and Sussex Medical School

1.4

1.5

1.6

1.7

1.8 2.0 2.1

2.2 2.3 2.4

2.5 2.6 2.7 2.8 2.9 2.10

2.11

of clinic space. Onsite visit from potential supplier of software system to support room use and allocation has taken place and further meetings to progress a pilot have been planned. A business case is being developed and this will be considered by CHIG and CWG in February. No capital has been allocated to this scheme at the moment and likely cost is estimated at ÂŁ24k. Accommodation for additional ophthalmology clinics being considered at Horsham and a meeting with a property developer has also been arranged to discuss the opportunity of having a community ophthalmology centre built Refurbishment of haematology clinic areas included in capital plan for 2015/16 but work planning to start in February/ March 2015. Plans have been agreed with clinical staff. Chemo outpatient clinics to be accommodated on ESH site following repatriation from Royal Surrey Hospital. Some of these clinics have commenced and the rest will be accommodated when rooms have been identified Report requested from information team to review allocation of patients waiting for outpatient clinics to nearest location to home address and information now available and to be used to inform appointment bookings. Outpatients refurbishment and works project group established and meeting on a weekly basis Systems and processes Trust wide review of demand and capacity underway and half day workshop for outpatient team originally planned for December now scheduled for January. This will be followed by a session with service managers for sign off and reviewing of job plans and templates. Service level review of demand and capacity underway and will be matched with trust wide review at beginning of 2015. New templates implemented and in place for ad hoc clinics, cancellations and room requests Separate partial booking project team established and plan to be completed. Aim to implement January 2015 using Cardiology and Rheumatology as pilot areas. Challenges experienced to support lock down of clinic templates by cerner back office team â&#x20AC;&#x201C; issue escalated to directors for resolution in January Electronic process for referrals being considered and developed with GPs. Trial being developed with two GP practices. KPIs and metrics agreed for monitoring outpatients by steering group Consultant to consultant process reviewed and referrals reduced to minimise financial penalties Monitoring of new to follow up ratios in place on a monthly basis to ensure financial penalties are minimised Weekly monitoring of KPIs commenced and reporting in place at divisional level. Detailed reports for key breaches to be developed Telephone clinics in place for some specialties and tariff being developed to support this more efficient and effective way of working. Rheumatology and gastroenterology are looking at this area in more detail and some software with a years free trial is being explored to support Bleep system to enable patients to leave the department has been explored with other trusts who have system in place. Not considered viable as patients too concerned that they will lose their appointment

G G

B G A

G B A

G B B B G G

4 An Associated University Hospital of Brighton and Sussex Medical School

2.12 3.0 3.1

3.2 3.3 3.4 3.5 3.6 4.0 4.1

4.2 4.3 4.4 4.5

slot. Self check kiosk option being considered as an alternative and pilot being explored with potential supplier and a case to support the trial will be considered y CHIG in January 2015 Outpatient booking office call answering currently at 98%. Plan in place to improve to 99% Workforce and leadership Interviews for Outpatient Service Manager completed and offer made to strong candidate who commenced at beginning of January 2015. Interim management arrangements in place. Skill mix review of outpatient services continually underway and reviewed each time vacancies arise. Single line management of all outpatient staff considered and agreed not to progress at this point Outpatient steering group and weekly operational groups all in place Back to the floor session by Director of Strategy undertaken in outpatients department Programme to extend skills of nurses being developed and to be worked up in more detail in New Year following appointment of new service manager Communications Lead clinician and members of outpatient team have met with a number of GP practices and CCG governance committee to consider views on referrals from GP perspective. This is key to improve working relationships between the Trust and primary care. Lead clinician meeting with clinicians on a 121 basis to gain views and feedback on outpatient services Outpatient services to be included on agenda item for all consultants meeting â&#x20AC;&#x201C; Mid September Outpatient nurse lead to meet with patient experience forum Outpatient focus group for patients planned for 2 December and 157 members interested in outpatients have been invited. Focus groups completed with 14 participants and feedback has informed an action plan which is monitored by monthly outpatient steering group.

G G B G B B B G G G

G B G B

Progress against KPIs Clinics cancelled with less than 6 weeks notice

5 An Associated University Hospital of Brighton and Sussex Medical School

Total ad hoc clinics

Ad hoc clinics â&#x20AC;&#x201C; general surgery

Ad hoc clinics â&#x20AC;&#x201C; general medicine

Ad hoc clinics - WACH

6 An Associated University Hospital of Brighton and Sussex Medical School

Calls in and out of booking office

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

7 An Associated University Hospital of Brighton and Sussex Medical School

Lower Ground Floor Crawley Hospital West Green Drive Crawley West Sussex RH11 7DH Richard Shaw Chairman of the Safety and Quality Committee Surrey and Sussex Healthcare NHS Trust

Tel: 01293 600300 (ext. 4255) Email: v.daley@nhs.net

23rd January 2015

CC: Karen Devanny – Director of Quality, East Surrey CCG

Crawley Clinical Commissioning Group Horsham and Mid Sussex Clinical Commissioning Group

Date: 29th January 2015

TRUST BOARD IN PUBLIC

Agenda Item: 4.2 Serious Incidents Report

REPORT TITLE:

Fiona Allsop Chief Nurse Katharine Horner Patient Safety & Risk Lead

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

Rado Dobransky Datix Admin

n/a

Action Required: Approval ()

Discussion ()

Assurance ()

Purpose of Report: To provide an update on the position of the Trust with regard to serious incidents. Summary of key issues This paper provides the Board with a report on the serious incidents declared in quarter 3 and an update on progress with known safety themes arising from serious incidents. 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 Trust Wide sharing of lessons learned and actions resulting from completed SI investigations. 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

Compliance with CQC, MHRA and Audit Commission

Financial impact

Serious incidents often become claims

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

Reporting, investigation and learning from serious incidents informs risk management

TRUST BOARD REPORT â&#x20AC;&#x201C; Quarter 3 2014/2015 Serious Incident Report for Public Board 1. Introduction This report informs the Board about incidents occurring within the Trust that have been declared to the CCG as Serious Incidents (SIs). All incidents are reported via the Datix database and any incidents that indicate major / extreme harm are considered as potential SIs however they may not all be declared as SIs. The National definition and criteria for an SI is always used when considering potential SIs and when declaring, or not, an SI. There were a total of 1489 clinical / patient safety incidents that occurred during the last quarter (October â&#x20AC;&#x201C; December 2014). The majority of clinical / patient safety incidents resulted in no harm or minor harm. Of the 78 moderate/major/extreme harm incidents 5 were declared as an SI. 2. Patient Safety Incidents in Quarter 3 compared to previous 3 quarters:

Q3 2014/2015 Pressure ulcers - hospital acquired Maternity / Delivery Care implementation Falls, slips and trips (Patient) Clinical diagnosis Diagnostic imaging Skin damage - hospital acquired Treatment / Procedure Appointments Surgery - management of operations Neonatal Transfer of patient Totals:

MOD

MAJOR 27 21 12 2 3 1 2 2 1 1

EXT

Total

3 1

1 1 73

An Associated University Hospital of Brighton and Sussex Medical School

27 21 12 5 3 2 2 2 1 1 1 1 78

3. Serious Incidents Declared in Quarter 3 2014/15 The graph below illustrates the number of SIs declared during the quarter by Division and in comparison to the previous 3 quarters. It shows that in this quarter there was a decrease in the number of SIs declared within the Medical Division (2) and CSS Division (2), the same number within the Surgical Division (2), there was again 1 SI declared within the WaCH Division and Cancer Division remained unchanged with 0 SI declared.

An Associated University Hospital of Brighton and Sussex Medical School

4. Serious Incidents Category Themes The table demonstrates the declared SI category themes identified this quarter in comparison to previous quarters. In quarter 3 patient falls formed the main type of SI declared which is similar to the previous quarters. Clinical diagnosis also remains a regular theme although the number declared as SIs in this quarter has decreased.

Falls, slips and trips (Patient) Clinical diagnosis Cancer - diagnosis failed / delayed Other clinical diagnosis failed / delayed Fracture - diagnosis failed / delayed Medicines management Cancer drugs All other drugs Neonatal Neonatal death Unexpected admission of term baby to NICU for >24hrs with ventilation Anaesthetics: Pneumothorax Care implementation: Care - unavailable Diagnostic imaging: Unexpected pt outcome whilst in Imaging Dept Surgery - management of operations: Perforation Infection control: MRSA - bacteraemia case Pathology processing: Wrong interpretation of pathology results Treatment / Procedure: Cardiac arrest Totals:

13/14 Q4 14/15 Q1 14/15 Q2 14/15 Q3 10 7 7 3 2 6 1 1 5 1 1 1 3 1 2 1 1 1 1 1 1 1 1 1 1 1 12 12 17 7

An Associated University Hospital of Brighton and Sussex Medical School

Total 27 9 6 2 1 3 1 2 2 1 1 1 1 1 1 1 1 1 48

5. Comparison of Serious Incidents themes with non-SI incidents over last 12 months The graph demonstrates the number of SIs by the incident date that occurred in the last 12 months compared to the number of non-SI incidents. Over the last 12 months only 2% of all reported patient slips, trips and falls and 9% of reported clinical diagnosis incidents were declared as an SI.

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 Trust Wide sharing of lessons learned and actions resulting from completed SI investigations. Fiona Allsop Chief Nurse January 2015

An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD IN PUBLIC

Date: 29th January 2015 Agenda Item: 4.3 CORPORATE GOVERNANCE MANUAL REVIEW (Standing Orders, Standing Financial Instructions & Scheme of Reservation and Delegation of Powers) Paul Simpson Chief Finance Officer

REPORT TITLE:

EXECUTIVE SPONSOR: Gillian Francis-Musanu Director of Corporate Affairs Lorraine Clegg Deputy Director of Finance Lee Edwards Head of Procurement

REPORT AUTHOR (s):

Colin Pink Corporate Governance Manager REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

Audit & Assurance Committee 13.1.15

Action Required: Approval (√)

Discussion ( )

Assurance (√)

Purpose of Report: This report presents amendments to the Corporate Governance Manual, Standing Orders and the Standing Financial Instructions and Scheme of Reservation and Delegation of Powers (SO’s & SFIs) as part of most recent review. Summary of key issues The main changes to the manual are summarised in the report and relate to the following areas:  Section A - Interpretation and definitions for Standing Orders and Standing Financial Instructions, and Section B - Standing Orders  Section C - Standing Financial Instructions: (were significantly updated in July 2013 v2 therefore no major changes required)  Section D – Scheme of Reservation and Delegation  Section E - Codes of Accountability and Conduct & Openness for NHS Boards

(no changes)  

Section F – Anti-Fraud and Corruption Section G – Tendering and Waiver Procedures: (were significantly updated in July 2013 v2 therefore no major changes required)

Recommendation: The Board is asked to approve and ratify the current amendments to the Corporate Governance Manual as listed in 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 â&#x20AC;&#x201C; Ensure patients are cared for and feel cared about SO4: Responsive â&#x20AC;&#x201C; 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

Ensures legal and regulatory requirements are met

Financial impact

Overriding policy for financial issues

Patient Experience/Engagement

No adverse impact reported or expected

Risk & Performance Management

Fulfils compliance issues

NHS Constitution/Equality & Diversity/Communication

No adverse impact

Attachment: Corporate Governance Manual

2 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT – 29th January 2015 CORPORATE GOVERNANCE MANUAL REVIEW 1.

Introduction

This paper presents amendments to the Corporate Governance Manual, Standing Orders and the Standing Financial Instructions and Scheme of Reservation and Delegation of Powers (SO’s & SFIs) which have been reviewed. 2.

Summary of changes from version 2.0 to current proposed version 3.0

2.1

Section A - Interpretation and definitions for Standing Orders and Standing Financial Instructions, and Section B - Standing Orders:  Updated versions of all Terms of Reference as approved by the TB in November (Rules of Procedure)  Updated roles & responsibilities of committees (tweaks)  Removal of reference to the Management Board replaced with Executive Committee And Executive Committee for Quality & Risk

2.2

Section C - Standing Financial Instructions: (were significantly updated in July 2013 v2 therefore no major changes required)  Removal of reference to Management Board and Transformation Delivery Group replaced with Executive Committee and PMO as appropriate  Section 24.1.2 capital expenditure – limit increased to £250k from £75k for format of full business case needed to match business case guidance

2.3

Section D – Scheme of Reservation and Delegation:  Delegated limits for approval by Committees amended to reflect current Committee structure

2.4

Section E - Codes of Accountability and Conduct & Openness for NHS

Boards 

No changes made

2.5

Section F – Anti-Fraud and Corruption:  A slightly expended introduction section  Changing references to the “Secretary of State” directions to “National Standard Commissioning Contract” direction  A few added examples of NHS Fraud  Section 7.2 amended to reflect 4 specific objectives of the National Counter Fraud Strategy

2.6

Section G – Tendering and Waiver Procedures: (were significantly updated in July 2013 v2 therefore no major changes required)  Organisational name changes  Committee name changes as appropriate to reflect current structure

3 An Associated University Hospital of Brighton and Sussex Medical School

Recommendation

The Board is asked to approve and ratify the current amendments to the Corporate Governance Manual as listed in the report.

Paul Simpson Chief Finance Officer January 2015

Gillian Francis-Musanu Director of Corporate Affairs

4 An Associated University Hospital of Brighton and Sussex Medical School

Corporate Governance Manual STANDING ORDERS STANDING FINANCIAL INSTRUCTIONS SCHEME OF RESERVATION AND DELEGATION of POWERS Codes of Accountability and Conduct for Boards Anti Fraud and Corruption policies Tendering and Waiver Procedures July 2013 Applies to 2013/14 Financial year onwards Review due July 2014 Amended July 2013 Document History First Draft

Paul Simpson, Chief Finance Officer

Date

Trust Board

Endorsed by the Board

Date:

Review draft

Paul Simpson, Chief Finance Officer

Date

15 February 2011

Date:

23 March 2012

Board Published Replaces Replaces Review and update New AntiFraud Policy Trust Board

AAC Trust Board

Changes to SOs and minor changes to SFIs Endorsed by the Board Trust website, publicly available document under the FOI Act through Trust Publication Scheme January 2010 document (amended)

September 2011

24 November 2011

March 2012 document (amended) Various responsible managers

Date

June 2013

Local Counter Fraud Services

Date

July 2013

Changes to SFI’s and SO’s Endorsed by the Board Minor changes to SFI’s, Anti Fraud and Corruption and Tendering and Waiver procedures. Updates to Sub-Committee Terms of Reference

Date:

25 July 2013

Date: Date:

13 January 2015 th 29 January 2015

Surrey and Sussex Healthcare NHS Trust ~ Corporate Governance Manual 2014/15 onwards Page 1 of 187

Contents Corporate Governance Manual 2014/15 onwards

Section A:

Interpretation and definitions for Standing Orders and Standing Financial Instructions

Section B:

Standing Orders

Section C:

Standing Financial Instructions

Section D:

Scheme of Delegation and Reservation

Section E:

Codes of Accountability and Conduct & Openness for NHS Boards

Section F:

Anti-Fraud and Corruption Policy Statement and Procedure & Anti-Fraud and Corruption Policy Code of Conduct for Employees

Section G:

Tendering and Waiver Procedures Note: each section has its own contents listing

Comments and enquiries concerning the manual may be sent to: The Trust Board Administrator Trust Headquarters Maple House East Surrey Hospital Canada Avenue REDHILL Surrey RH1 5RH Tel: Fax:

01737 768511 Ext 1817 01737 231771

The manual is also available on the Trust internet www.surreyandsussex.nhs.uk

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Corporate Governance Manual 2014/15 onwards Contents

Page

SECTION A

Interpretation And Definitions For Standing Orders And Standing Financial Instructions

SECTION B

Standing Orders 1

Introduction 1.1

Statutory Framework

1.2

NHS Framework

1.3

Delegation of Powers

1.4

Integrated Governance

The Trust Board: Composition of Membership, Tenure and Role of Members 2.1

Composition of the Trust Board

2.2

Appointment of the Chairman and Members

2.3

Terms of Office of the Chairman and Members

2.4

Appointment and Powers of Vice-Chairman

2.5

Joint Members

2.6

Healthwatch

2.7

Role of Members

2.8

Corporate Role of the Board

2.9

Schedule of Matters Reserved to the Board and Scheme of Delegation

2.10

Lead Roles for Board Members

Meetings of the Trust 3.1

Calling Meetings

3.2

Notice of Meetings and the business to be transacted

3.3

Agenda and Supporting Papers

3.4

Petitions

3.5

Notice of Motion

3.6

Emergency Motions

3.7

Motions: Procedure at and during a meeting i. who may propose ii. contents of motions

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Corporate Governance Manual 2014/15 onwards Contents

Page

iii. amendments to motions iv. rights of reply to motions v. withdrawing a motion vi. motions once under debate

3.8

Motion to Rescind a Resolution

3.9

Chairman of meeting

3.10

Chairmanâ&#x20AC;&#x2122;s ruling

3.11

Quorum

3.12

Voting

3.13

Suspension of Standing Orders

3.14

Variation and amendment of Standing Orders

3.15

Record of Attendance

3.16

Minutes

3.17

Admission of public and the press

3.18

Observers at Trust meetings

Appointment of Committees and Sub-Committees 4.1

Appointment of Committees

4.2

Joint Committees

4.3

Applicability of Standing Orders and Standing Financial Instructions to Committees

4.4

Terms of Reference

4.5

Delegation of powers by Committees to Sub-Committees

4.6

Approval of Appointments to Committees

4.7

Appointments for Statutory functions

4.8

Committees to be established by the Trust Board

4.9

Rules of Procedure

Arrangements for the Exercise of Functions by Delegation 5.1

Delegation of functions to Committees, Officers or other bodies

5.2

Emergency powers and urgent decisions

5.3

Delegations of Committees

5.4

Delegation to Officers

5.5

Schedule of matters reserved to the Trust and Scheme of Delegation of Powers

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Corporate Governance Manual 2014/15 onwards Contents 5.6 6

Page

Duty to report non-compliance with Standing Orders and Standing Financial Instructions

Overlap with other Trust Policy Statements/Procedures, Regulations and the Standing Financial Instructions 6.1

Policy statements: general principles

6.2

Specific Policy statements

6.3

Standing Financial Instructions

6.4

Specific guidance

Duties and Obligations of Board Members, Members, Directors and Senior Managers under the Standing Orders and Standing Financial Instructions 7.1

Declaration of Interests

7.2

7.3

Exclusion of Chairman and Members in Proceedings on Account of Pecuniary Interest

7.4

Standards of Business Conduct Policy

Custody of Seal, Sealing of Documents and Signature of Documents 8.1

Custody of Seal

8.2

Sealing of Documents

8.3

8.4

Signature of Documents

Miscellaneous 9.1

Joint Finance Arrangements

SECTION C

Standing Financial Instructions 10

Introduction 10.1

General

10.2

Responsibilities and delegation

11.1

Audit and Assurance Committee

11.2

Chief Finance Officer

11.3

Role of Internal Audit

11.4

External Audit

Audit

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Page

11.5

Fraud and Corruption

11.6

Security Management

Annual Accounts and Reports 12.1

The Chief Finance Officer responsibilities: preparation and submission of financial returns and reports

12.2

Annual Accounts

12.3

Annual Report

Bank and (Government Banking Services) GBS Accounts 13.1

General

13.2

Bank and GBS Accounts

13.3

Banking Procedures

13.4

Tendering and Review

Income, Fees and Charges and Security of Cash, Cheques and other Negotiable Instruments 14.1

Income Systems

14.2

Fees and Charges

14.3

Debt Recovery

14.4

Security of Cash, Cheques and other Negotiable Instruments

Income â&#x20AC;&#x201C; NHS Contracts for Provision of Services 15.1

Introduction â&#x20AC;&#x201C; commissioning healthcare in the NHS

15.2

The NHS national contract

15.3

Trust responsibilities to agree the contract with Commissioners

15.4

Contractual Control and Reports to Board

15.5

Work done that is not Covered or Restricted by the Contract

Allocations, Planning, Budgets, Budgetary Control and Monitoring 16.1

Preparation and Approval of Plans and Budgets

16.2

Budget Holders

16.3

Budgetary Delegation

16.4

Budgetary Control and Reporting

16.5

Capital Expenditure

16.6

Monitoring Returns

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Corporate Governance Manual 2014/15 onwards Contents 17

Page

Tendering and Contracting 17.1

Duty to comply with Standing Orders and Standing Financial Instructions

17.2

EU Directives Governing Public Procurement

17.3

Reverse eAuctions

17.4

Capital Investment Manual and other Department of Health Guidance

17.5

Formal Competitive Tendering

17.6

Contracting/Tendering Procedure

17.7

Quotations: Competitive and Non-Competitive

17.8

Authorisation of Tenders and Competitive Quotations

17.9

Instances where Formal Competitive Tendering or Competitive Quotation is not required

17.10

Private Finance for capital procurement (see overlap with SFI No. 24)

17.11

Compliance requirements for all Contracts

17.12

Personnel and Agency or Temporary Staff Contracts

17.13

Healthcare Services Agreements (see overlap with SFI No. 18)

17.14

Disposals (see overlap with SFI No. 26)

17.15

In-house Services

17.16

Applicability of SFIs on Tendering and Contracting to funds held in trust (see overlap with SFI No. 29)

Pay Expenditure 18.1

Remuneration and Terms of Service (see overlap with SO No. 4)

18.2

Funded Establishment

18.3

Staff Appointments

18.4

Processing Payroll

18.5

Expenses Payable to Staff

18.6

Contracts of Employment

Non-Pay Expenditure 19.1

Delegation of Authority

19.2

Choice, Requisitioning, Ordering, Receipt and Payment for Goods and Services (see overlap with Standing Financial Instruction No. 17)

19.3

Paying in advance - Prepayments

19.4

Official Orders

19.5

Duties of Managers and Officers

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Corporate Governance Manual 2014/15 onwards Contents 19.6 20

Page

Joint Finance Arrangements with Local Authorities and Voluntary Bodies (see overlap with Standing Order No. 9.1)

Trust Commissioning of Healthcare Services 20.1

Role of the Chief Executive

20.2

Role of Chief Finance Officer

BLANK

External Borrowing

22.2

Investments

BLANK

Capital Investment, Private Financing, Fixed Asset Registers and Security of Assets

24.1

Capital Investment

24.2

Private Finance (see overlap with SFI No. 17.10)

24.3

Asset Registers

24.4

Security of Assets

Stores and Receipt of Goods 25.1

General position

25.2

Control of Stores, Stocktaking, condemnations and disposal

25.3

Goods supplied by NHS supply chain

Disposals and Condemnations, Losses and Special Payments 26.1

Disposals and Condemnations

26.2

Losses and Special Payments

Information Technology 27.1

Responsibilities and duties of the Chief Finance Officer

27.2

Responsibilities and duties of other Directors and Officers in relation to computer systems of a general application

27.3

Contracts for Computer Services with other health bodies or outside agencies

27.4

Risk Assessment

27.5

Requirements for Computer Systems which have an impact on corporate financial systems

Patientsâ&#x20AC;&#x2122; Property

Funds held on Trust 29.1

Corporate Trustee

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Page

29.2

Accountability to Charity Commission and Secretary of State for Health

29.3

Applicability of Standing Financial Instructions to funds held on Trust

Acceptance of Gifts by Staff and Link to Standards of Business Conduct (see overlap with SO No. 6 and SFI No. 21.2.6 (d))

Payments to Independent Contractors

Retention of Records

Risk Management and Insurance 33.1

Programme of Risk Management

33.2

Insurance: Risk Pooling Schemes administered by NHSLA

33.3

Insurance arrangements with Commercial Insurers

33.4

Arrangements to be followed by the Board in agreeing Insurance cover

SECTION D

Scheme of Reservation and Delegation (i)

Reservation of Matters to the Board

90 90 90 90 90 91 91 91 91

General Enabling Provision Regulations and Control Appointments/Dismissal Strategy Plans and Budgets Policy Determination Audit Annual Reports and Accounts Monitoring (ii)

Decisions/Duties Delegated by the Board to Committees: Audit and Assurance Committee and Terms of Service Committee Remuneration Committee and Terms of Service Committee Safety and Quality Committee and Terms of Service Committee Finance and Workforce CommitteeFinance and Workforce Committee and Terms of Service Committee Charitable Funds Committee and Terms of Service Committee Other Committees

92 92 92 92 93 93 95

(iii)

Scheme of Delegation Derived from The Accountable Officer Memorandum

(iv)

Scheme of Delegation Derived from the Codes of Conduct and Accountability

(v)

Scheme of Delegation (Standing Orders) â&#x20AC;&#x201C; specific duties delegated

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Corporate Governance Manual 2014/15 onwards Contents (vi)

Page

Scheme of Delegation (Standing Financial Instructions) – specific duties delegated Board Committees Terms of Reference

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

108 113 115 120 123

Schedule 1

128

Authority to commit to spend money

Code of Accountability and Conduct & Openness (i)

NHS Appointments Commission & Department of Health: Codes of Accountability and Conduct & Openness (FOI)

132

(ii)

The Nolan Principles

139

Anti Fraud & Corruption Policies

140

SECTION F

(i)

Anti-Fraud and Corruption Policy Statement and Procedures

(ii)

Anti-Fraud and Corruption Policy Code of Conduct for Employees

SECTION G 164

Tendering and Waiver Procedures 1.

Tendering Procedure Instructions, including • Tender Master Schedule • Tendering Procedure Table

Procedure for obtaining Waivers Delegated Financial Limits

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SECTION A 1.

INTERPRETATION AND DEFINITIONS FOR STANDING ORDERS AND STANDING FINANCIAL INSTRUCTIONS

1.1

Save as otherwise permitted by law, at any meeting the Chairman of the Trust shall be the final authority on the interpretation of Standing Orders (on which they should be advised by the Chief Executive or Secretary to the Board).

1.2

Any expression to which a meaning is given in the National Health Service Act 1977, National Health Service and Community Care Act 1990 and other Acts relating to the National Health Service or in the Financial Regulations made under the Acts shall have the same meaning in these Standing Orders and Standing Financial Instructions and in addition:

1.2.1

"Accountable Officer" means the NHS Officer responsible and accountable for funds entrusted to the Trust. The officer shall be responsible for ensuring the proper stewardship of public funds and assets. For this Trust it shall be the Chief Executive.

1.2.2

"Trust" means the Surrey and Sussex Healthcare NHS Trust.

1.2.3

"Board" means the Board of Directors – the Chairman, officer and non-officer members of the Trust collectively as a body.

1.2.4

"Budget" means a resource, expressed in financial terms, proposed by the Board for the purpose of carrying out, for a specific period, any or all of the functions of the Trust.

1.2.5

“Budget holder” means the director or employee with delegated authority to manage finances (Income and Expenditure) for a specific area of the organisation.

1.2.6

"Chairman of the Board (or Trust)" is the person appointed by the Secretary of State for Health to lead the Board and to ensure that it successfully discharges its overall responsibility for the Trust as a whole. The expression “the Chairman of the Trust” shall be deemed to include the Vice-Chairman of the Trust if the Chairman is absent from the meeting or is otherwise unavailable.

1.2.7

"Chief Executive" means the chief officer of the Trust. The Chief Executive is the Trust’s accountable officer.

1.2.8

“Safety and Quality Committee" means a committee whose functions are concerned with the arrangements for the purpose of monitoring and improving the safety and quality of healthcare for which the Surrey and Sussex Healthcare NHS Trust has responsibility.

1.2.9

"Commissioning" means the process for determining the need for and for obtaining the supply of healthcare and related services either by clinical Commissioning groups, the National Commissioning Board, the Trust itself or others. Can sometimes be referred to as “purchasing” or “procuring” healthcare. .

1.2.10

"Committee" means a committee or sub-committee created and appointed by the Trust.

1.2.11

"Committee members" means persons formally appointed by the Board or delegated body to sit on or to chair specific committees.

Page 11 of 187

1.2.12

"Contracting and procuring" means the systems for obtaining the supply of goods, materials, manufactured items, services, building and engineering services, works of construction and maintenance and for disposal of surplus and obsolete assets.

1.2.13

"Chief Finance Officer" means the Director with responsibility for oversight of Trust finances (and other areas as defined in their specific job description).

1.2.14

“Funds held on trust” shall mean those funds which the Trust holds on date of incorporation, receives on distribution by statutory instrument or chooses subsequently to accept under powers derived under S.90 of the NHS Act 1977, as amended. Such funds may or may not be charitable.

1.2.15

"Member" means officer or non-officer member of the Board as the context permits. Member in relation to the Board does not include its Chairman.

1.2.16

“Associate Member” means a person appointed to perform specific statutory and non-statutory duties which have been delegated by the Trust Board for them to perform and these duties have been recorded in an appropriate Trust Board minute or other suitable record.

1.2.17

"Membership, Procedure and Administration Arrangements Regulations" means NHS Membership and Procedure Regulations (SI1990/2024) and subsequent amendments.

1.2.18

"Nominated officer" means an officer charged with the responsibility for discharging specific tasks within Standing Orders and Standing Financial Instructions.

1.2.19

"Non-officer Member" means a member of the Trust who is not an officer of the Trust and is not to be treated as an officer by virtue of regulation 1(3) of the Membership, Procedure and Administration Arrangements Regulations.

1.2.20

"Officer" means employee of the Trust or any other person holding a paid appointment or office with the Trust.

1.2.21

"Officer Member" means a member of the Trust who is either an officer of the Trust or is to be treated as an officer by virtue of regulation 1(3) (i.e. the Chairman of the Trust or any person nominated by such a Committee for appointment as a Trust member).

1.2.22

Secretary means a person or a person who is undertaking the duties of Board Secretary appointed to act independently of the Board to provide advice on corporate governance issues to the Board and the Chairman and monitor the Trust’s compliance with the law, Standing Orders, and Department of Health guidance.

1.2.23

"SFIs" means Standing Financial Instructions.

1.2.24

"SOs" means Standing Orders.

1.2.25

"SOFIs" means Standing Orders and Standing Financial Instructions.

1.2.26

"Vice-Chairman" means the non-officer member appointed by the Board to take on the Chairman’s duties if the Chairman is absent for any reason.

Page 12 of 187

Section B

Standing Orders Corporate Governance Manual 2013/14 onwards

Comments and enquiries concerning the manual may be sent to: The Trust Board Administrator Trust Headquarters Maple House East Surrey Hospital Canada Avenue REDHILL Surrey RH1 5RH Tel: Fax:

01737 768511 Ext 1817 01737 231771

The manual is also available on the Trust internet site www.surreyandsussex.nhs.uk

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SECTION B – STANDING ORDERS 1.

INTRODUCTION

1.1 Statutory Framework 1.1.1

The Surrey and Sussex Healthcare NHS Trust (the Trust) is a statutory body which st came into existence on 1 April 1998 under The Surrey and Sussex Healthcare NHS Trust (Establishment) Order 1998 No 651, (the Establishment Order).

1.1.2

The principal place of business of the Trust is East Surrey Hospital, Canada Avenue, Redhill, Surrey RH1 5RH.

1.1.3

NHS Trusts are governed by Act of Parliament. Most health legislation made since 1977 has been summarised within three Acts of Parliament. They received Royal Assent on 8 November 2006 and came into effect on 1 March 2007 (subject to a few exceptions). i. The new Acts are:

• The National Health Service Act 2006; • The National Health Service (Wales) Act 2006 • The National Health Service (Consequential Provisions) Act 2006 ii The consolidation repeals and re-enacts in its entirety the National Health Service Act 1977, which was itself a consolidation. It also incorporates provisions from: • • • • • • • • •

Health and Social Care Act 2012 Health Act 2006 Health and Social Care (Community Health and Standards) Act 2003 National Health Service Reform and Health Care Professions Act 2002 Health and Social Care Act 2001 Health Act 1999 Primary Care Act 1997 Health Authorities Act 1995 National Health Service and Community Care Act 1990

1.1.4

The functions of the Trust are conferred by this legislation.

1.1.5

As a statutory body, the Trust has specified powers to contract in its own name and to act as a corporate trustee. In the latter role it is accountable to the Charity Commission for those funds deemed to be charitable as well as to the Secretary of State for Health.

1.1.6

The Trust also has statutory powers under the legislation to fund projects jointly planned with local authorities, voluntary organisations and other bodies.

1.1.7

The Code of Accountability requires the Trust to adopt Standing Orders for the regulation of its proceedings and business. The Trust must also adopt Standing Financial Instructions (SFIs) as an integral part of Standing Orders setting out the responsibilities of individuals.

1.1.8

The Trust will also be bound by such other statutes and legal provisions which govern the conduct of its affairs.

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1.2

NHS Framework

1.2.1

In addition to the statutory requirements the Secretary of State through the Department of Health issues further directions and guidance. These are normally issued under cover of a circular or letter. a)

The Operating Framework (and other relevant relevant guidance) for the NHS in England is issued annually by the Department (available on the DoH website www.dh.gov.uk)

This sets out: The health and service priorities for the year ahead; The reform levers and enabling strategies; The financial regime; The business processes.

1.2.2

The Code of Accountability requires that, inter alia, Boards draw up a schedule of decisions reserved to the Board, and ensure that management arrangements are in place to enable responsibility to be clearly delegated to senior executives (a scheme of delegation). The code also requires the establishment of audit and remuneration committees with formally agreed terms of reference. The Codes of Conduct makes various requirements concerning possible conflicts of interest of Board members.

1.2.3

The Code of Practice on Openness in the NHS sets out the requirements for public access to information on the NHS. The Freedom of Information Act 2000 which came into effect on 1 January 2005 supersedes the Code of Practice on Access to Government Information 1997 (The Code of Practice). [The Trust has in place its policy and procedures for the management of Freedom of Information requests].

1.3

Delegation of Powers

1.3.1

The Trust has powers to delegate and make arrangements for delegation. The Standing Orders set out the detail of these arrangements. Under the Standing Order relating to the Arrangements for the Exercise of Functions (SO 5) the Trust is given powers to "make arrangements for the exercise, on behalf of the Trust of any of their functions by a committee, sub-committee or joint committee appointed by virtue of Standing Order 4 or by an officer of the Trust, in each case subject to such restrictions and conditions as the Trust thinks fit or as the Secretary of State may direct". Delegated Powers are covered in a separate document (Reservation of Powers to the Board and Delegation of Powers). (See Section 1.8 and Appendix 2 of the Corporate Governance Framework Manual.) This document has effect as if incorporated into the Standing Orders. Delegated Powers are covered in a separate document entitled – ‘Schedule of Matters reserved to the Board and Scheme of Delegation’ and have effect as if incorporated into the Standing Orders and Standing Financial Instructions.

1.4

Integrated Governance

1.4.1

Governance describes the processes the Trust uses to ensure it: • is led and managed properly; • delivers what it is expected and required to, and; • manages risks that might prevent that delivery.

1.4.2

At the heart of these processes is decision making informed by intelligent information covering the full range of performance against objectives and targets for corporate, financial, clinical, service, information and research functions. The processes themselves are integrated into the way the Trust operates and define its internal

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control, which in turn is reported on as a formal statement in the annual accounts (the statement of internal control). 1.4.3

Guidance from the Department of Health on integrated governance is incorporated in the Trust’s Governance Strategy (and is set out in the Departmental “Integrated Governance Handbook” 2006). Integrated governance better enables the Board to take a holistic view of the organisation and its capacity to meet its legal and statutory requirements and clinical, quality and financial objectives.

1.4.4

At the centre of the governance framework for the Trust are the assurance framework (which is a document tabled at public Board meetings) and risk management strategy (available on the Trust’s website www.surreyandsussex.nhs.uk).

THE TRUST BOARD: COMPOSITION OF MEMBERSHIP, TENURE AND ROLE OF MEMBERS

2.1

Composition of the Membership of the Trust Board

2.1.2

In accordance with the Membership, Procedure and Administration Arrangements regulations the composition of the Board shall be: (a) The Chairman of the Trust (Appointed by the Trust Development Authority); (b) Up to 5 Non-executive members (appointed by the Trust Development Authority); (c) Up to 5 Executive members (but not exceeding the number of Nonexecutive members) including: (d) the Chief Executive; (e) the Chief Finance Officer;

2.1.3

The Trust shall have not more than 11 and not less than 8 members (unless otherwise determined by the Secretary of State for Health and set out in the Trust’s Establishment Order or such other communication from the Secretary of State).

2.2

Appointment of Chairman and Members of the Trust

2.2.1

Appointment of the Chairman and Members of the Trust - Paragraph 4 of Schedule 5A to the 1977 Act, as inserted by the Health Act 1999, provides that the Chairman is appointed by the Secretary of State, but otherwise the appointment and tenure of office of the Chairman and members are set out in the Membership, Procedure and Administration Arrangements Regulations.

2.3

Terms of Office of the Chairman and Members

2.3.1

The regulations setting out the period of tenure of office of the Chairman and members and for the termination or suspension of office of the Chairman and members are contained in Sections 2 to 4 of the Membership, Procedure and Administration Arrangements and Administration Regulations.

2.4

Appointment and Powers of Vice-Chairman

2.4.1

Subject to Standing Order 2.4 (2) below, the Chairman and members of the Trust may appoint one of their numbers, who is not also an executive member, to be ViceChairman, for such period, not exceeding the remainder of his term as a member of the Trust, as they may specify on appointing him.

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2.4.2

Any member so appointed may at any time resign from the office of Vice-Chairman by giving notice in writing to the Chairman. The Chairman and members may thereupon appoint another member as Vice-Chairman in accordance with the provisions of Standing Order 2.4 (1).

2.4.3

Where the Chairman of the Trust has died or has ceased to hold office, or where they have been unable to perform their duties as Chairman owing to illness or any other cause, the Vice-Chairman shall act as Chairman until a new Chairman is appointed or the existing Chairman resumes their duties, as the case may be; and references to the Chairman in these Standing Orders shall, so long as there is no Chairman able to perform those duties, be taken to include references to the Vice-Chairman.

2.5

Joint Members

2.5.1

Where more than one person is appointed jointly to a post mentioned in regulation 2(4)(a) of the Membership, Procedure and Administration Arrangements Regulations those persons shall count for the purpose of Standing Order 2.1 as one person.

2.5.2

Where the office of a member of the Board is shared jointly by more than one person:

2.6

(a)

either or both of those persons may attend or take part in meetings of the Board;

(b)

if both are present at a meeting they should cast one vote if they agree;

(c)

in the case of disagreements no vote should be cast;

(d)

the presence of either or both of those persons should count as the presence of one person for the purposes of Standing Order 3.11 Quorum.

Healthwatch 2.6.1 Healthwatch is the new consumer champion for both health and social care. It exists in two distinct forms â&#x20AC;&#x201C; local Healthwatch, at local level, and Healthwatch England, at national level. Both are established by The Health and Social Care Act 2012. 2.6.2 Local Healthwatch - A local Healthwatch will be an independent organisation, able to employ its own staff and involve volunteers, so it can become the influential and effective voice of the public. It will have to keep accounts and make its annual reports available to the public. The aim of local Healthwatch will be to give citizens and communities a stronger voice to influence and challenge how health and social care services are provided within their locality. 2.6.3

Local Healthwatch will:

â&#x20AC;&#x201C;

have a seat on the new statutory health and wellbeing boards, ensuring that the views and experiences of patients, carers and other service users are taken into account when local needs assessments and strategies are prepared, such as the Joint Strategic Needs Assessment (JSNA) and the authorisation of Clinical Commissioning Groups. This will ensure that local Healthwatch has a role in promoting public health, health improvements and in tackling health inequalities

â&#x20AC;&#x201C;

enable people to share their views and concerns about their local health and social care services and understand that their contribution will help build a picture of where services are doing well and where they can be improved

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–

be able to alert Healthwatch England to concerns about specific care providers

–

provide people with information about their choices and what to do when things go wrong; this includes either signposting people to the relevant provider, or itself providing (if commissioned by the local authority), support to individuals who want to complain about NHS services

–

provide, or signpost people to, information about local health and care services and how to access them

–

provide authoritative, evidence-based feedback to organisations responsible for commissioning or delivering local health and social care services

–

can help and support Clinical Commissioning Groups to make sure that services really are designed to meet citizens’ needs

–

have to be inclusive and reflect the diversity of the community it serves. There is an explicit requirement in the Health & Social Care Act that the way in which a local Healthwatch exercises its functions must be representative of local people and different users of services, including carers.

2.6.4 Healthwatch England will be a national body that enables the collective views of the people who use NHS and social care services to influence national policy, advice and guidance. It will be a statutory committee of the Care Quality Commission (CQC) with a Chair who will be a nonexecutive director of the CQC. Healthwatch England will have its own identity within the CQC, but be able to use the CQC’s expertise and infrastructure. Healthwatch England will be funded as part of the Department of Health’s grant in aid to the CQC. It will: –

provide leadership, guidance and support to local Healthwatch organisations

–

provide advice to the Secretary of State, NHS Commissioning Board, Monitor and the English local authorities and they must have regard to that advice

–

be able to escalate concerns about health and social care services raised by local Healthwatch to the CQC

–

be a requirement for the CQC to respond to advice from Healthwatch England

–

have a strong principle of continuous dialogue with local Healthwatch, keeping communication lines open and transparent. This will facilitate Healthwatch England’s responsibility to provide national leadership and support

The Secretary of State for Health will be required to consult Healthwatch England on the mandate for the NHS Commissioning Board be required to make an annual report to Parliament 2.6.5 The latest information on Healthwatch England can be found on the DH website 2.7

Role of Members

2.7.1

The Board will function as a corporate decision-making body, Executive and NonExecutive Members will be full and equal members. Their role as members of the Board of Directors will be to consider the key strategic and managerial issues facing the Trust in carrying out its statutory and other functions.

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(a)

Executive Members Executive Members shall exercise their authority within the terms of these Standing Orders and Standing Financial Instructions and the Scheme of Delegation.

(b)

Chief Executive The Chief Executive shall be responsible for the overall performance of the executive functions of the Trust. He/she is the Accountable Officer for the Trust and shall be responsible for ensuring the discharge of obligations under Financial Directions and in line with the requirements of the Accountable Officer Memorandum for Trust Chief Executives.

(c)

Chief Finance Officer The Chief Finance Officer shall be responsible for the provision of advice to the Trust and to its members and for the supervision of control and accounting systems. He/she shall be responsible along Chief Executive for ensuring the discharge of obligations under Financial Directions.

(d)

financial financial with the relevant

Non-Executive Members The Non-Executive Members shall not be granted nor shall they seek to exercise any individual executive powers on behalf of the Trust. They may however, exercise collective authority when acting as members of or when chairing a committee of the Trust which has delegated powers.

(e)

Chairman The Chairman shall be responsible for the operation of the Board and chair all Board meetings when present. The Chairman has certain delegated executive powers. The Chairman must comply with the terms of appointment and with these Standing Orders. The Chairman shall liaise with the Trust Development Authority over the appointment of Non-Executive Directors and once appointed shall take responsibility either directly or indirectly for their induction, their portfolios of interests and assignments, and their performance. The Chairman shall work in close harmony with the Chief Executive and shall ensure that key and appropriate issues are discussed by the Board in a timely manner with all the necessary information and advice being made available to the Board to inform the debate and ultimate resolutions.

2.8

Corporate role of the Board

2.8.1

All business shall be conducted in the name of the Trust.

2.8.2

All funds received in trust shall be held in the name of the Trust as corporate trustee.

2.8.3

The powers of the Trust established under statute shall be exercised by the Board meeting in public session except as otherwise provided for in Standing Order No. 3.

2.8.4

The Board shall define and regularly review the functions it exercises on behalf of the Secretary of State.

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2.9

Schedule of Matters reserved to the Board and Scheme of Delegation

2.9.1

The Board has resolved that certain powers and decisions may only be exercised by the Board in formal session. These powers and decisions are set out in the ‘Schedule of Matters Reserved to the Board’ and shall have effect as if incorporated into the Standing Orders. Those powers which it has delegated to officers and other bodies are contained in the Scheme of Delegation.

2.10

Lead Roles for Board Members

2.10.1 The Chairman will ensure that the designation of Lead roles or appointments of Board members as required by the Department of Health or as set out in any statutory or other guidance will be made in accordance with that guidance or statutory requirement (e.g. appointing a Lead Board Member with responsibilities for Infection Control or Child Protection Services etc.).

MEETINGS OF THE TRUST

3.1

Calling meetings

3.1.1

Ordinary meetings of the Board shall be held at regular intervals at such times and places as the Board may determine.

3.1.2

The Chairman of the Trust may call a meeting of the Board at any time.

3.1.3

One third or more members of the Board may requisition a meeting in writing. If the Chairman refuses, or fails, to call a meeting within seven days of a requisition being presented, the members signing the requisition may forthwith call a meeting.

3.2

Notice of Meetings and the Business to be transacted

3.2.1

Before each meeting of the Board a written notice specifying the business proposed to be transacted shall be delivered to every member, or sent by post to the usual place of residence of each member, so as to be available to members at least three clear days before the meeting. The notice shall be signed by the Chairman or by an officer authorised by the Chairman to sign on their behalf. Want of service of such a notice on any member shall not affect the validity of a meeting.

3.2.2

In the case of a meeting called by members in default of the Chairman calling the meeting, the notice shall be signed by those members.

3.2.3

No business shall be transacted at the meeting other than that specified on the agenda, or emergency motions allowed under Standing Order 3.6.

3.2.4

A member desiring a matter to be included on an agenda shall make his/her request in writing to the Chairman at least 15 clear days before the meeting. The request should state whether the item of business is proposed to be transacted in the presence of the public and should include appropriate supporting information. Requests made less than 15 days before a meeting may be included on the agenda at the discretion of the Chairman.

3.2.5

Before each meeting of the Board a public notice of the time and place of the meeting, and the public part of the agenda, shall be displayed at the Trust’s principal offices at least three clear days before the meeting, (required by the Public Bodies (Admission to Meetings) Act 1960 Section 1 (4) (a)).

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3.3

Agenda and Supporting Papers

3.3.1

The Agenda will be sent to members 5 days before the meeting and supporting papers, whenever possible, shall accompany the agenda, but will certainly be despatched no later than three clear days (not working days) before the meeting, save in emergency.

3.3.2

There is no formal date for publication of Board papers on the Trust website (making the papers available publicly) but the Trust preference is for this to match the requirements of paragraph (3.3 (1)) above. Spare sets of papers will always be available on the day of the Board meeting.

3.4

Petitions

3.4.1

Where a petition has been received by the Trust the Chairman shall include the petition as an item for the agenda of the next meeting.

3.5

Notice of Motion

3.5.1

Subject to the provision of Standing Orders 3.7 ‘Motions: Procedure at and during a meeting’ and 3.8 ‘Motions to rescind a resolution’, a member of the Board wishing to move a motion shall send a written notice to the Chief Executive who will ensure that it is brought to the immediate attention of the Chairman.

3.5.2

The notice shall be delivered at least 5 clear days before the meeting. The Chief Executive shall include in the agenda for the meeting all notices so received that are in order and permissible under governing regulations. This Standing Order shall not prevent any motion being withdrawn or moved without notice on any business mentioned on the agenda for the meeting.

3.6

Emergency Motions

3.6.1

Subject to the agreement of the Chairman, and subject also to the provision of Standing Order 3.7 ‘Motions: Procedure at and during a meeting’, a member of the Board may give written notice of an emergency motion after the issue of the notice of meeting and agenda, up to one hour before the time fixed for the meeting. The notice shall state the grounds of urgency. If in order, it shall be declared to the Trust Board at the commencement of the business of the meeting as an additional item included in the agenda. The Chairman's decision to include the item shall be final.

3.7

Motions: Procedure at and during a meeting

3.7.1

Who may propose? A motion may be proposed by the Chairman of the meeting or any member present. It must also be seconded by another member.

3.7.2

Contents of motions The Chairman may exclude from the debate at their discretion any such motion of which notice was not given on the notice summoning the meeting other than a motion relating to: • • • • • •

the reception of a report; consideration of any item of business before the Trust Board; the accuracy of minutes; that the Board proceed to next business; that the Board adjourn; that the question be now put.

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3.7.3

Amendments to motions • A motion for amendment shall not be discussed unless it has been proposed and seconded. • Amendments to motions shall be moved relevant to the motion, and shall not have the effect of negating the motion before the Board. • If there are a number of amendments, they shall be considered one at a time. When a motion has been amended, the amended motion shall become the substantive motion before the meeting, upon which any further amendment may be moved.

3.7.4

Rights of reply to motions a)

Amendments

The mover of an amendment may reply to the debate on their amendment immediately prior to the mover of the original motion, who shall have the right of reply at the close of debate on the amendment, but may not otherwise speak on it. b)

Substantive/original motion

The member who proposed the substantive motion shall have a right of reply at the close of any debate on the motion. 3.7.5

Withdrawing a motion A motion, or an amendment to a motion, may be withdrawn.

3.7.6

Motions once under debate When a motion is under debate, no motion may be moved other than: an amendment to the motion; the adjournment of the discussion, or the meeting; that the meeting proceed to the next business; that the question should be now put; the appointment of an 'ad hoc' committee to deal with a specific item of business; • that a member/director be not further heard; • a motion under Section l (2) or Section l (8) of the Public Bodies (Admissions to Meetings) Act l960 resolving to exclude the public, including the press (see Standing Order 3.17).

• • • • •

In those cases where the motion is either that the meeting proceeds to the ‘next business’ or ‘that the question be now put’ in the interests of objectivity these should only be put forward by a member of the Board who has not taken part in the debate and who is eligible to vote. If a motion to proceed to the next business or that the question be now put, is carried, the Chairman should give the mover of the substantive motion under debate a right of reply, if not already exercised. The matter should then be put to the vote. 3.8

Motion to Rescind a Resolution

3.8.1

Notice of motion to rescind any resolution (or the general substance of any resolution) which has been passed within the preceding six calendar months shall bear the

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signature of the member who gives it and also the signature of three other members, and before considering any such motion of which notice shall have been given, the Trust Board may refer the matter to any appropriate Committee or the Chief Executive for recommendation. 3.8.2

When any such motion has been dealt with by the Trust Board it shall not be competent for any director/member other than the Chairman to propose a motion to the same effect within six months. This Standing Order shall not apply to motions moved in pursuance of a report or recommendations of a Committee or the Chief Executive.

3.9

Chairman of meeting

3.9.1

At any meeting of the Trust Board the Chairman, if present, shall preside. If the Chairman is absent from the meeting, the Vice-Chairman (if the Board has appointed one), if present, shall preside.

3.9.2

If the Chairman and Vice-Chairman are absent, such member (who is not also an Officer/Executive Member of the Trust) as the members present shall choose shall preside.

3.10

Chairman's ruling

3.10.1 The decision of the Chairman of the meeting on questions of order, relevancy and regularity (including procedure on handling motions) and their interpretation of the Standing Orders and Standing Financial Instructions, at the meeting, shall be final. 3.11

Quorum

3.11.1 No business shall be transacted at a meeting unless at least one-third of the whole number of the Chairman and members (including at least one member who is also an Officer/Executive Member of the Trust and two members who is not) is present. 3.11.2 An Officer in attendance for an Executive Director (Officer Member) but without formal acting up status may not count towards the quorum. 3.11.3 If the Chairman or member has been disqualified from participating in the discussion on any matter and/or from voting on any resolution by reason of a declaration of a conflict of interest (see SO No.7) that person shall no longer count towards the quorum. If a quorum is then not available for the discussion and/or the passing of a resolution on any matter, that matter may not be discussed further or voted upon at that meeting. Such a position shall be recorded in the minutes of the meeting. The meeting must then proceed to the next business. 3.12

Voting

3.12.1 Save as provided in Standing Orders 3.13 - Suspension of Standing Orders and 3.14 - Variation and Amendment of Standing Orders, every question put to a vote at a meeting shall be determined by a majority of the votes of members present and voting on the question. In the case of an equal vote, the person presiding (i.e.: the Chairman of the meeting) shall have a casting vote. 3.12.2 At the discretion of the Chairman all questions put to the vote shall be determined by oral expression or by a show of hands, unless the Chairman directs otherwise, or it is proposed, seconded and carried that a vote be taken by paper ballot. 3.12.3 If at least one third of the members present so request, the voting on any question may be recorded so as to show how each member present voted or did not vote (except when conducted by paper ballot).

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3.12.4 If a member so requests, their vote shall be recorded by name. 3.12.5 In no circumstances may an absent member vote by proxy. Absence is defined as being absent at the time of the vote. 3.12.6 A manager who has been formally appointed to act up for an Officer Member during a period of incapacity or temporarily to fill an Executive Director vacancy shall be entitled to exercise the voting rights of the Officer Member. 3.12.7 A manager attending the Trust Board meeting to represent an Officer Member during a period of incapacity or temporary absence without formal acting up status may not exercise the voting rights of the Officer Member. An Officer’s status when attending a meeting shall be recorded in the minutes. 3.12.8 For the voting rules relating to joint members see Standing Order 2.5. 3.13

Suspension of Standing Orders

3.13.1 Except where this would contravene any statutory provision or any direction made by the Secretary of State or the rules relating to the Quorum (SO 3.11), any one or more of the Standing Orders may be suspended at any meeting, provided that at least twothirds of the whole number of the members of the Board are present (including at least one member who is an Officer Member of the Trust and one member who is not) and that at least two-thirds of those members present signify their agreement to such suspension. The reason for the suspension shall be recorded in the Trust Board's minutes. 3.13.2 A separate record of matters discussed during the suspension of Standing Orders shall be made and shall be available to the Chairman and members of the Trust. 3.13.3 No formal business may be transacted while Standing Orders are suspended. 3.13.4 The Audit and Assurance Committee shall review every decision to suspend Standing Orders. 3.14

Variation and amendment of Standing Orders

3.14.1 These Standing Orders shall not be varied except in the following circumstances:

• upon a notice of motion under Standing Order 3.5; • upon a recommendation of the Chairman or Chief Executive included on the • • 3.15

agenda for the meeting; that two thirds of the Board members are present at the meeting where the variation or amendment is being discussed, and that at least half of the Trust’s Non-Officer members vote in favour of the amendment; providing that any variation or amendment does not contravene a statutory provision or direction made by the Secretary of State.

Record of Attendance

3.15.1 The names of the Chairman and Directors/members present at the meeting shall be recorded.

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3.16

Minutes

3.16.1 The minutes of the proceedings of a meeting shall be drawn up and submitted for agreement at the next ensuing meeting where they shall be signed by the person presiding at it. 3.16.2 No discussion shall take place upon the minutes except upon their accuracy or where the Chairman considers discussion appropriate. 3.17

Admission of public and the press

3.17.1 Admission and exclusion on grounds of confidentiality of business to be transacted The public and representatives of the press may attend all meetings of the Trust, but shall be required to withdraw upon the Trust Board as follows: 'that representatives of the press, and other members of the public, be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest', Section 1 (2), Public Bodies (Admission to Meetings) Act l960. Guidance should be sought from the NHS Trustâ&#x20AC;&#x2122;s Freedom of Information Lead to ensure correct procedure is followed on matters to be included in the exclusion. 3.17.2 General disturbances The Chairman (or Vice-Chairman if one has been appointed) or the person presiding over the meeting shall give such directions as he thinks fit with regard to the arrangements for meetings and accommodation of the public and representatives of the press such as to ensure that the Trustâ&#x20AC;&#x2122;s business shall be conducted without interruption and disruption and, without prejudice to the power to exclude on grounds of the confidential nature of the business to be transacted, the public will be required to withdraw upon the Trust Board resolving as follows: `That in the interests of public order the meeting adjourn for (the period to be specified) to enable the Trust Board to complete its business without the presence of the public'. Section 1(8) Public Bodies (Admissions to Meetings) Act l960. 3.17.3 Business proposed to be transacted when the press and public have been excluded from a meeting Matters to be dealt with by the Trust Board following the exclusion of representatives of the press, and other members of the public, as provided in (1) and (2) above, shall be confidential to the members of the Board. Members and Officers or any employee of the Trust in attendance shall not reveal or disclose the contents of papers marked 'In Confidence' or minutes headed 'Items Taken in Private' outside of the Trust, without the express permission of the Trust. This prohibition shall apply equally to the content of any discussion during the Board meeting which may take place on such reports or papers. 3.17.4 Use of Mechanical or Electrical Equipment for Recording or Transmission of Meetings Nothing in these Standing Orders shall be construed as permitting the introduction by the public, or press representatives, of recording, transmitting, video or similar apparatus into meetings of the Trust or Committee thereof. Such permission shall be granted only upon resolution of the Trust.

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3.18

Observers at Trust meetings The Trust will decide what arrangements and terms and conditions it feels are appropriate to offer in extending an invitation to observers to attend and address any of the Trust Board's meetings and may change, alter or vary these terms and conditions as it deems fit.

APPOINTMENT OF COMMITTEES AND SUB-COMMITTEES

4.1

Appointment of Committees Subject to such directions as may be given by the Secretary of State for Health, the Trust Board may appoint committees of the Trust. The Trust shall determine the membership and terms of reference of committees and sub-committees and shall if it requires to, receive and consider reports of such committees.

4.2

Joint Committees Joint committees may be appointed by the Trust by joining together with one or more other organisations, or other Trusts consisting of, wholly or partly of the Chairman and members of the Trust or other health service bodies, or wholly of persons who are not members of the Trust or other health bodies in question. Any committee or joint committee appointed under this Standing Order may, subject to such directions as may be given by the Secretary of State or the Trust or other health bodies in question, appoint sub-committees consisting wholly or partly of members of the committees or joint committee (whether or not they are members of the Trust or health bodies in question) or wholly of persons who are not members of the Trust or health bodies in question or the committee of the Trust or health bodies in question.

4.3

Applicability of Standing Orders and Standing Financial Instructions to Committees The Standing Orders and Standing Financial Instructions of the Trust, as far as they are applicable, shall as appropriate apply to meetings and any committees established by the Trust. In which case the term “Chairman” is to be read as a reference to the Chairman of other committee as the context permits, and the term “member” is to be read as a reference to a member of other committee also as the context permits. (There is no requirement to hold meetings of committees established by the Trust in public.)

4.4

Terms of Reference Each such committee shall have such terms of reference and powers and be subject to such conditions (as to reporting back to the Board), as the Board shall decide and shall be in accordance with any legislation and regulation or direction issued by the Secretary of State. Such terms of reference shall have effect as if incorporated into the Standing Orders.

4.5

Delegation of powers by Committees to Sub-Committees Where committees are authorised to establish sub-committees they may not delegate executive powers to the sub-committee unless expressly authorised by the Trust Board.

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4.6

Approval of Appointments to Committees The Board shall approve the appointments to each of the committees which it has formally constituted. Where the Board determines, and regulations permit, that persons, who are neither members nor officers, shall be appointed to a committee the terms of such appointment shall be within the powers of the Board as defined by the Secretary of State. The Board shall define the powers of such appointees and shall agree allowances, including reimbursement for loss of earnings, and/or expenses in accordance where appropriate with national guidance.

4.7

Appointments for Statutory functions Where the Board is required to appoint persons to a committee and/or to undertake statutory functions as required by the Secretary of State, and where such appointments are to operate independently of the Board such appointment shall be made in accordance with the regulations and directions made by the Secretary of State.

4.8

Committees established by the Trust Board The committees, sub-committees, and joint-committees established by the Board are: 1. Audit and Assurance Committee (AAC) The requirements of the Audit and Assurance Committee are built on the work of the Cadbury Committee, Greenbury Reports and reports by Smith, Higgs and Turnbull (“Combined Code – Principles of Good Governance and Code of Best practice”) and subsequent guidance and best practice in the private and public sector. They reflect the growing role within the NHS of the committee in developing integrated governance arrangements and providing assurance that bodies are well managed across the whole range of their activities. The Committee is a non-executive committee of the Board, consisting of not less than three non executives, one of which should have significant financial experience. Head of External and Internal Audit and Counter Fraud attend the Committee – it is normal in the Trust for the Chief Finance Officer and Director of Corporate Affairs (who has responsibility for corporate governance) and Chief Executive to attend regularly. It must meet at least four times a year. The Committee is authorised to investigate any activity in its terms of reference, providing assurance to the Board in relation to the Board Assurance Framework, Governance, Risk Management and Internal Control. The Trust’s financial statements, annual report and annual governance statement are reviewed by the AAC prior to submission to the Board. The Committee’s powers are described in its Terms of Reference which are detailed within the “Rules of Procedure” and in the Scheme of Reservation and Delegation. Please also see Section 11 of the SFIs for more detail on the requirements for the Trust Audit and Assurance Committee. Minutes of the AAC are formally recorded and submitted to the main Trust Board.

2. Safety and Quality Committee (SQC) The Safety and Quality Committee has delegated authority to ensure the on-going development and delivery of the Trust’s Safety and Quality Strategy and that this drives the Trust’s overall strategy. The Trust’s arrangements reflect the national drive for greater quality in healthcare, with a focus on safety, effectiveness and patient experience and reflect the reforms and principles set out in the July 2010 White Paper Equity and excellence: Liberating the NHS and the Francis Report, published in February 2013: which highlighted the fundamental responsibility of providing safe care which sits with the Trust Board.

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There is significant regulation in place for healthcare providers that is designed to ensure delivery of high quality and safe services and the Committee has responsibility for seeking assurance in respect of that and ensuring actions are taken in respect of corrective measures. The Committee has three non- executive directors and five executives and meets monthly. In summary, the Committee undertakes a number of duties, including (this list is not exhaustive):

Ensuring that accurate and appropriate returns are submitted in response to regulators’ requirements;

Ensuring the implementation, delivery and monitoring of the Trust’s Safety and Quality Strategy;

Ensuring the management of the safety in line with legislation, standards and regulation.

Seeking assurances that the quality of patient services is of the appropriate standard and that risks and safety issues are being managed appropriately.

Seeking assurances that the Patient Experience Strategy is part of everyday business and that patient feedback and involvement is happening;

Sign off the Trust’s Quality Account;

Overview of Clinical Audit

The Committee’s powers are described in its Terms of Reference which are detailed within the “Rules of Procedure” and in the Scheme of Reservation and Delegation. Minutes of the SQC are formally recorded and submitted to the main Trust Board.

3. Finance and Workforce Committee (FWC) The purpose of the Finance and Workforce Committee is to provide oversight of the Trust’s business planning (including in particular strategic financial and workforce planning) and oversee investment (treasury/working capital management and capital projects) and financial sustainability. The Committee is responsible for the following key areas: •

Business planning, including strategic financial and workforce planning

•

Delivery, monitoring and approving major investment decisions, including capital projects, treasury and working capital management, and;

•

Monitoring delivery of significant projects and investments, and any potential business combinations.

The Committee provides assurance to the Board that the business plan and supporting strategies are in place and fit for purpose. It has three non-executive directors and six executives, meeting monthly. The Committee’s powers are described in its Terms of Reference which are detailed within the “Rules of Procedure” and in the Scheme of Reservation and Delegation. Minutes of the FWC are formally recorded and submitted to the main Trust Board.

4. The Remuneration Committee The Remuneration Committee’s role is to, establish and monitor the level and structure of reward for executive directors, ensuring transparency, fairness and consistency. The Committee shall receive reports from the Chairman of the Board of

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Directors on the annual appraisal of the Chief Executive and from the Chief Executive on the annual appraisals of executive directors, as part of determining their remuneration. The Committee, which will meet at least twice per year, is comprised of the Board Chair and all Non-Executive Directors. A minimum of three members should be present at meetings who are independent of management. The Committee will report in writing to the Board at least once annually the basis for its decisions and recommendations.

5. Charitable Funds Committee (CFC) In line with its role as a corporate trustee for any funds held in trust, either as charitable or non charitable funds, the Trust Board will establish a Trust and Charitable Funds Committee to administer those funds in accordance with any statutory or other legal requirements or best practice required by the Charities Commission. The Surrey and Sussex Healthcare NHS Trust is the Corporate Trustee of the Charity governed by the law applicable to Trusts, principally the Trustee Act 2000 and the Charities Act 1993 and 2006. The Board has devolved responsibility for the on-going management of funds to the Charitable Funds Committee, which administers the funds on behalf of the Corporate Trustee. As such the Committee acts independently of the Board. Members of the Committee are not individual trustees under charity law but act as agents on behalf of the Corporate Trustee. The Committee has three non-executive directors and two executives, meeting at least 3 times a year. The provisions of this Standing order must be read in conjunction with Standing Order 2.8 and Standing Financial Instruction 29. The Committee’s powers are described in its Terms of Reference which are detailed within the “Rules of Procedure” and in the Scheme of Reservation and Delegation. Minutes of the CFC are formally recorded and submitted to the main Trust Board. 6. Other Committees The Board may also establish such other committees as required to discharge the Trust’s responsibilities.

4.9

Rules of Procedure The Trust has provided a document called “Rules of Procedure” which provides greater detail on the function and operation of the Board and its Committees. This is updated regularly, approved by the Board and complements the standing orders.

ARRANGEMENTS FOR THE EXERCISE OF TRUST FUNCTIONS BY DELEGATION

5.1

Delegation of Functions to Committees, Officers or other bodies

5.1.1

Subject to such directions as may be given by the Secretary of State, the Board may make arrangements for the exercise, on behalf of the Board, of any of its functions by a committee, sub-committee appointed by virtue of Standing Order 4, or by an officer of the Trust, or by another body as defined in Standing Order 5.1.2 below, in each case subject to such restrictions and conditions as the Trust thinks fit.

5.1.2

Legislation allows for regulations to provide for the functions of Trust’s to be carried out by third parties. In accordance with The Trusts (Membership, Procedure and

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Administration Arrangements) Regulations 2000 the functions of the Trust may also be carried out in the following ways: (i)

by another Trust;

(ii)

jointly with any one or more of the following: NHS trusts, Trust Development Authorities or Commissioners;

(iii)

by arrangement with the appropriate Trust or Commissioners, by a joint committee or joint sub-committee of the Trust and one or more other health service bodies;

(iv)

in relation to arrangements made under S63(1) of the Health Services and Public Health Act 1968, jointly with one or more Trust Development Authorities,, NHS Trusts or Commissioners.

5.1.3

Where a function is delegated by these Regulations to another Trust, then that Trust or health service body exercises the function in its own right; the receiving Trust has responsibility to ensure that the proper delegation of the function is in place. In other situations, i.e. delegation to committees, sub-committees or officers, the Trust delegating the function retains full responsibility.

5.2

Emergency Powers and urgent decisions The powers which the Board has reserved to itself within these Standing Orders (see Standing Order 2.9) may in emergency or for an urgent decision be exercised by the Chief Executive and the Chairman after having consulted at least two non-executive members. The exercise of such powers by the Chief Executive and Chairman shall be reported to the next formal meeting of the Trust Board in public session for formal ratification.

5.3

Delegation to Committees

5.3.1

The Board shall agree from time to time to the delegation of executive powers to be exercised by other committees, or sub-committees, or joint-committees, which it has formally constituted in accordance with directions issued by the Secretary of State. The constitution and terms of reference of these committees, or sub-committees, or joint committees, and their specific executive powers shall be approved by the Board in respect of its sub-committees.

5.3.2

When the Board is not meeting as the Trust in public session it shall operate as a committee and may only exercise such powers as may have been delegated to it by the Trust in public session.

5.4

Delegation to Officers

5.4.1

Those functions of the Trust which have not been retained as reserved by the Board or delegated to other committee or sub-committee or joint-committee shall be exercised on behalf of the Trust by the Chief Executive. The Chief Executive shall determine which functions he/she will perform personally and shall nominate officers to undertake the remaining functions for which he/she will still retain accountability to the Trust.

5.4.2

The Chief Executive shall prepare a Scheme of Delegation identifying his/her proposals which shall be considered and approved by the Board. The Chief Executive may periodically propose amendment to the Scheme of Delegation which shall be considered and approved by the Board.

5.4.3

Nothing in the Scheme of Delegation shall impair the discharge of the direct accountability to the Board of the Chief Finance Officer to provide information and

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advise the Board in accordance with statutory or Department of Health requirements. Outside these statutory requirements the roles of the Chief Finance Officer shall be accountable to the Chief Executive for operational matters. 5.5

Schedule of Matters Reserved to the Trust and Scheme of Delegation of powers

5.5.1

The arrangements made by the Board as set out in the "Schedule of Matters Reserved to the Board” and “Scheme of Delegation” of powers shall have effect as if incorporated in these Standing Orders.

5.6

Duty to report non-compliance with Standing Orders and Standing Financial Instructions If for any reason these Standing Orders are not complied with, full details of the noncompliance and any justification for non-compliance and the circumstances around the non-compliance, shall be reported to the next formal meeting of the Board for action or ratification. All members of the Trust Board and staff have a duty to disclose any non-compliance with these Standing Orders to the Chief Executive as soon as possible.

OVERLAP WITH OTHER TRUST POLICY STATEMENTS / PROCEDURES, REGULATIONS AND THE STANDING FINANCIAL INSTRUCTIONS

6.1

Policy statements: general principles The Trust Board will from time to time agree and approve Policy statements/ procedures which will apply to all or specific groups of staff employed by Surrey and Sussex Healthcare NHS Trust. The decisions to approve such policies and procedures will be recorded in an appropriate Trust Board minute and will be deemed where appropriate to be an integral part of the Trust's Standing Orders and Standing Financial Instructions.

6.2

Specific Policy statements Notwithstanding the application of SO 6.1 above, these Standing Orders and Standing Financial Instructions must be read in conjunction with the following Policy statements:

6.3

the Standards of Business Conduct and Conflicts of Interest Policy for Surrey and Sussex Healthcare NHS Trust staff;

the staff Disciplinary and Appeals Procedures adopted by the Trust both of which shall have effect as if incorporated in these Standing Orders.

Standing Financial Instructions Standing Financial Instructions adopted by the Trust Board in accordance with the Financial Regulations shall have effect as if incorporated in these Standing Orders.

6.4

Specific guidance Notwithstanding the application of SO 6.1 above, these Standing Orders and Standing Financial Instructions must be read in conjunction with the following guidance and any other issued by the Secretary of State for Health: -

Caldicott Guardian 1997; Human Rights Act 1998;

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Freedom of Information Act 2000.

DUTIES AND OBLIGATIONS OF BOARD MEMBERS/DIRECTORS AND SENIOR MANAGERS UNDER THESE STANDING ORDERS

7.1

Declaration of Interests

7.1.1

Requirements for Declaring Interests and applicability to Board Members i)

7.1.2

The NHS Code of Accountability requires Trust Board Members to declare interests which are relevant and material to the NHS Board of which they are a member. All existing Board members should declare such interests. Any Board members appointed subsequently should do so on appointment.

Interests which are relevant and material (i)

Interests which should be regarded as "relevant and material" are: a)

Directorships, including Non-Executive Directorships held in private companies or PLCs (with the exception of those of dormant companies);

Ownership or part-ownership of private companies, businesses or consultancies likely or possibly seeking to do business with the NHS;

Majority or controlling share holdings in organisations likely or possibly seeking to do business with the NHS;

A position of Authority in a charity or voluntary organisation in the field of health and social care;

Any connection with a voluntary or other organisation contracting for NHS services;

Research funding/grants that may be received by an individual or their department;

Interests in pooled funds that are under separate management. (ii)

7.1.3

Any member of the Trust Board who comes to know that the Trust has entered into or proposes to enter into a contract in which he/she or any person connected with him/her (as defined in Standing Order 7.3 below and elsewhere) has any pecuniary interest, direct or indirect, the Board member shall declare his/her interest by giving notice in writing of such fact to the Trust as soon as practicable.

Advice on Interests If Board members have any doubt about the relevance of an interest, this should be discussed with the Chairman of the Trust or with the Trustâ&#x20AC;&#x2122;s Company Secretary. Influence rather than the immediacy of the relationship is more important in assessing the relevance of an interest. The interests of partners in professional partnerships including general practitioners should also be considered.

7.1.4

Recording of Interests in Trust Board minutes At the time Board members' interests are declared, they should be recorded in the Trust Board minutes.

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Any changes in interests should be declared at the next Trust Board meeting following the change occurring and recorded in the minutes of that meeting. 7.1.5

Publication of declared interests in Annual Report Board members' directorships of companies likely or possibly seeking to do business with the NHS should be published in the Trust's annual report. The information should be kept up to date for inclusion in succeeding annual reports.

7.1.6

Conflicts of interest which arise during the course of a meeting During the course of a Trust Board meeting, if a conflict of interest is established, the Board member concerned should withdraw from the meeting and play no part in the relevant discussion or decision. (See overlap with SO 7.3)

7.2

7.2.1

The Chief Executive will ensure that a Register of Interests is established to record formally declarations of interests of Board or Committee members. In particular the Register will include details of all directorships and other relevant and material interests (as defined in SO 7.1.2) which have been declared by both executive and nonexecutive Trust Board members.

7.2.2.

These details will be kept up to date by means of an annual review of the Register in which any changes to interests declared during the preceding twelve months will be incorporated.

7.2.3

The Register will be available to the public and the Chief Executive will take reasonable steps to bring the existence of the Register to the attention of local residents and to publicise arrangements for viewing it.

7.3

Exclusion of Chairman and Members in proceedings on account of pecuniary interest

7.3.1

Definition of terms used in interpreting ‘Pecuniary’ interest For the sake of clarity, the following definition of terms is to be used in interpreting this Standing Order: (i)

"spouse" shall include any person who lives with another person in the same household (and any pecuniary interest of one spouse shall, if known to the other spouse, be deemed to be an interest of that other spouse);

(ii)

"contract" shall include any proposed contract or other course of dealing.

(iii)

“Pecuniary interest” Subject to the exceptions set out in this Standing Order, a person shall be treated as having an indirect pecuniary interest in a contract if:a)

he/she, or a nominee of his/her, is a member of a company or other body (not being a public body), with which the contract is made, or to be made or which has a direct pecuniary interest in the same, or

he/she is a partner, associate or employee of any person with whom the contract is made or to be made or who has a direct pecuniary interest in the same.

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iv)

Exception to Pecuniary interests A person shall not be regarded as having a pecuniary interest in any contract if:a)

neither he/she or any person connected with him/her has any beneficial interest in the securities of a company of which he/she or such person appears as a member, or

any interest that he/she or any person connected with him/her may have in the contract is so remote or insignificant that it cannot reasonably be regarded as likely to influence him/her in relation to considering or voting on that contract, or

those securities of any company in which he/she (or any person connected with him/her) has a beneficial interest do not exceed ÂŁ5,000 in nominal value or one per cent of the total issued share capital of the company or of the relevant class of such capital, whichever is the less.

Provided however, that where paragraph (c) above applies the person shall nevertheless be obliged to disclose/declare their interest in accordance with Standing Order 7.1.2 (ii). 7.3.2

Exclusion in proceedings of the Trust Board (i)

Subject to the following provisions of this Standing Order, if the Chairman or a member of the Trust Board has any pecuniary interest, direct or indirect, in any contract, proposed contract or other matter and is present at a meeting of the Trust Board at which the contract or other matter is the subject of consideration, they shall at the meeting and as soon as practicable after its commencement disclose the fact and shall not take part in the consideration or discussion of the contract or other matter or vote on any question with respect to it.

(ii)

The Secretary of State may, subject to such conditions as he/she may think fit to impose, remove any disability imposed by this Standing Order in any case in which it appears to him/her in the interests of the National Health Service that the disability should be removed. (See SO 7.3.3 on the â&#x20AC;&#x2DC;Waiverâ&#x20AC;&#x2122; which has been approved by the Secretary of State for Health).

(iii)

The Trust Board may exclude the Chairman or a member of the Board from a meeting of the Board while any contract, proposed contract or other matter in which he/she has a pecuniary interest is under consideration.

(iv)

Any remuneration, compensation or allowance payable to the Chairman or a Member by virtue of paragraph 11 of Schedule 5A to the National Health Service Act 1977 (pay and allowances) shall not be treated as a pecuniary interest for the purpose of this Standing Order.

(v)

This Standing Order applies to a committee or sub-committee and to a joint committee or sub-committee as it applies to the Trust and applies to a member of any such committee or sub-committee (whether or not he/she is also a member of the Trust) as it applies to a member of the Trust.

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7.3.3

Waiver of Standing Orders made by the Secretary of State for Health (1)

Power of the Secretary of State to make waivers

Under regulation 11(2) of the NHS (Membership and Procedure Regulations SI 1999/2024 (“the Regulations”), there is a power for the Secretary of State to issue waivers if it appears to the Secretary of State in the interests of the health service that the disability in regulation 11 (which prevents a chairman or a member from taking part in the consideration or discussion of, or voting on any question with respect to, a matter in which he has a pecuniary interest) is removed. A waiver has been agreed in line with sub-sections (2) to (4) below. (2)

Definition of ‘Chairman’ for the purpose of interpreting this waiver

For the purposes of paragraph 7.3.3.(3) (below), the “relevant chairman” is – (a)

at a meeting of the Trust, the Chairman of that Trust;

(b)

at a meeting of a Committee –

(3)

(i)

in a case where the member in question is the Chairman of that Committee, the Chairman of the Trust;

(ii)

in the case of any other member, the Chairman of that Committee.

Application of waiver

A waiver will apply in relation to the disability to participate in the proceedings of the Trust on account of a pecuniary interest. It will apply to: (i)

A member of the Surrey and Sussex Healthcare NHS Trust (“the Trust”), who is a healthcare professional, within the meaning of regulation 5(5) of the Regulations, and who is providing or performing, or assisting in the provision or performance, of – (a)

services under the National Health Service Act 2006; or

(b)

services in connection with a pilot scheme under NHS legislation

for the benefit of persons for whom the Trust is responsible. (ii)

Where the ‘pecuniary interest’ of the member in the matter which is the subject of consideration at a meeting at which he is present:(a)

arises by reason only of the member’s role as such a professional providing or performing, or assisting in the provision or performance of, those services to those persons;

(b)

has been declared by the relevant chairman as an interest which cannot reasonably be regarded as an interest more substantial than that of the majority of other persons who:– (i)

are members of the same profession as the member in question,

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(ii)

(4)

are providing or performing, or assisting in the provision or performance of, such of those services as he provides or performs, or assists in the provision or performance of, for the benefit of persons for whom the Trust is responsible.

Conditions which apply to the waiver and the removal of having a pecuniary interest

The removal is subject to the following conditions: (a)

the member must disclose his/her interest as soon as practicable after the commencement of the meeting and this must be recorded in the minutes;

(b)

the relevant chairman must consult the Chief Executive before making a declaration in relation to the member in question pursuant to paragraph 7.3.3 (2) (b) above, except where that member is the Chief Executive;

(c)

in the case of a meeting of the Trust:

(d)

(i)

the member may take part in the consideration or discussion of the matter which must be subjected to a vote and the outcome recorded;

(ii)

may not vote on any question with respect to it.

in the case of a meeting of the Committee: (i)

the member may take part in the consideration or discussion of the matter which must be subjected to a vote and the outcome recorded;

(ii)

may vote on any question with respect to it; but

(iii)

the resolution which is subject to the vote must comprise a recommendation to, and be referred for approval by, the Trust Board.

7.4

Standards of Business Conduct

7.4.1

Trust Policy and National Guidance All Trust staff and members of must comply with the Trust’s Standards of Business Conduct and Conflicts of Interest Policy and the national guidance contained in HSG(93)5 on ‘Standards of Business Conduct for NHS staff’ (the guidance contained within this document referring to the ‘Prevention of Corruption Acts 1889 - 1916’ has been superseded by the ‘Bribery Act 2010’) (see SO 6.2).

7.4.2

Interest of Officers in Contracts i)

Any officer or employee of the Trust who comes to know that the Trust has entered into or proposes to enter into a contract in which he/she or any person connected with him/her (as defined in SO 7.3) has any pecuniary interest, direct or indirect, the Officer shall declare their interest by giving notice in writing of such fact to the Chief Executive or the Trust’s Board/Company Secretary as soon as practicable.

ii)

An Officer should also declare to the Chief Executive any other employment or business or other relationship of his/her, or of a cohabiting spouse, that conflicts, or might reasonably be predicted could conflict with the interests of the Trust.

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iii) 7.4.3

7.4.4

The Trust will require interests, employment or relationships so declared to be entered in a register of interests of staff.

Canvassing of and Recommendations by Members in Relation to Appointments i)

Canvassing of members of the Trust or of any Committee of the Trust directly or indirectly for any appointment under the Trust shall disqualify the candidate for such appointment. The contents of this paragraph of the Standing Order shall be included in application forms or otherwise brought to the attention of candidates.

ii)

Members of the Trust shall not solicit for any person any appointment under the Trust or recommend any person for such appointment; but this paragraph of this Standing Order shall not preclude a member from giving written testimonial of a candidate’s ability, experience or character for submission to the Trust.

Relatives of Members or Officers i)

Candidates for any staff appointment under the Trust shall, when making an application, disclose in writing to the Trust whether they are related to any member or the holder of any office under the Trust. Failure to disclose such a relationship shall disqualify a candidate and, if appointed, render him liable to instant dismissal.

ii)

The Chairman and every member and officer of the Trust shall disclose to the Trust Board any relationship between himself and a candidate of whose candidature that member or officer is aware. It shall be the duty of the Chief Executive to report to the Trust Board any such disclosure made.

iii)

On appointment, members (and prior to acceptance of an appointment in the case of Executive Directors) should disclose to the Trust whether they are related to any other member or holder of any office under the Trust.

iv)

Where the relationship to a member of the Trust is disclosed, the Standing Order headed ‘Disability of Chairman and members in proceedings on account of pecuniary interest’ (SO 7) shall apply.

CUSTODY OF SEAL, SEALING OF DOCUMENTS AND SIGNATURE OF DOCUMENTS

8.1

Custody of Seal The common seal of the Trust shall be kept by the Chief Executive or a nominated Manager by him/her in a secure place.

8.2

Sealing of Documents Where it is necessary that a document shall be sealed, the seal shall be affixed in the presence of two senior managers duly authorised by the Chief Executive, and not also from the originating department, and shall be attested by them.

8.3

Register of Sealing The Chief Executive shall keep a register in which he/she, or another manager of the Authority authorised by him/her, shall enter a record of the sealing of every document.

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8.4

Signature of documents Where any document will be a necessary step in legal proceedings (including the signing of contracts and agreements) on behalf of the Trust, it shall, unless any enactment otherwise requires or authorises, be signed by the Chief Executive or any Executive Director. Directors should follow Trust procedures in the procurement or negotiations of contracts. In land transactions, the signing of certain supporting documents will be delegated to Managers and set out clearly in the Scheme of Delegation but will not include the main or principal documents effecting the transfer (e.g. sale/purchase agreement, lease, contracts for construction works and main warranty agreements or any document which is required to be executed as a deed).

MISCELLANEOUS (see overlap with SFI No. 21.3)

9.1

Joint Finance Arrangements The Board may confirm contracts to purchase from a voluntary organisation or a local authority using its powers under Section 28A of the NHS Act 1977. The Board may confirm contracts to transfer money from the NHS to the voluntary sector or the health related functions of local authorities where such a transfer is to fund services to improve the health of the local population more effectively than equivalent expenditure on NHS services, using its powers under Section 28A of the NHS Act 1977, as amended by section 29 of the Health Act 1999. See overlap with Standing Financial Instruction No. 21.3.

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Section C

Standing Financial Instructions Corporate Governance Manual 2014/15 onwards

Comments and enquiries concerning the manual may be sent to: The Trust Board Administrator Trust Headquarters East Surrey Hospital Canada Avenue REDHILL Surrey RH1 5RH Tel: Fax:

01737 768511 Ext 1817 01737 231771

The manual is also available on the Trust internet site www.surreyandsussex.nhs.uk

Section C: Standing Financial Instructions

Page

Contents SECTION C

Standing Financial Instructions 10

Introduction 10.1

General

10.2

Responsibilities and delegation

11.1

Audit and Assurance Committee

11.2

Chief Finance Officer

11.3

Role of Internal Audit

11.4

External Audit

11.5

Fraud and Corruption

11.6

Security Management

Audit

Annual Accounts and Reports 12.1

The Chief Finance Officer responsibilities: preparation and submission of financial returns and reports

12.2

Annual Accounts

12.3

Annual Report

Bank and GBS Accounts 13.1

General

13.2

Bank and GBS Accounts

13.3

Banking Procedures

13.4

Tendering and Review

Income, Fees and Charges and Security of Cash, Cheques and other Negotiable Instruments 14.1

Income Systems

14.2

Fees and Charges

14.3

Debt Recovery

14.4

Security of Cash, Cheques and other Negotiable Instruments

Income â&#x20AC;&#x201C; NHS Contracts for Provision of Services 15.1

Introduction â&#x20AC;&#x201C; commissioning healthcare in the NHS

15.2

The NHS national contract

15.3

Trust responsibilities to agree the contract with Commissioners

15.4

Contractual Control and Reports to Board

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Section C: Standing Financial Instructions Page

Contents SECTION C 15.5 16

Work done that is not Covered or Restricted by the Contract

Allocations, Planning, Budgets, Budgetary Control and Monitoring 16.1

Preparation and Approval of Plans and Budgets

16.2

Budget Holders

16.3

Budgetary Delegation

16.4

Budgetary Control and Reporting

16.5

Capital Expenditure

16.6

Monitoring Returns

Tendering and Contracting 17.1

Duty to comply with Standing Orders and Standing Financial Instructions

17.2

EU Directives Governing Public Procurement

17.3

Reverse eAuctions

17.4

Capital Investment Manual and other Department of Health Guidance

17.5

Formal Competitive Tendering

17.6

Contracting/Tendering Procedure

17.7

Quotations: Competitive and Non-Competitive

17.8

Authorisation of Tenders and Competitive Quotations

17.9

Instances where Formal Competitive Tendering or Competitive Quotation is not required

17.10

Private Finance for capital procurement (see overlap with SFI No. 24)

17.11

Compliance requirements for all Contracts

17.12

Personnel and Agency or Temporary Staff Contracts

17.13

Healthcare Services Agreements (see overlap with SFI No. 18)

17.14

Disposals (see overlap with SFI No. 26)

17.15

In-house Services

17.16

Applicability of SFIs on Tendering and Contracting to funds held in trust (see overlap with SFI No. 29)

Pay Expenditure 18.1

Remuneration and Terms of Service (see overlap with SO No. 4)

18.2

Funded Establishment

18.3

Staff Appointments

18.4

Processing Payroll

18.5

Expenses Payable to Staff

18.6

Contracts of Employment

Non-Pay Expenditure

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Section C: Standing Financial Instructions Page

Contents SECTION C

19.1

Delegation of Authority

19.2

Choice, Requisitioning, Ordering, Receipt and Payment for Goods and Services (see overlap with Standing Financial Instruction No. 17)

19.3

Paying in advance - Prepayments

19.4

Official Orders

19.5

Duties of Managers and Officers

19.6

Joint Finance Arrangements with Local Authorities and Voluntary Bodies (see overlap with Standing Order No. 9.1)

Trust Commissioning of Healthcare Services 20.1

Role of the Chief Executive

20.2

Role of Chief Finance Officer

BLANK

External Borrowing

22.2

Investments

BLANK

Capital Investment, Private Financing, Fixed Asset Registers and Security of Assets

24.1

Capital Investment

24.2

Private Finance (see overlap with SFI No. 17.10)

24.3

Asset Registers

24.4

Security of Assets

Stores and Receipt of Goods 25.1

General position

25.2

Control of Stores, Stocktaking, condemnations and disposal

25.3

Goods supplied by NHS supply chain

Disposals and Condemnations, Losses and Special Payments 26.1

Disposals and Condemnations

26.2

Losses and Special Payments

Information Technology 27.1

Responsibilities and duties of the Chief Finance Officer

27.2

Responsibilities and duties of other Directors and Officers in relation to computer systems of a general application

27.3

Contracts for Computer Services with other health bodies or outside agencies

27.4

Risk Assessment

27.5

Requirements for Computer Systems which have an impact on corporate

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Section C: Standing Financial Instructions financial systems

Page

Contents SECTION C 28

Patientsâ&#x20AC;&#x2122; Property

Funds held on Trust

29.1

Corporate Trustee

29.2

Accountability to Charity Commission and Secretary of State for Health

29.3

Applicability of Standing Financial Instructions to funds held on Trust

Acceptance of Gifts by Staff and Link to Standards of Business Conduct (see overlap with SO No. 6 and SFI No. 21.2.6 (d))

Blank

Retention of Records

Risk Management and Insurance 33.1

Programme of Risk Management

33.2

Insurance: Risk Pooling Schemes administered by NHSLA

33.3

Insurance arrangements with Commercial Insurers

33.4

Arrangements to be followed by the Board in agreeing Insurance cover

Page 43 of 187

Section C: Standing Financial Instructions SECTION C - STANDING FINANCIAL INSTRUCTIONS 10.

INTRODUCTION

10.1

General

10.1.1

These Standing Financial Instructions (SFIs) are issued in accordance with the Trust (Functions) Directions 2000 issued by the Secretary of State which require that each Trust shall agree Standing Financial Instructions for the regulation of the conduct of its members and officers in relation to all financial matters with which they are concerned. They shall have effect as if incorporated in the Standing Orders (SOs).

10.1.2

These Standing Financial Instructions detail the financial responsibilities and policies adopted by the Trust. They are designed to ensure that the Trust's financial transactions are carried out in accordance with the law and with Government policy in order to achieve probity, accuracy, economy, efficiency and effectiveness. They should be used in conjunction with the Schedule of Decisions Reserved to the Board and the Scheme of Delegation adopted by the Trust.

10.1.3

These Standing Financial Instructions identify the financial responsibilities which apply to everyone working for the Trust and its constituent organisations including Trading Units. They do not provide detailed procedural advice and should be read in conjunction with the detailed departmental and financial procedure notes. All financial procedures must be approved by the Chief Finance Officer.

10.1.4

Should any difficulties arise regarding the interpretation or application of any of the Standing Financial Instructions then the advice of the Chief Finance Officer must be sought before acting. The user of these Standing Financial Instructions should also be familiar with and comply with the provisions of the Trustâ&#x20AC;&#x2122;s Standing Orders (dealing with non-financial aspects).

10.1.5

The failure to comply with Standing Financial Instructions and Standing Orders can in certain circumstances be regarded as a disciplinary matter that could result in dismissal.

10.1.6

Overriding Standing Financial Instructions â&#x20AC;&#x201C; If for any reason these Standing Financial Instructions are not complied with, full details of the non-compliance and any justification for non-compliance and the circumstances around the noncompliance shall be reported to the next formal meeting of the Audit and Assurance Committee for referring action or ratification. All members of the Board and staff have a duty to disclose any non-compliance with these Standing Financial Instructions to the Chief Finance Officer as soon as possible.

10.2

Responsibilities and delegation

10.2.1

The Trust Board The Board exercises financial supervision and control by: (a)

formulating the financial strategy;

(b)

requiring the submission and approval of budgets within approved allocations/overall income;

(c)

defining and approving essential features in respect of important procedures and financial systems (including the need to obtain value for money);

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Section C: Standing Financial Instructions (d)

defining specific responsibilities placed on members of the Board and employees as indicated in the Scheme of Delegation document.

10.2.2

The Board has resolved that certain powers and decisions may only be exercised by the Board in formal session. These are set out in the ‘Reservation of Matters Reserved to the Board’ document above. All other powers have been delegated to such other committees as the Trust has established.

10.2.4

The Chief Executive and Chief Finance Officer The Chief Executive and Chief Finance Officer will, as far as possible, delegate their detailed responsibilities, but they remain accountable for financial control. Within the Standing Financial Instructions, it is acknowledged that the Chief Executive is ultimately accountable to the Board, and as Accountable Officer, to the Secretary of State, for ensuring that the Board meets its obligation to perform its functions within the available financial resources. The Chief Executive has overall executive responsibility for the Trust’s activities; is responsible to the Chairman and the Board for ensuring that its financial obligations and targets are met and has overall responsibility for the Trust’s system of internal control.

10.2.5

It is a duty of the Chief Executive to ensure that Members of the Board and, employees and all new appointees are notified of, and put in a position to understand their responsibilities within these Instructions.

10.2.6

The Chief Finance Officer The Chief Finance Officer is responsible for:

10.2.7

(a)

implementing the Trust’s financial policies and for coordinating any corrective action necessary to further these policies;

(b)

maintaining an efficient and effective system of internal financial control including ensuring that detailed financial procedures and systems incorporating the principles of separation of duties and internal checks are prepared, documented and maintained to supplement these instructions;

(c)

ensuring that sufficient records are maintained to show and explain the Trust’s transactions, in order to disclose, with reasonable accuracy, the financial position of the Trust at any time;

(d)

without prejudice to any other functions of the Trust, and employees of the Trust, the duties of the Chief Finance Officer include: (i)

the provision of financial advice to other members of the Board and employees;

(ii)

the design, implementation and supervision of systems of internal financial control;

(iii)

the preparation and maintenance of such accounts, certificates, estimates, records and reports as the Trust may require for the purpose of carrying out its statutory duties.

Board Members and Employees All members of the Board and employees, severally and collectively, are responsible for:

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Section C: Standing Financial Instructions

10.2.8

(a)

the security of the property of the Trust;

(b)

avoiding loss;

(c)

exercising economy, efficiency and effectiveness in the use of resources;

(d)

conforming the requirements of Standing Orders, Standing Financial Instructions, Financial Procedures and the Scheme of Delegation.

Contractors and their employees Any contractor or employee of a contractor who is empowered by the Trust to commit the Trust to expenditure or who is authorised to obtain income shall be covered by these instructions. It is the responsibility of the Chief Executive to ensure that such persons are made aware of this.

10.2.9

For all members of the Board and any employees who carry out a financial function, the form in which financial records are kept and the manner in which members of the Board and employees discharge their duties must be to the satisfaction of the Chief Finance Officer.

11.

AUDIT

11.1

Audit and Assurance Committee In accordance with Standing Orders (please see para 4.8.1), the Board shall formally establish an Audit Committee (this Trust has renamed it “Audit and Assurance Committee” to better describe its function), with clearly defined terms of reference and following guidance from the NHS Audit Committee Handbook (2011), which will provide an independent and objective review of assurances in respect of all Trust systems of control by:

11.1.2

reviewing opinions and recommendations from Internal Audit, External Audit and also Local counter Fraud Services in recommending the adoption of financial and quality accounts

considering views and opinions from other external regulatory bodies (for example the Care Quality Commission);

reviewing the effectiveness and efficiency of financial, non-financial and information systems and monitoring the integrity of the financial statements and reviewing significant financial reporting judgments;

review the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the Trust’s activities (both clinical and non-clinical), that supports the achievement of the Trust’s corporate objectives;

monitoring compliance with Standing Orders and Standing Financial Instructions;

reviewing schedules of losses recommendations to the Board;

reviewing the arrangements in place to support the Board Assurance Framework process prepared on behalf of the Board and advising the Board accordingly.

and

special

payments

and

making

Where the Audit and Assurance Committee considers there is evidence of ultra vires transactions, evidence of improper acts, or if there are other important matters that the Committee wishes to raise, the Chairman of the Audit and Assurance Committee should raise the matter at a full meeting of the Board. Exceptionally, the

Page 46 of 187

Section C: Standing Financial Instructions matter may need to be referred to the Department of Health. (To the Chief Finance Officer in the first instance). 11.1.3

It is the responsibility of the Chief Finance Officer to ensure an adequate Internal Audit service is provided and the Audit and Assurance Committee shall be involved in the selection process when/if an Internal Audit service provider is changed.

11.2

Chief Finance Officer

11.2.1

The Chief Finance Officer is responsible for: (a)

ensuring there are arrangements to review, evaluate and report on the effectiveness of internal financial control including the establishment of an effective Internal Audit function;

(b)

ensuring that the Internal Audit is adequate and meets the NHS mandatory audit standards;

(c)

deciding at what stage to involve the police, in conjunction with the LSMS, in cases of misappropriation and other irregularities not involving fraud or corruption;

(d)

ensuring that an annual internal audit report is prepared for the consideration of the Audit and Assurance Committee [and the Board]. The report must cover: (i)

(ii) (iii) (iv) (v) (vi) 11.2.2

a clear opinion on the effectiveness of internal control in accordance with current assurance framework guidance issued by the Department of Health including for example compliance with control criteria and standards; major internal financial control weaknesses discovered; progress on the implementation of internal audit recommendations; progress against plan over the previous year; strategic audit plan covering the coming three years; a detailed plan for the coming year.

The Chief Finance Officer or designated auditors are entitled without necessarily giving prior notice to require and receive: a)

access to all records, documents and correspondence relating to any financial or other relevant transactions, including documents of a confidential nature;

(b)

access at all reasonable times to any land, premises or members of the Board or employee of the Trust;

(c)

the production of any cash, stores or other property of the Trust under a member of the Board and an employee's control; and

(d)

explanations concerning any matter under investigation.

11.3

Role of Internal Audit

11.3.1

The responsibilities of internal audit are set out in the International Standards for the Professional Practice of Internal Auditing, published by the Chartered Institute of Internal Auditors (CIIA0 in the UK and Ireland. Internal Audit will essentially review and evaluate the risk management, control and governance arrangements that the organisation has in place, and also to appraise and report upon:

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Section C: Standing Financial Instructions (a)

the extent of compliance with, and the financial effect of relevant, established policies, plans and procedures;

(b)

the adequacy and application of financial and other related management controls;

(c)

the suitability of financial and other related management data;

(d)

the extent to which the Trustâ&#x20AC;&#x2122;s assets and interests are accounted for and safeguarded from loss of any kind, arising from: (i) (ii) (iii)

fraud and other offences; waste, extravagance, inefficient administration; poor value for money or other causes.

(e)

Internal Audit shall also independently verify the Assurance Statements in accordance with guidance from the Department of Health.

(f)

The degree of implementation achieved in relation to recommendations agreed by management during the prior and current financial year are tracked every month by Internal Audit as well as the trust and presented to the AAC. This will serve to inform the adequacy of the trusts speed and efficiency in implementing control recommendations.

11.3.2

Whenever any matter arises which involves, or is thought to involve, irregularities concerning cash, stores, or other property or any suspected irregularity in the exercise of any function of a pecuniary nature, the Chief Finance Officer and the LSMS must be notified immediately.

11.3.3

The Head of Internal Audit will normally attend Audit and Assurance Committee meetings and has a right of access to all Audit and Assurance Committee members, the Chairman and Chief Executive of the Trust.

11.3.4

The Head of Internal Audit shall be accountable to the Chief Finance Officer. The reporting system for internal audit shall be agreed between the Chief Finance Officer, the Audit and Assurance Committee and the Chief Internal Auditor. The agreement shall be in writing and shall comply with the guidance on reporting contained in the NHS Internal Audit Standards. The reporting system shall be reviewed at least every three years.

11.3.5

Internal audit will ensure that the level and quality of audit resource is appropriate and available given the level of assurance required.

11.3.6

Internal audit will also give consideration to government initiatives such as spending reviews and other austerity measures which impact upon the NHS and provision of health services where they can impact upon risk management, governance and internal controls.

11.3.7 Internal audit will meet with the Trustâ&#x20AC;&#x2122;s External Auditors to confirm the scope of the work in the area of Internal Financial Control inorder to ensure that they can continue to place their planned level of reliance on the work of internal audit. 11.4

External Audit

11.4.1

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

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Section C: Standing Financial Instructions 11.5

Fraud and Corruption

11.5.1

In line with their responsibilities, the Trust Chief Executive and Chief Finance Officer shall monitor and ensure compliance with Directions issued by the Secretary of State for Health on fraud and corruption.

11.5.2

The Trust shall nominate a suitable person to carry out the duties of the Local Counter Fraud Specialist as specified by the Department of Health Counter Fraud and Corruption Manual and guidance.

11.5.3

The Bribery Act 2010 replaces the “Prevention of Corruption Acts 1889 - 1916” with new corporate and individual offences as defined within Section 17 of these Standing Financial Instructions. All staff and contractors should be made aware of the Act to ensure compliance. Any breach of the Act may result in criminal proceedings.

11.5.4

The Local Counter Fraud Specialist shall report to the Trust Chief Finance Officer and shall work with staff in NHS Protect in accordance with the Department of Health Fraud and Corruption Manual.

11.5.5

The “Counter Fraud Policy and Response Plan” sets out the action to be taken both by persons detecting a suspected fraud and those persons responsible for investigating it.

11.5.6

The Local Counter Fraud Specialist will attend Audit & Assurance Committee meetings when necessary and has a right of access to all Audit & Assurance Committee members, the Chair and Chief Executive of the Trust.

11.5.7

The Local Counter Fraud Specialist shall be accountable to the Trust Chief Finance Officer. The reporting system for Counter Fraud services shall be agreed between the Chief Finance Officer, the Audit & Assurance Committee and the Local Counter Fraud Specialist. The agreement shall be in writing and shall comply with the guidance on reporting contained in the NHS Counter Fraud and Corruption Manual and guidance. The reporting system shall be reviewed at least every 3 years.

11.5.8

The Local Counter Fraud Specialist will provide a written report, at least annually, on counter fraud work within the Trust.

11.6

Security Management

11.6.1

In line with their responsibilities, the Trust Chief Executive will monitor and ensure compliance with Directions issued by the Secretary of State for Health on NHS security management.

11.6.2

The Trust shall nominate a suitable person to carry out the duties of the Local Security Management Specialist (LSMS) as specified by the Secretary of State for Health guidance on NHS security management.

11.6.3 The Trust shall nominate a Non-Executive Director to be responsible to the Board for NHS security management. 11.6.4 The Chief Executive has overall responsibility for controlling and coordinating security. However, key tasks are delegated to the Director responsible for Security Management and the appointed Local Security Management Specialist (LSMS).

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Section C: Standing Financial Instructions 12.

ANNUAL ACCOUNTS AND REPORTS

12.1

The Chief Finance Officer, on behalf of the Trust, will: (a)

prepare financial returns in accordance with the accounting policies and guidance given by the Department of Health and the Treasury, the Trust’s accounting policies, and International Financial Reporting Standards;

(b)

prepare and submit annual financial reports to the Department of Health certified in accordance with current guidelines;

(c)

submit financial returns to the Department of Health for each financial year in accordance with the timetable prescribed by the Department of Health.

12.2

The Trust’s annual accounts must be audited by an auditor appointed by the Audit Commission. The Trust’s audited annual accounts must be presented to a public meeting and made available to the public.

12.3

The Trust will publish an annual report, in accordance with guidelines on local accountability, and present it at a public meeting. The document will comply with the Department of Health's Manual for Accounts.

13.

BANK ACCOUNTS

13.1

General

13.1.1

The Trust will make changes to its banking arrangements in line with instructions provided by the Government Banking Service (GBS).

13.1.2

The Board shall approve the banking arrangements.

13.2

Bank Accounts

13.2.1

The Chief Finance Officer is responsible for: (a)

commercial bank accounts and Government Banking Service accounts;

(b)

establishing separate bank accounts for the Trust’s non-exchequer funds;

(c)

ensuring payments made from commercial bank or accounts do not exceed the amount credited to the account except where arrangements have been made;

(d)

reporting to the Board all arrangements made with the Trust’s bankers for accounts to be overdrawn.

(e)

monitoring compliance with DH guidance on the level of cleared funds.

(f)

ensuring payments made from the Trust credit cards do not exceed the authorised limits assigned to each card and that the cards are used solely for the purposes of Trust business in line with Trust procedures.

13.3

Banking Procedures

13.3.1

The Chief Finance Officer will prepare detailed instructions on the operation of bank and GBS accounts which must include: (a)

the conditions under which each commercial bank and account is to be operated;

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Section C: Standing Financial Instructions (b)

those authorised to sign cheques or other orders drawn on the Trust’s accounts.

13.3.2

The Chief Finance Officer must advise the Trust’s bankers in writing of the conditions under which each account will be operated.

13.4

Tendering and Review

13.4.1

The Chief Finance Officer will review the commercial banking arrangements of the Trust at regular intervals to ensure they reflect best practice and represent best value for money by periodically seeking competitive tenders for the Trust’s commercial banking business.

13.4.2

Competitive tenders should be sought at least every five years. The results of the tendering exercise should be reported to the Board.

14.

INCOME, FEES AND CHARGES AND SECURITY OF CASH, CHEQUES AND OTHER NEGOTIABLE INSTRUMENTS

14.1

Income Systems

14.1.1

The Chief Finance Officer is responsible for designing, maintaining and ensuring compliance with systems for the proper recording, invoicing, collection and coding of all monies due.

14.1.2

The Chief Finance Officer is also responsible for the prompt banking of all monies received.

14.2

Fees and Charges

14.2.1

The Trust shall follow the Department of Health's advice in the "Costing" Manual in setting prices for NHS service agreements.

14.2.2

The Chief Finance Officer is responsible for approving and regularly reviewing the level of all fees and charges other than those determined by the Department of Health or by Statute. Independent professional advice on matters of valuation shall be taken as necessary.

14.2.3

All employees must inform the Chief Finance Officer promptly of money due arising from transactions which they initiate/deal with, including all contracts, leases, tenancy agreements, private patient undertakings and other transactions.

14.3

Debt Recovery

14.3.1

The Chief Finance Officer is responsible for the appropriate recovery action on all outstanding debts.

14.3.2

Income not received should be dealt with in accordance with losses procedures.

14.3.3

Overpayments should be detected (or preferably prevented) and recovery initiated.

14.4

Security of Cash, Cheques and other Negotiable Instruments

14.4.1

The Chief Finance Officer is responsible for: (a) (b) (c)

approving the form of all receipt books, agreement forms, or other means of officially acknowledging or recording monies received or receivable; ordering and securely controlling any such stationery; the provision of adequate facilities and systems for employees whose duties include collecting and holding cash, including the provision of safes or

Page 51 of 187

Section C: Standing Financial Instructions

(d) (e)

lockable cash boxes, the procedures for keys, and for coin operated machines; prescribing systems and procedures for handling cash and negotiable securities on behalf of the Trust. ensuring that Trust credit cards are kept within a secure location and used appropriately in line with Trust procedures.

14.4.2

Official money shall not under any circumstances be used for the encashment of private cheques or IOUs.

14.4.3

All cheques, postal orders, cash etc., shall be banked intact. Disbursements shall not be made from cash received, except under arrangements approved by the Chief Finance Officer.

14.4.4

The holders of safe keys shall not accept unofficial funds for depositing in their safes unless such deposits are in special sealed envelopes or locked containers. It shall be made clear to the depositors that the Trust is not to be held liable for any loss, and written indemnities must be obtained from the organisation or individuals absolving the Trust from responsibility for any loss.

INCOME - NHS CONTRACTS FOR PROVISION OF SERVICES

15.1

Introduction - commissioning healthcare in the NHS

15.1.1

These SFIs have been significantly revised to take account of the new national contract for commissioning healthcare services and the rules surrounding it. It is important to understand the principles of the contract to appreciate the instructions set out in these SFIs concerning work done in the Trust.

15.1.2

The main source of income to fund Trust services is from Contracts with Clinical Commissioning Groups (CCGs) as well as the National Commissioning Board (Commissioners). are expected to take the lead on behalf of the local population, seeking their views as well as assessing their needs, act as the catalyst for service improvement and commission the health care services they require.

15.1.3

The key mechanism in the way patients access NHS services in secondary care (e.g.: an acute trust) is the GPâ&#x20AC;&#x2122;s role in referring people â&#x20AC;&#x201C; the GP acts as the gatekeeper to secondary care services (as provided in an acute trust).

15.1.4

The NHS Operating Framework (and other relevant guidance) outlines ambitions to deliver world-class commissioning, in turn delivering better health outcomes, narrowing health inequalities and adding years to life.

15.1.5

GP Commissioning is central to these changes (providing the linkage to local communities and the drive to a more personalised health service) and sees the delegation of commissioning to GP Clinical Commissioning Groups.

15.2

The NHS Standard contract

15.2.1

A national contract for CCGs as well as the National Commissioning Board commissioning of healthcare services is now mandatory. The contract is based upon principles of cooperation and competition and Commissioners must use it as the basis for all agreements with NHS acute trusts. [The NHS Standard contract is available at: www.england.nhs.uk/nhs-standard-

contract/)

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Section C: Standing Financial Instructions 15.3

Trust responsibilities to agree the contract with Commissioners

15.3.1

The Chief Executive, as the Accountable Officer, is responsible for ensuring the Trust enters into suitable Contracts with service commissioners for the provision of NHS services. They will be advised by the Chief Finance Officer.

15.3.2

A good contract will result from a dialogue of clinicians, users, carers, public health professionals and managers. It will reflect knowledge of local needs and inequalities. This will require the Chief Executive to ensure that the Trust works with all partner agencies involved in both the delivery and the commissioning of the service required. The contract will apportion responsibility for handling a particular risk to the party or parties in the best position to influence the event and financial arrangements should reflect this. In this way the Trust can jointly manage risk with all interested parties.

15.4

Contractual control and reports to Board

15.4.1

The Chief Executive, as the Accountable Officer, will need to ensure that regular reports are provided to the Board detailing actual and forecast income from the contract. These will in turn be the responsibility of the Chief Finance Officer.

15.4.2

Additionally, the Chief Finance Officer will devise and maintain systems of contractual control. These will include: (a) Monthly reconciliation of Trust activity data with the data used by Commissioners and the agreement of the figures used to confirm payment with the Commissioners; (b) The monthly identification of any dispute that could lead to financial penalty and its escalation for speedy resolution; (c) Monthly reports to the Board in a form approved by the Board: (d) The issue of timely, accurate and comprehensible advice and activity reports to relevant budget holders and other key staff, covering the areas for which they are responsible; (e) Investigation and reporting of variances from activity and income; (f)

Monitoring of management action to correct variances.

15.5

Work done that is not covered or restricted by the contract

15.5.1

Trust staff responsible for making decisions about healthcare procedures should not normally commit Trust resources for work/procedures that are either not covered by the contract or subject to specific restriction, unless there is reasonable justification to do so. It is expected that such instances are exceptional.

15.5.2

Staff making healthcare decisions must be aware of the contractual requirements for the provision of services for which they are responsible and the Chief Executive, through Trust Directors, has a responsibility to ensure systems are in place to enable that and support common sense management of any grey area.

15.5.3

Responsibilities to effect the above can be described as follows: (a)

the Chief Finance Officer must ensure that the hierarchy of managers and clinicians overseeing healthcare decision making is clearly aware of what Commissioners are commissioning, provide this information at Divisional and specialty levels and to individual staff as necessary;

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Section C: Standing Financial Instructions (b)

For areas where there is likely to be potential uncertainty (for example identification of previously unspecified healthcare needs related to an excluded procedure) the Chief Finance Officer is responsible for putting in place effective processes to deal with that eventuality (for example a pro forma approval process with the Commisioners);

(c)

Individual staff who carry responsibility for healthcare decision making should make themselves aware of the contractual requirements. This means that they are expected to involve themselves in business planning and operational management, liaise actively with Trust managers and access and read Trust communications (notably the intranet).

(d)

Where an issue arises that provides a conflict with clinical governance, individual staff have a responsibility to notify that through the Trustâ&#x20AC;&#x2122;s integrated governance and risk management processes and seek a resolution. It is explicitly acknowledged that this is a complex area. Healthcare is complex, individual and includes safety and clinical governance considerations whose specificity cannot be legislated for in every case, however good a contract document. Many decisions require on the spot judgements that may need to be made immediately. Trust staff should therefore follow these principles: (a)

The patientâ&#x20AC;&#x2122;s immediate needs and safety outweighs any other consideration;

(b)

If there is uncertainty over or a potential clash with contractual requirements and there is time to do so, the Commissioners should be contacted and asked to confirm in writing that a procedure can proceed;

(c)

If Trust guidance or instruction is incorrect, unclear or poorly considered it should be highlighted through Trust governance structures and resolved;

(d)

Trust guidance or instruction that is adequately validated, formally agreed and tested should only be ignored in very exceptional circumstances;

(e)

Persistent failure to follow formally notified Trust guidance or instruction is unreasonable and unacceptable.

15.5.4

In addition, any persistent and unreasonable failure to provide information necessary to secure payment from the Commissioners, and that results in financial loss, will also be taken as a breach of these SFIs.

ALLOCATIONS, PLANNING, BUDGETS, BUDGETARY CONTROL, AND MONITORING

16.1

Preparation and Approval of Plans and Budgets

16.1.1

The Director of Corporate Affairs on behalf of the Chief Executive, will compile and submit to the Board a Business Plan which takes into account financial targets and forecast limits of available resources as advised by the Chief Finance Officer. The Business Plan will contain: (a)

a statement of the significant assumptions and risks on which the plan is based;

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Section C: Standing Financial Instructions (b) 16.1.2

details of major changes in workload, delivery of services or resources required to achieve the plan.

Prior to the start of the financial year the Chief Finance Officer will, on behalf of the Chief Executive, prepare and submit a Trust budget for approval by the Board. The budget will: (a)

be in accordance with the aims and objectives set out in the Business Plan;

(b)

accord with workload and workforce plans;

(c)

be produced following discussion with appropriate budget holders;

(d)

be prepared within the limits of available funds;

(e)

identify potential risks.

16.1.3

The Chief Finance Officer shall monitor financial performance against budget and plan, periodically review them, and report to the Board of major changes in workload, delivery of services or resources required to achieve the plan.

16.1.4

All budget holders must provide information as required by the Chief Finance Officer to enable budgets to be compiled. The Chief Finance Officer should foster ownership of budgets by actively involving budget holders in the setting of budgets and savings plans.

16.1.5

All budget holders will sign up to their allocated budgets (including savings plans) at the commencement of each financial year. A budget holder who declines to do so cannot remain a budget holder, whatever the reason for their non acceptance of the budget.

16.2

Budget Holders

16.2.1

The Chief Finance Officer is responsible for specifying the criteria allowing an individual to be a budget holder and may, without prior notification, withdraw that permission or restrict their delegated authority at any point if there is reasonable justification to do so.

16.2.2

The budget holder must have a specific objective in their annual objectives describing their responsibilities as a budget holder and their manager has a responsibility to ensure they carry out those responsibilities. The annual appraisal should record their performance in delivering this objective.

16.2.3

The budget holder must make themselves aware of relevant Trust guidance, procedures and instructions on financial management â&#x20AC;&#x201C; ignorance is not an excuse for failure to follow procedures or instructions.

16.2.4

The Chief Finance Officer has a responsibility to ensure that adequate training is delivered on an on-going basis to budget holders to help them manage successfully and the budget holder has a responsibility to attend that training and identify and use other development aids to help them be equipped to perform the budget holder function.

16.3

Budgetary Delegation

16.3.1

The Chief Executive may delegate the management of a budget to permit the performance of a defined range of activities. This delegation must be in writing (recorded on an authorised signatory pro-forma or through the electronic records of the Trustâ&#x20AC;&#x2122;s financial systems) and be accompanied by a clear definition of:

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Section C: Standing Financial Instructions (a)

the amount of the budget (from the budget statement);

(b)

the purpose(s) of each budget heading (from the budget statement);

(c)

individual and group responsibilities (from the local business plan and individual objectives);

(d)

authority to exercise virement (from the authorised signatory pro-forma);

(e)

achievement of planned levels of service (from the local business plan and individual objectives);

(f)

the provision of regular reports (from the local business plan and individual objectives).

16.3.2

Budget holders are responsible for all expenditure against their budget and the use of Trust resources to deliver work outlined in their local business plans and in Commissioners contracts. In relation to the requirements of section 15.5 (work done that is not covered or restricted by the Commissioners contract) budget holders are responsible for taking all reasonable action to minimise the use of Trust resources for work that will not be paid for by the Commissioners.

16.3.3

The Chief Executive and delegated budget holders must not exceed the budgetary control total or virement limits set by the Board. The control total is the surplus/(deficit) position set in the Trust budget.

16.3.4

This allows for the incorporation of income increases and matching spend (a feature of payment by results) and the reallocation of under and over spending between different parts of the budget.

16.3.5

However, any single annual revenue expenditure budget (gross – not netted off by income) increase above the budgets approved by the Board at the start of the year that exceeds £1.0M must be approved by the Board. Amounts below this can be approved by the Chief Executive, but should be notified to the Board.

16.3.6

Budget managers wishing to secure additional budget should follow Trust procedures for the business case required. The business case will be used to make any decision and must identify the source of funding for the additional budget – be that income, virement from elsewhere or from additional savings.

16.3.7

Any budgeted funds not required for their designated purpose(s) revert to the immediate control of the Chief Executive, subject to any authorised use of virement.

16.3.8

Non-recurring budgets should not be used to finance recurring expenditure without the authority in writing of the Chief Executive, as advised by the Chief Finance Officer. This includes things like the recruitment of permanent staff to cover maternity leave or other temporary staff absence.

16.4

Budgetary Control and Reporting

16.4.1

The Chief Finance Officer will devise and maintain systems of budgetary control. These will include: (a)

monthly financial reports to the Board in a form approved by the Board containing: ∗

income and expenditure to date showing trends and forecast year-end position;

∗

movements in working capital;

∗

Movements in cash and capital;

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Section C: Standing Financial Instructions

16.4.2

â&#x2C6;&#x2014;

capital project spend and projected outturn against plan;

â&#x2C6;&#x2014;

explanations of any material variances from plan;

â&#x2C6;&#x2014;

details of any corrective action where necessary and the Chief Executive's and/or Chief Finance Officer's view of whether such actions are sufficient to correct the situation;

(b)

the issue of timely, accurate and comprehensible advice and financial reports to each budget holder, covering the areas for which they are responsible;

(c)

investigation and reporting of variances from financial, activity, income, workload and manpower budgets;

(d)

monitoring of management action to correct variances; and

(e)

arrangements for the authorisation of budget transfers.

Each Budget Holder is responsible for ensuring that: (a)

any likely overspending or reduction of income which cannot be met by virement within the overall Trust income and expenditure budget control total is not incurred without the prior consent of the Chief Executive (as set out in Trust delegated procedures);

(b)

an action plan (appropriate to the materiality of the shortfall, but recorded) is provided to correct any overspending/under-collection of income in their budgets;

(c)

the amount provided in the approved budget is not used in whole or in part for any purpose other than that specifically authorised subject to the rules of virement;

(d)

any income included within their budget is subject to a formal written contractual agreement specifying the amount, services covered, notice period and other relevant information;

(e)

no permanent employees are appointed without the approval of the Chief Executive (as set out in Trust delegated procedures) other than those provided for within the available resources and manpower establishment as approved by the Board.

(f)

Financial savings agreed in budgets at the start of the year are delivered and that any overspending elsewhere in the budget that reduces those savings is compensated by additional savings, virement or permission to overspend.

16.4.3

The Chief Executive is responsible for identifying and implementing cost improvements and income generation initiatives in accordance with the requirements of the Business Plan and a balanced budget.

16.5

Capital Expenditure

16.5.1

The general rules applying to delegation and reporting shall also apply to capital expenditure. (The particular applications relating to capital are contained in SFI 24).

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Section C: Standing Financial Instructions 16.6

Monitoring Returns The Chief Executive is responsible for ensuring that the appropriate monitoring forms are submitted to the requisite monitoring organisation.

TENDERING AND CONTRACTING

17.1

Duty to comply with Standing Orders and Standing Financial Instructions The procedure for making all contracts by or on behalf of the Trust shall comply with these Standing Orders and Standing Financial Instructions (except where Standing Order No.3.13 Suspension of Standing Orders is applied). The Bribery Act 2010 replaces the fragmented and complex offences at common law and in the Prevention of Corruption Acts 1889-1916. This broadly defines the two sections below; • Two general offences of bribery – 1) Offering or giving a bribe to induce someone to behave, or to reward someone for behaving, improperly and 2) requesting or accepting a bribe either in exchange for acting improperly, or where the request or acceptance is itself improper; • The new corporate offence of negligently failing by a company or limited liability partnership to prevent bribery being given or offered by an employee or agent on behalf of that organisation. All personnel involved in tendering and contacting activities must be aware of the Bribery Act 2010 and must ensure that all dealings with other organisations and their staff do not bring them in breach of the Act that could leave them open to criminal proceedings being commenced.

17.2

EU Directives Governing Public Procurement Directives by the Council of the European Union promulgated by the Department of Health (DH) prescribing procedures for awarding all forms of contracts shall have effect as if incorporated in these Standing Orders and Standing Financial Instructions.

17.3

Reverse eAuctions The Trust should have policies and procedures in place for the control of all tendering activity carried out through Reverse eAuctions. For further guidance on Reverse eAuctions refer to www.ogc.gov.uk

17.4

Capital Investment Manual and other Department of Health Guidance The Trust shall comply as far as is practicable with the requirements of the Department of Health "Capital Investment Manual", together with its supplementary guidance, and “Health Building Note 00-08Estate code in respect of capital investment and estate and property transactions. In the case of management consultancy contracts the Trust shall comply as far as is practicable with Department of Health guidance "Agreement for the appointment of architects, surveyors and engineers for commissions in the National Health Service"; together with its supplementary annexure. Similarly the Department of Health guidance "Agreement for the appointment of project managers for commissions for construction projects in the National Health Service" will apply for project management consultancy.

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Section C: Standing Financial Instructions 17.5

Formal Competitive Tendering

17.5.1

General Applicability The Trust shall ensure that competitive tenders are invited for:

17.5.2

•

the supply of goods, materials and manufactured articles;

•

the rendering of services including all forms of management consultancy services (other than specialised services sought from or provided by the DH);

•

For the design, construction and maintenance of building and engineering works (including construction and maintenance of grounds and gardens); for disposals.

Health Care Services Where the Trust elects to invite tenders for the supply of healthcare services these Standing Orders and Standing Financial Instructions shall apply as far as they are applicable to the tendering procedure and need to be read in conjunction with Standing Financial Instruction No. 15 and No. 20.

17.5.3

Exceptions and instances where formal tendering need not be applied Formal tendering procedures need not be applied where: (a)

the estimated expenditure or income does not, or is not reasonably expected to, exceed £5,000;

(b)

where the supply is proposed under special arrangements negotiated by the DH in which event the said special arrangements must be complied with;

(c)

regarding disposals as set out in Standing Financial Instructions No. 25; (d) The expenditure is for maintenance and the only supplier available is the original equipment manufacturer. The equipment must have previously been through an appropriate procurement route. Formal tendering procedures may be waived in the following circumstances: (e)

in very exceptional circumstances where the Chief Executive decides that formal tendering procedures would not be practicable or the estimated expenditure or income would not warrant formal tendering procedures, and the circumstances are detailed in an appropriate Trust record;

(f) where the requirement is covered by an existing contract; (g) where Crown Commercial Services agreements are in place and have been approved by the Board; (g) where a consortium arrangement is in place and a lead organisation has been appointed to carry out tendering activity on behalf of the consortium members; (h)

where the timescale genuinely precludes competitive tendering but failure to plan the work properly would not be regarded as a justification for a single tender;

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Section C: Standing Financial Instructions (i)

where specialist expertise is required and is available from only one source;

(j)

when the task is essential to complete the project, and arises as a consequence of a recently completed assignment and engaging different consultants for the new task would be inappropriate;

(k)

(l)

for the provision of legal advice and services providing that any legal firm or partnership commissioned by the Trust is regulated by the Law Society for England and Wales for the conduct of their business (or by the Bar Council for England and Wales in relation to the obtaining of Counselâ&#x20AC;&#x2122;s opinion) and are generally recognised as having sufficient expertise in the area of work for which they are commissioned. The Chief Finance Officer will ensure that any fees paid are reasonable and within commonly accepted rates for the costing of such work.

(m)

where allowed and provided for in the Capital Investment Manual. The waiving of competitive tendering procedures should not be used to avoid competition or for administrative convenience or to award further work to a consultant originally appointed through a competitive procedure. Where it is decided that competitive tendering is not applicable and should be waived, the fact of the waiver and the reasons should be documented and recorded in an appropriate Trust record and reported to the Audit and Assurance Committee periodically..

17.5.4

Fair and Adequate Competition Where the exceptions set out in SFI Nos. 17.1 and 17.5.3 apply, the Trust shall ensure that invitations to tender are sent to a sufficient number of firms/individuals to provide fair and adequate competition as appropriate, and in no case less than two firms/individuals, having regard to their capacity to supply the goods or materials or to undertake the services or works required.

17.5.5

Building and Engineering Construction Works Competitive Tendering cannot be waived for building and engineering construction works and maintenance subject to the provisions of clause 17.5.3 of these SFIs.

17.5.6

Items which subsequently breach thresholds after original approval Items estimated to be below the limits set in this Standing Financial Instruction for which formal tendering procedures are not used which subsequently prove to have a value above such limits shall be reported to the Chief Executive, and be recorded in an appropriate Trust record.

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Section C: Standing Financial Instructions 17.6

Contracting/Tendering Procedure

17.6.1

Invitation to tender (i)

All invitations to tender shall state the date and time as being the latest time for the receipt of tenders.

(ii)

All invitations to tender shall state that no tender will be accepted unless: (a) submitted in a plain sealed package or envelope bearing a pre-printed label supplied by the Trust (or the word "tender" followed by the subject to which it relates) and the latest date and time for the receipt of such tender addressed to the Chief Executive or nominated Manager; (b) that tender envelopes/ packages shall not bear any names or marks indicating the sender. The use of courier/postal services must not identify the sender on the envelope or on any receipt so required by the deliverer.

17.6.2

(iii)

Every tender for goods, materials, services or disposals shall embody such of the NHS Standard Contract Conditions as are applicable.

(iv)

Every tender for building or engineering works except for maintenance work, shall embody or be in the terms of the current edition of one of the Joint Contracts Tribunal Standard Forms of Building Contract or, when the content of the work is primarily engineering, the General Conditions of Contract recommended by the Institution of Mechanical and Electrical Engineers and the Association of Consulting Engineers, or (in the case of civil engineering work) the General Conditions of Contract recommended by the Institute of Civil Engineers, the Association of Consulting Engineers and the Federation of Civil Engineering Contractors. These documents shall be modified and/or amplified to accord with Department of Health guidance and, in minor respects, to cover special features of individual projects.

Receipt and safe custody of tenders The Chief Executive or his nominated representative will be responsible for the receipt, endorsement and safe custody of tenders received until the time appointed for their opening. The date and time of receipt of each tender shall be endorsed on the tender envelope/package.

17.6.3

Opening tenders and Register of tenders (i)

As soon as practicable after the date and time stated as being the latest time for the receipt of tenders, they shall be opened by two senior officers/managers designated by the Chief Executive and not from the originating department.

(ii)

A member of the Trust Board will be required to be one of the two approved persons present for the opening of tenders estimated above £20,000. The rules relating to the opening of tenders will need to be read in conjunction with any delegated authority set out in the Trust’s Scheme of Delegation.

(iii)

The ‘originating’ Department will be taken to mean the Department sponsoring or commissioning the tender.

(iv)

The involvement of Finance Directorate staff in the preparation of a tender proposal will not preclude the Chief Finance Officer or any approved Senior

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Section C: Standing Financial Instructions Manager from the Finance Directorate from serving as one of the two senior managers to open tenders. (v)

All Executive Directors/members will be authorised to open tenders regardless of whether they are from the originating department provided that the other authorised person opening the tenders with them is not from the originating department. The Trustâ&#x20AC;&#x2122;s Company Secretary will count as a Director for the purposes of opening tenders.

(vi)

Every tender received shall be marked with the date of opening and initialled by those present at the opening.

(vii)

A register shall be maintained by the Chief Executive, or a person authorised by them, to show for each set of competitive tender invitations despatched: the name of all firms individuals invited; the names of firms individuals from which tenders have been received; the date the tenders were opened; the persons present at the opening; the price shown on each tender; a note where price alterations have been made on the tender.

Each entry to this register shall be signed by those present. A note shall be made in the register if any one tender price has had so many alterations that it cannot be readily read or understood. (viii)

17.6.4

17.6.5

Incomplete tenders, i.e. those from which information necessary for the adjudication of the tender is missing, and amended tenders i.e., those amended by the tenderer upon his own initiative either orally or in writing after the due time for receipt, but prior to the opening of other tenders, should be dealt with in the same way as late tenders. (Standing Order No. 17.6.5 below).

Admissibility i)

If for any reason the designated officers are of the opinion that the tenders received are not strictly competitive (for example, because their numbers are insufficient or any are amended, incomplete or qualified) no contract shall be awarded without the approval of the Chief Executive.

(ii)

Where only one tender is sought and/or received, the Chief Executive and Chief Finance Officer shall, as far practicable, ensure that the price to be paid is fair and reasonable and will ensure value for money for the Trust.

Late tenders (i)

Tenders received after the due time and date, but prior to the opening of the other tenders, may be considered only if the Chief Executive or his nominated officer decides that there are exceptional circumstances i.e. despatched in good time but delayed through no fault of the tenderer.

(ii)

Only in the most exceptional circumstances will a tender be considered which is received after the opening of the other tenders and only then if the tenders that have been duly opened have not left the custody of the Chief Executive or his nominated officer or if the process of evaluation and adjudication has not started.

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Section C: Standing Financial Instructions (iii)

17.6.6

While decisions as to the admissibility of late, incomplete or amended tenders are under consideration, the tender documents shall be kept strictly confidential, recorded, and held in safe custody by the Chief Executive or his nominated officer.

Acceptance of formal tenders (See overlap with SFI No. 17.7) (i)

Any discussions with a tenderer which are deemed necessary to clarify technical aspects of his tender before the award of a contract will not disqualify the tender.

(ii)

The lowest tender, if payment is to be made by the Trust, or the highest, if payment is to be received by the Trust, shall be accepted unless there are good and sufficient reasons to the contrary. Such reasons shall be set out in either the contract file, or other appropriate record. It is accepted that for professional services such as management consultancy, the lowest price does not always represent the best value for money. Other factors affecting the success of a project include: (a) experience and qualifications of team members; (b) understanding of clientâ&#x20AC;&#x2122;s needs; (c) feasibility and credibility of proposed approach; (d) ability to complete the project on time. Where other factors are taken into account in selecting a tenderer, these must be clearly recorded and documented in the contract file, and the reason(s) for not accepting the lowest tender clearly stated.

(iii)

No tender shall be accepted which will commit expenditure in excess of that which has been allocated by the Trust and which is not in accordance with these Instructions except with the authorisation of the Chief Executive.

(iv)

The use of these procedures must demonstrate that the award of the contract was: (a) not in excess of the going market rate / price current at the time the contract was awarded; (b) that best value for money was achieved.

(v) 17.6.7

All tenders should be treated as confidential and should be retained for inspection.

Tender reports to the Trust Board Reports to the Trust Board will be made on an exceptional circumstance basis only.

17.6.8

Firms who can tender (a)

Building and Engineering Construction Works

Tenderers shall ensure that when engaging, training, promoting or dismissing employees or in any conditions of employment, shall not discriminate against any person because of colour, race, ethnic or national origins, religion or sex, and will comply with the provisions of the Equal Pay Act 1970, the Sex

Page 63 of 187

Section C: Standing Financial Instructions Discrimination Act 1975, the Race Relations Act 1976, and the Disabled Persons (Employment) Act 1944 and any amending and/or related legislation. ii)

Firms shall conform at least with the requirements of the Health and Safety at Work Act and any amending and/or other related legislation concerned with the health, safety and welfare of workers and other persons, and to any relevant British Standard Code of Practice issued by the British Standard Institution. Firms must provide to the appropriate manager a copy of its safety policy and evidence of the safety of plant and equipment, when requested.

(b)

Financial Standing and Technical Competence of Contractors The Chief Finance Officer may make or institute any enquiries he deems appropriate concerning the financial standing and financial suitability of approved contractors. The Director with lead responsibility for clinical governance will similarly make such enquiries as is felt appropriate to be satisfied as to their technical / medical competence.

17.7

Quotations: Competitive and non-competitive

17.7.1

General Position on quotations Quotations are required where formal tendering procedures are not adopted and where the intended expenditure or income exceeds, or is reasonably expected to exceed ÂŁ5, 000 but not exceed ÂŁ20,000.

17.7.2

17.7.3

Competitive Quotations (i)

Quotations should be obtained from at least 3 firms/individuals based on specifications or terms of reference prepared by, or on behalf of, the Trust.

(ii)

Quotations should be in writing unless the Chief Executive or his nominated officer determines that it is impractical to do so in which case quotations may be obtained by telephone. Confirmation of telephone quotations should be obtained as soon as possible and the reasons why the telephone quotation was obtained should be set out in a permanent record.

(iii)

All quotations should be treated as confidential and should be retained for inspection.

(iv)

The Chief Executive or his nominated officer should evaluate the quotation and select the quote which gives the best value for money. If this is not the lowest quotation if payment is to be made by the Trust, or the highest if payment is to be received by the Trust, then the choice made and the reasons why should be recorded in a permanent record.

Non-Competitive Quotations Non-competitive quotations in writing may be obtained in the following circumstances (waiver procedures still apply refer to section G): (i)

the supply of proprietary or other goods of a special character and the rendering of services of a special character, for which it is not, in the opinion of the responsible officer, possible or desirable to obtain competitive quotations;

(ii)

the supply of goods or manufactured articles of any kind which are required quickly and are not obtainable under existing contracts;

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Section C: Standing Financial Instructions

17.7.4

(iii)

miscellaneous services, supplies and disposals;

(iv)

where the goods or services are for building and engineering maintenance the responsible works manager must certify that the first two conditions of this SFI (i.e.: (i) and (ii) of this SFI) apply.

Quotations to be within Financial Limits No quotation shall be accepted which will commit expenditure in excess of that which has been allocated by the Trust and which is not in accordance with Standing Financial Instructions except with the authorisation of either the Chief Executive or Chief Finance Officer.

17.8

Authorisation of Tenders and Competitive Quotations Providing all the conditions and circumstances set out in these Standing Financial Instructions have been fully complied with, formal authorisation and awarding of a contract may be decided as follows:

a. Up to £5,000, including VAT, quotations i. initiated and specified by ii. organised and despatched by iii. received by iv. opened by v. evaluated and recommended by v. accepted by b. £5,001 to £20,000 including VAT, minimum option three written quotes i. initiated and specified by ii. organised and despatched by iii. received by iv. opened by v. evaluated and recommended by vi. accepted by c. Between £20,001 and EU limit including VAT, minimum three written tenders i. initiated and specified by ii. organised and despatched by iii. received by iv. opened by v. evaluated and recommended by

vi. accepted by d. Between EU limit and £1m including VAT, minimum three written tenders i. initiated and specified by ii. organised and despatched by iii. received by iv. opened by

Head Of Procurement or delegated officer and Originating Department Procurement Department Procurement Department Procurement Department Procurement Department and Originating department Budget Holder

Project Board / Originating Department supported by Head Of Procurement Procurement Department with support from Originating Department on request Trust Board Secretary or relevant Administrator Two Executive Directors or one Executive Director and Deputy Chief Finance Officer Project Board / Originating Department supported by Head Of Procurement and including senior Finance and Clinical leads as appropriate. Chief Executive or Chief Finance Officer

Project Board / Originating Department supported by Head Of Procurement and Senior Finance Representative Procurement Department with support from Originating Department/Project Board Trust Board Secretary or relevant Administrator Trust Board Secretary or relevant administrator and Two Executive Directors or one Executive Director and Deputy Chief Finance Officer

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Section C: Standing Financial Instructions v. evaluated and recommended by

vi. accepted by e Greater than £1m, minimum three written tenders (Revenue and Capital) i. Initiated and specified by ii. organised and despatched by iii. received by iv. opened by

v. evaluated and recommended by

vi. accepted by

Project Board / Originating Department supported by the Head Of Procurement and including senior representation from Finance and the relevant specialties Chief Executive or Chief Finance Officer

Project Board / Originating Department supported by Head Of Procurement and Senior Finance Representative Procurement Department with Senior Finance Representative and Project Board support Trust Board Secretary or relevant Administrator Trust Board Secretary or relevant Administrator and Two Executive Directors or one Executive Director and Deputy Chief Finance Officer Project Board / Originating Department supported by the Head Of Procurement or Contracts Manager and including senior representation from Finance and the relevant specialties Trust Board

Delegated administration is approved by the Board as Deputy Chief Finance Officer Head of Capital projects Head of Procurement These levels of authorisation may be varied or changed and need to be read in conjunction with the Trust Board’s Scheme of Delegation. Formal authorisation must be put in writing. In the case of authorisation by the Trust Board this shall be recorded in their minutes. 17.9

Instances where formal competitive tendering or competitive quotation is not required Where competitive tendering or a competitive quotation is not required the Trust should adopt one of the following alternatives: a) The Trust shall use NHS National Frameworksfor the procurement of all goods and services unless the Chief Executive or nominated officers deem it inappropriate. The decision to use alternative sources must be documented. b) If the Trust does not use the NHS National Frameworks where tenders or quotations are not required because expenditure is below £5,000, the Trust shall procure goods and services in accordance with procurement procedures approved by the Chief Finance Officer.

17.10

Private Finance for capital procurement (see overlap with SFI No. 24) The Trust should normally market-test for PFI (Private Finance Initiative funding) when considering a capital procurement. When the Board proposes, or is required, to use finance provided by the private sector the following should apply: (a)

The Chief Executive shall demonstrate that the use of private finance represents value for money and genuinely transfers risk to the private sector.

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Section C: Standing Financial Instructions

17.11

(b)

Where the sum exceeds delegated limits, a business case must be referred to the appropriate Department of Health for approval or treated as per current guidelines.

(c)

The proposal must be specifically agreed by the Board of the Trust.

(d)

The selection of a contractor/finance company must be on the basis of competitive tendering or quotations.

Compliance requirements for all contracts The Board may only enter into contracts on behalf of the Trust within the statutory powers delegated to it by the Secretary of State and shall comply with:

17.12

(a)

The Trustâ&#x20AC;&#x2122;s Standing Orders and Standing Financial Instructions;

(b)

EU Directives and other statutory provisions;

(c)

any relevant directions including the Capital Project Management Procedure Manual

(d)

such of the NHS Standard Contract Conditions as are applicable.

(e)

contracts with Foundation Trusts must be in a form compliant with appropriate NHS guidance.

(f)

Where appropriate contracts shall be in or embody the same terms and conditions of contract as was the basis on which tenders or quotations were invited.

(g)

In all contracts made by the Trust, the Board shall endeavour to obtain best value for money by use of all systems in place. The Chief Executive shall nominate an officer who shall oversee and manage each contract on behalf of the Trust.

Personnel and Agency or Temporary Staff Contracts The Chief Executive shall nominate officers with delegated authority to enter into contracts of employment, regarding staff, agency staff or temporary staff service contracts. (a) All responsible officers entering into Off-Payroll contracts should ensure that these contracts comply with the Her Majestyâ&#x20AC;&#x2122;s Tax arrangements for public sector appointees. (b) Where arrangements are entered into directly between the responsible officer and the consultancy then the officer must ensure that the Trust Consultancy service Agreement is completed accurately and completely.

17.13

Healthcare Services Agreements (see overlap with SFI No. 18) Service agreements with NHS providers for the supply of healthcare services shall be drawn up in accordance with the NHS and Community Care Act 1990 and administered by the Trust. Service agreements with many NHS bodies are not normally contracts in law and therefore not enforceable by the courts. However, a contract with a Foundation Trust is a legal document and is enforceable in law. The Chief Executive shall nominate officers to commission service agreements with providers of healthcare.

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Section C: Standing Financial Instructions 17.14

Disposals (See overlap with SFI No. 26) Competitive Tendering or Quotation procedures shall not apply to the disposal of:

17.15

(a)

any matter in respect of which a fair price can be obtained only by negotiation or sale by auction as determined (or pre-determined in a reserve) by the Chief Executive or his nominated officer;

(b)

obsolete or condemned articles and stores, which may be disposed of in accordance with the supplies policy of the Trust;

(c)

items to be disposed of with an estimated sale value of less than £1,000, this figure to be reviewed on a periodic basis;

(d)

items arising from works of construction, demolition or site clearance, which should be dealt with in accordance with the relevant contract;

(e)

land or buildings concerning which DH guidance has been issued but subject to compliance with such guidance.

In-house Services

17.15.1 The Chief Executive shall be responsible for ensuring that best value for money can be demonstrated for all services provided on an in-house basis. The Trust may also determine from time to time that in-house services should be market tested by competitive tendering. 17.15.2 In all cases where the Board determines that in-house services should be subject to competitive tendering the following groups shall be set up: (a) Specification group, comprising the Chief Executive or nominated officer/s and specialist. (b) In-house tender group, comprising a nominee of the Chief Executive and technical support. (c) Evaluation team, comprising normally a specialist officer, a supplies officer and a Chief Finance Officer representative. For services having a likely annual expenditure exceeding £10,000, a non-Executive member should be a member of the evaluation team. 17.15.3 All groups should work independently of each other and individual officers may be a member of more than one group but no member of the in-house tender group may participate in the evaluation of tenders. 17.15.4 The evaluation team shall make recommendations to the Board. 17.15.5 The Chief Executive shall nominate an officer to oversee and manage the contract on behalf of the Trust. 17.16

Applicability of SFIs on Tendering and Contracting to funds held in trust (see overlap with SFI No. 29) These Instructions shall not only apply to expenditure from Exchequer funds but also to works, services and goods purchased from the Trust’s trust funds and private resources.

Page 68 of 187

Section C: Standing Financial Instructions 18.

PAY EXPENDITURE

18.1

Remuneration and Terms of Service (see overlap with SO No. 4) In accordance with Standing Orders the Board shall establish a Remuneration Committee, with clearly defined terms of reference, specifying which posts fall within its area of responsibility, its composition, and the arrangements for reporting. (See NHS guidance contained in the Higgs report.)

18.1.1

The Committee will: (a)

advise the Board about appropriate remuneration and terms of service for the Chief Executive, other officer members employed by the Trust and: (i) all aspects of salary (including any performance-related elements/bonuses); (ii) provisions for other benefits, including pensions and cars; (iii) arrangements for termination of employment and other contractual terms;

(b)

make such recommendations to the Board on the remuneration and terms of service of officer members of the Board (and other senior employees) to ensure they are fairly rewarded for their individual contribution to the Trust having proper regard to the Trustâ&#x20AC;&#x2122;s circumstances and performance and to the provisions of any national arrangements for such members and staff where appropriate;

(c)

monitor and evaluate the performance of individual officer members (and other senior employees);

(d)

advise on and oversee appropriate contractual arrangements for such staff including the proper calculation and scrutiny of termination payments taking account of such national guidance as is appropriate.

18.1.2

The Committee shall report in writing to the Board the basis for its recommendations. The Board shall use the report as the basis for their decisions, but remain accountable for taking decisions on the remuneration and terms of service of officer members. Minutes of the Board's meetings should record such decisions.

18.1.3

The Board will consider and need to approve proposals presented by the Chief Executive for the setting of remuneration and conditions of service for those employees and officers not covered by the Committee.

18.1.4

The Trust will pay allowances to the Chairman and non-Executive members of the Board in accordance with instructions issued by the Secretary of State for Health. Subject to legal requirements all claims for additional pay (e.g. overtime) must be submitted within 3 months or the Trust can decline payment.

18.2

Funded Establishment

The workforce plans incorporated within the annual budget will form the funded establishment. The funded establishment of any department may not be varied without the approval of the Chief Executive.

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Section C: Standing Financial Instructions 18.3

Staff Appointments

18.3.1 No officer or Member of the Trust Board or employee may engage, re-engage, or re grade employees, either on a permanent or temporary nature, or hire agency staff, or agree to changes in any aspect of remuneration: (a)

unless authorised to do so by the Chief Executive;

(b)

within the limit of their approved budget and funded establishment.

The Board will approve procedures presented by the Chief Executive for the determination of commencing pay rates, condition of service, etc, for employees. 18.4

Processing Payroll

18.4.1 The Director of HR is responsible for: (a)

specifying timetables for submission of properly authorised time records and other notifications;

(b)

the final determination of pay and allowances;

(c)

making payment on agreed dates;

(d)

agreeing method of payment.

18.4.2 The Director of HR will issue instructions regarding: (a)

verification and documentation of data;

(b)

the timetable for receipt and preparation of payroll data and the payment of employees and allowances;

(c)

maintenance of subsidiary records for superannuation, income tax, social security and other authorised deductions from pay;

(d)

security and confidentiality of payroll information;

(e)

checks to be applied to completed payroll before and after payment;

(f)

authority to release payroll data under the provisions of the Data Protection Act;

(g)

methods of payment available to various categories of employee and officers;

(h)

procedures for payment by cheque, bank credit, or cash to employees and officers;

(I)

procedures for the recall of cheques and bank credits;

(j)

pay advances and their recovery;

(k)

maintenance of regular and independent reconciliation of pay control accounts;

(l)

separation of duties of preparing records and handling cash;

(m)

a system to ensure the recovery from those leaving the employment of the Trust of sums of money and property due by them to the Trust.

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Section C: Standing Financial Instructions 18.4.3 Appropriately nominated managers have delegated responsibility for: (a)

submitting time records, and other notifications in accordance with agreed timetables;

(b)

completing time records and other notifications in accordance with the Chief Finance Officer's instructions and in the form prescribed by the Chief Finance Officer;

(c)

submitting termination forms in the prescribed form immediately upon knowing the effective date of an employee's or officerâ&#x20AC;&#x2122;s resignation, termination or retirement. Where an employee fails to report for duty or to fulfil obligations in circumstances that suggest they have left without notice, the Chief Finance Officer must be informed immediately.

18.4.4

Regardless of the arrangements for providing the payroll service, the Director of HR shall ensure that the chosen method is supported by appropriate (contracted) terms and conditions, adequate internal controls and audit review procedures and that suitable arrangements are made for the collection of payroll deductions and payment of these to appropriate bodies.

18.5

Expenses payable to staff Expenses are non pay expenditure, but should be paid with salary and only exceptionally by any other means. Trust procedures for expense claims must be followed by all staff and it is each individualâ&#x20AC;&#x2122;s responsibility to submit claims on a regular basis, which enables the Trust to monitor and control expenditure and provide payment. The Trust will withhold the payment of expenses claimed 3 months or more after they were incurred. In exceptional circumstances appeals can go to the Chief Finance Officer.

18.6

Contracts of Employment The Board shall delegate responsibility to an officer for: (a)

ensuring that all employees are issued with a Contract of Employment in a form approved by the Board and which complies with employment legislation;

(b)

dealing with variations to, or termination of, contracts of employment.

19.

NON-PAY EXPENDITURE

19.1

Delegation of Authority

The Board will approve the level of non-pay expenditure on an annual basis and the Chief Executive will determine the level of delegation to budget managers. The Chief Executive will set out: (a)

the list of managers who are authorised to place requisitions for the supply of goods and services;

(b)

the maximum level of each requisition and the system for authorisation above that level.

The Chief Executive shall set out procedures on the seeking of professional advice regarding the supply of goods and services.

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Section C: Standing Financial Instructions 19.2

Choice, Requisitioning, Ordering, Receipt and Payment for Goods and Services (see overlap with Standing Financial Instruction No. 17)

19.2.1 Requisitioning The requisitioner, in choosing the item to be supplied (or the service to be performed) shall always obtain the best value for money for the Trust. In so doing, the advice of the Trustâ&#x20AC;&#x2122;s adviser on supply shall be sought. Where this advice is not acceptable to the requisitioner, the Chief Finance Officer (and/or the Chief Executive) shall be consulted 19.2.2 Use of purchase orders 19.2.3 There is a trade off between security, cost and the administration necessary to buy items for the Trust. The aim is to make things as simple as possible while keeping the right balance between these considerations. 19.2.4 There are 4 key instructions, repeated in the detail that follows: a) Staff must use purchase orders (order forms based mainly on catalogues) to buy goods and services, unless the item cannot be purchased this way. This is a MANDATORY instruction. b) Staff must not buy items using petty cash unless it is absolutely unavoidable. c) If staff are unable to use a purchase order, any paperwork that comes back to the Trust after purchase must have the cost centre and subjective code written on them and signed and dated by the Budget Holder. d) The Purchasing Departmentâ&#x20AC;&#x2122;s role is to improve the way we buy goods and services and obtain the best price - it saves the Trust substantial amounts of money and staff should make use of it rather than negotiate themselves. e) The use of purchase orders will not be required for purchases made from internet based suppliers. 19.2.5 System of Payment and Payment Verification 19.2.6 The Chief Finance Officer shall be responsible for the prompt payment of accounts and claims. Payment of contract invoices shall be in accordance with contract terms, or otherwise, in accordance with national guidance. 19.2.7 The Chief Finance Officer will: (a)

advise the Board regarding the setting of thresholds above which quotations (competitive or otherwise) or formal tenders must be obtained; and, once approved, the thresholds should be incorporated in Standing Orders and Standing Financial Instructions and regularly reviewed;

(b)

prepare procedural instructions or guidance within the Scheme of Delegation on the obtaining of goods, works and services incorporating the thresholds;

(c)

be responsible for the prompt payment of all properly authorised accounts and claims;

(d)

be responsible for designing and maintaining a system of verification, recording and payment of all amounts payable. The system shall provide for: (i) A list of Board employees (including specimens of their signatures) authorised to certify invoices.

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Section C: Standing Financial Instructions (ii) Certification that: -

goods have been duly received, examined and are in accordance with specification and the prices are correct;

work done or services rendered have been satisfactorily carried out in accordance with the order, and, where applicable, the materials used are of the requisite standard and the charges are correct;

in the case of contracts based on the measurement of time, materials or expenses, the time charged is in accordance with the time sheets, the rates of labour are in accordance with the appropriate rates, the materials have been checked as regards quantity, quality, and price and the charges for the use of vehicles, plant and machinery have been examined;

where appropriate, the expenditure is in accordance with regulations and all necessary authorisations have been obtained;

the account is arithmetically correct;

the account is in order for payment.

(iii) A timetable and system for submission to the Chief Finance Officer of accounts for payment; provision shall be made for the early submission of accounts subject to cash discounts or otherwise requiring early payment. (iv) Instructions to employees regarding the handling and payment of accounts within the Finance Department. (e) 19.3

be responsible for ensuring that payment for goods and services is only made once the goods and services are received.

Paying in advance â&#x20AC;&#x201C; prepayments

19.3.1 The payment of goods/services in advance presents a financial risk for the Trust if the item being purchased is not delivered, or the company or organisation supplying the goods/services disappears or goes into liquidation or bankruptcy. As a result, the general rule is to avoid paying for anything in advance of delivery. 19.3.2 The exception to the above rule is for the following situations where it is generally accepted that payment is made before delivery of the goods/service:

Training course or conference fees

Council Tax and Uniform Business Rates

Rent or Operating Lease Payments

Insurance premium payments

When the Trust agrees to pay something on behalf of a third party (for example, legal costs incurred by a member of staff and the invoice is made out to that third party).

Where purchases are made from a web based organisation in line with Trust procedures.

19.3.3 The majority of items in the list are paid under statutory (legal) requirements (Council Tax/Uniform Business Rates), or are supported by a legal contract (Rent or Lease Payments). In such situations, budget managers should arrange to pay these invoices where they exist.

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Section C: Standing Financial Instructions 19.3.4 Prepayments for any other item not listed above are only permitted where exceptional circumstances apply. In such instances:

19.4

(a)

Prepayments are only permitted where the financial advantages outweigh the disadvantages (i.e. cash flows must be discounted to NPV using the National Loans Fund (NLF) rate plus 2%).

(b)

The appropriate officer must provide, in the form of a written report, a case setting out all relevant circumstances of the purchase. The report must set out the effects on the Trust if the supplier is at some time during the course of the prepayment agreement unable to meet his commitments;

(c)

The Chief Finance Officer will need to be satisfied with the proposed arrangements before contractual arrangements proceed (taking into account the EU public procurement rules where the contract is above a stipulated financial threshold);

(d)

The budget holder is responsible for ensuring that all items due under a prepayment contract are received and they must immediately inform the appropriate Director or Chief Executive if problems are encountered.

Official orders Official Orders must:

19.5

(a)

be consecutively numbered;

(b)

be in a form approved by the Chief Finance Officer;

(c)

state the Trustâ&#x20AC;&#x2122;s terms and conditions of trade;

(d)

only be issued to, and used by, those duly authorised by the Chief Executive.

Duties of Managers and Officers Managers and officers must ensure that they comply fully with the guidance and limits specified by the Chief Finance Officer and that: (a)

all contracts (except as otherwise provided for in the Scheme of Delegation), leases, tenancy agreements and other commitments which may result in a liability are notified to the Chief Finance Officer in advance of any commitment being made;

(b)

contracts above specified thresholds are advertised and awarded in accordance with EU rules on public procurement;

(c)

where consultancy advice is being obtained, the procurement of such advice must be in accordance with guidance issued by the Department of Health;

(d)

no order shall be issued for any item or items to any firm which has made an offer of gifts, reward or benefit to directors or employees, other than: (i)

isolated gifts of a trivial character or inexpensive seasonal gifts, such as calendars;

(ii)

conventional hospitality, such as lunches in the course of working visits;

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Section C: Standing Financial Instructions (This provision needs to be read in conjunction with Standing Order No. 6 and the principles outlined in the national guidance contained in HSG 93(5) “Standards of Business Conduct for NHS Staff”) (the guidance contained within this document referring to the ‘Prevention of Corruption Acts 1889 - 1916’ has been superseded by the ‘Bribery Act 2010’); (e)

no requisition/order is placed for any item or items for which there is no budget provision unless authorised by the Chief Finance Officer on behalf of the Chief Executive;

(f)

all goods, services, or works are ordered on an official order except works and services executed in accordance with a contract and purchases from petty cash. Internet purchases are ordered by Procurement and recorded separately.

(g)

verbal orders must only be issued very exceptionally - by an employee designated by the Chief Executive and only in cases of emergency or urgent necessity. These must be confirmed by an official order and clearly marked "Confirmation Order";

(h)

orders are not split or otherwise placed in a manner devised so as to avoid the financial thresholds;

(i)

goods are not taken on trial or loan in circumstances that could commit the Trust to a future uncompetitive purchase;

(j)

changes to the list of employees and officers authorised to certify invoices are notified to the Chief Finance Officer;

(k)

purchases from petty cash are restricted in value and by type of purchase in accordance with instructions issued by the Chief Finance Officer;

(l)

petty cash records are maintained in a form as determined by the Chief Finance Officer.

19.5.1

The Chief Executive, Chief Finance Officer and Director of Information & Facilities shall ensure that the arrangements for financial control and financial audit of building and engineering contracts and property transactions comply with the relevant guidance contained. The technical audit of these contracts shall be the responsibility of the relevant Director.

19.6

Joint Finance Arrangements with Local Authorities and Voluntary Bodies (see overlap with Standing Order No. 9.1)

19.6.1

Payments to local authorities and voluntary organisations made under the powers of section 28A of the NHS Act shall comply with procedures laid down by the Chief Finance Officer which shall be in accordance with these Acts. (See overlap with Standing Order No. 9.1).

20.

TRUST COMMISSIONING OF HEALTHCARE SERVICES

20.1

Role of the Chief Executive

20.1.1

The Chief Executive as the Accountable Officer has responsibility for ensuring secondary services are commissioned in accordance with the priorities agreed in the Business Plan. This will involve ensuring Service Level Agreements (SLAs)/contracts are put in place with the relevant providers, based upon integrated care pathways.

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Section C: Standing Financial Instructions 20.1.2

SLAs/contracts are essential for different organisations to manage services provided between them. For healthcare they need to have a wide scope. The Chief Executive will need to ensure that all SLAs; •

Meet the standards of service quality expected;

•

Fit the relevant national service framework (if any);

•

Enable the provision of reliable information on cost and volume of services;

•

Fit the NHS Operating Framework (and other relevant guidance);

•

that SLAs build where appropriate on existing Joint Investment Plans;

•

that SLAs are based upon cost-effective services;

20.1.3

The Chief Executive, as the Accountable Officer, will need to ensure that regular reports are provided (including as necessary to the Board) detailing actual and forecast expenditure and activity for each SLA.

20.1.4

Where the Trust makes arrangements for the provision of services by non-NHS providers it is the Chief Executive, as the Accountable Officer, who is responsible for ensuring that the agreements put in place have due regard to the quality and cost-effectiveness of services provided. Before making any agreement with nonNHS providers, the Trust should explore fully the scope to make maximum costeffective use of NHS facilities.

20.2

Role of Chief Finance Officer

20.2.1

The Chief Finance Officer has responsibility for advising the Chief Executive on all contracting aspects and for maintaining a system of financial monitoring to ensure the effective accounting of expenditure under the SLA. This should provide a suitable audit trail for all payments made under the agreements, but maintains patient confidentiality.

21.

BLANK

22.

EXTERNAL BORROWING

22.1.1

The Chief Finance Officer will advise the Board concerning the Trust’s ability to pay dividend on, and repay Public Dividend Capital and any proposed new borrowing, within the limits set by the Department of Health. The Chief Finance Officer is also responsible for reporting periodically to the Board concerning the PDC debt and all loans and overdrafts.

22.1.2

The Board will agree the list of employees (including specimens of their signatures) who are authorised to make short term borrowings on behalf of the Trust. This must contain the Chief Executive and the Chief Finance Officer.

22.1.3

The Chief Finance Officer must prepare detailed procedural instructions concerning applications for loans and overdrafts.

22.1.4

All short-term borrowings should be kept to the minimum period of time possible, consistent with the overall cashflow position, represent good value for money, and comply with the latest guidance from the Department of Health.

22.1.5

Any short-term borrowing must be with the authority of two members of an authorised panel, one of which must be the Chief Executive or the Chief Finance

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Section C: Standing Financial Instructions Officer. The Board must be made aware of all short term borrowings at the next Board meeting. 22.1.6

All long-term borrowing must be consistent with the plans outlined in the current LTFM and be approved by the Trust Board.

22.2

INVESTMENTS

22.2.1

Temporary cash surpluses must be held only in such public or private sector investments as notified by the Secretary of State and authorised by the Board.

22.2.2

The Chief Finance Officer is responsible for advising the Board on investments and shall report periodically to the Board concerning the performance of investments held.

22.2.3

The Chief Finance Officer will prepare detailed procedural instructions on the operation of investment accounts and on the records to be maintained.

23.

BLANK

24.

CAPITAL INVESTMENT, PRIVATE FINANCING, FIXED ASSET REGISTERS AND SECURITY OF ASSETS

24.1

Capital Investment

24.1.1

The Chief Executive:

24.1.2

(a)

shall ensure that there is an adequate appraisal and approval process in place for determining capital expenditure priorities and the effect of each proposal upon business plans;

(b)

is responsible for the management of all stages of capital schemes and for ensuring that schemes are delivered on time and to cost;

(c)

shall ensure that the capital investment is not undertaken without confirmation of purchaser(s) support and the availability of resources to finance all revenue consequences, including capital charges.

For every capital expenditure proposal the Chief Executive shall ensure: (a)

that where expenditure is less than £250k that a Capital investment proforma is completed and for investment programmes above £250k a business case is produced (in line with TDA guidance) setting out:

(b) 24.1.3

(i)

an option appraisal of potential benefits compared with known costs to determine the option with the highest ratio of benefits to costs;

(ii)

the involvement of appropriate Trust personnel and external agencies;

(ii)

appropriate project management and control arrangements;

that the Chief Finance Officer has certified professionally to the costs and revenue consequences detailed in the business case.

For capital schemes where the contracts stipulate stage payments, the Chief Executive will issue procedures for their management, incorporating the recommendations of “Capital Project Management Procedure Manual”

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Section C: Standing Financial Instructions 24.1.4

The Chief Finance Officer shall assess on an annual basis the requirement for the operation of the construction industry tax deduction scheme in accordance with Inland Revenue guidance.

24.1.5

The Chief Finance Officer shall issue procedures for the regular reporting of expenditure and commitment against authorised expenditure.

24.1.6

The approval of a capital programme shall not constitute approval for expenditure on any scheme. The Chief Executive shall issue to the manager responsible for any scheme: (a)

specific authority to commit expenditure;

(b)

authority to proceed to tender ( see overlap with SFI No. 17.6);

(c)

approval to accept a successful tender (see overlap with SFI No. 17.6).

The Chief Executive will delegate capital investment management in accordance with "Capital Project Management Procedure Manual" guidance and the Trust’s Standing Orders to allow the above to operate effectively – this will be through the Executive Team, Finance and Workforce Committee, and the Capital Investment Group). 24.1.7

• • • •

Approval of capital projects and the purchase of capital items must be made within the budget and programme agreed by the Trust Board within the delegated limits below: Capital Investment group will approve upto £250k; , the Executive committeewill approve upto £1m; Finance and Workforce Committee and Trust Board to approve over £1m; Over £5m business cases also need approval by the TDA.

24.1.8

The Chief Finance Officer shall issue procedures governing the financial management, including variations to contract, of capital investment projects and valuation for accounting purposes. These procedures shall fully take into account the delegated limits for capital schemes issued by the Department of Health and the Trust Development Authority (describing organisational delegated limits).

24.2

Private Finance (see overlap with SFI No. 17.10)

24.2.1

The Trust should normally test for PFI when considering capital procurement. When the Trust proposes to use finance which is to be provided other than through its Allocations, the following procedures shall apply: (a)

The Chief Finance Officer shall demonstrate that the use of private finance represents value for money and genuinely transfers significant risk to the private sector.

(b)

Where the sum involved exceeds delegated limits, the business case must be referred to the Department of Health or in line with any current guidelines.

(c)

The proposal must be specifically agreed by the Board.

24.3

Asset Registers

24.3.1

The Chief Executive is responsible for the maintenance of registers of assets, taking account of the advice of the Chief Finance Officer concerning the form of any register and the method of updating, and arranging for a physical check of assets against the asset register to be conducted once a year.

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Section C: Standing Financial Instructions 24.3.2

The Trust shall maintain an asset register recording fixed assets. The minimum data set to be held within these registers shall be as guided by the Capital Accounting Manual.

24.3.3

Additions to the fixed asset register must be clearly identified to an appropriate budget holder and be validated by reference to: (a)

properly authorised and approved agreements, architect's certificates, supplier's invoices and other documentary evidence in respect of purchases from third parties;

(b)

stores, requisitions and wages records for own materials and labour including appropriate overheads;

(c)

lease agreements in respect of assets held under a finance lease and capitalised.

24.3.4

Where capital assets are sold, scrapped, lost or otherwise disposed of, their value must be removed from the accounting records and each disposal must be validated by reference to authorisation documents and invoices (where appropriate).

24.3.5

The Chief Finance Officer shall approve procedures for reconciling balances on fixed assets accounts in ledgers against balances on fixed asset registers.

24.3.6

The value of each asset shall be indexed to current values in accordance with methods specified in the Capital Accounting Manual.

24.3.7

The value of each asset shall be depreciated using methods and rates as specified in the Capital Accounting Manual.

24.3.8

The Chief Finance Officer of the Trust shall calculate and pay capital charges as specified in the Capital Accounting Manual.

24.4

Security of Assets

24.4.1

The overall control of fixed assets is the responsibility of the Chief Executive.

24.4.2

Asset control procedures (including fixed assets, cash, cheques and negotiable instruments, and also including donated assets) must be approved by the Chief Finance Officer. This procedure shall make provision for:

24.4.3

(a)

recording managerial responsibility for each asset;

(b)

identification of additions and disposals;

(c)

identification of all repairs and maintenance expenses;

(d)

physical security of assets;

(e)

periodic verification of the existence of, condition of, and title to, assets recorded;

(f)

identification and reporting of all costs associated with the retention of an asset;

(g)

reporting, recording and safekeeping of cash, cheques, and negotiable instruments.

All discrepancies revealed by verification of physical assets to fixed asset register shall be notified to the Chief Finance Officer.

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Section C: Standing Financial Instructions 24.4.4

Whilst each employee and officer has a responsibility for the security of property of the Trust, it is the responsibility of Board members and senior employees in all disciplines to apply such appropriate routine security practices in relation to NHS property as may be determined by the Board. Any breach of agreed security practices must be reported in accordance with agreed procedures.

24.4.5

Any damage to the Trustâ&#x20AC;&#x2122;s premises, vehicles and equipment, or any loss of equipment, stores or supplies must be reported by Board members and employees in accordance with the procedure for reporting losses.

24.4.6

Where practical, assets should be marked as Trust property.

25.

STORES AND RECEIPT OF GOODS

25.1

General position

25.1.1

Stores, defined in terms of controlled stores and departmental stores (for immediate use) should be: (a)

kept to a minimum;

(b)

subjected to annual stock take;

(c)

valued at the lower of cost and net realisable value.

25.2

Control of Stores, Stocktaking, condemnations and disposal

25.2.1

Subject to the responsibility of the Chief Finance Officer for the systems of control, overall responsibility for the control of stores shall be delegated to an employee by the Chief Executive. The day-to-day responsibility may be delegated by him to departmental employees and stores managers/keepers, subject to such delegation being entered in a record available to the Chief Finance Officer. The control of any Pharmaceutical stocks shall be the responsibility of a designated Pharmaceutical Officer; the control of any fuel oil and coal of a designated estates manager.

25.2.2

The responsibility for security arrangements and the custody of keys for any stores and locations shall be clearly defined in writing by the designated manager/Pharmaceutical Officer. Wherever practicable, stocks should be marked as health service property.

25.2.3

The Chief Finance Officer shall set out procedures and systems to regulate the stores including records for receipt of goods, issues, and returns to stores, and losses.

25.2.4

Stocktaking arrangements shall be agreed with the Chief Finance Officer and there shall be a physical check covering all items in store at least once a year.

25.2.5

Where a complete system of stores control is not justified, alternative arrangements shall require the approval of the Chief Finance Officer.

25.2.6

The designated Manager/Pharmaceutical Officer shall be responsible for a system approved by the Chief Finance Officer for a review of slow moving and obsolete items and for condemnation, disposal, and replacement of all unserviceable articles. The designated Officer shall report to the Chief Finance Officer any evidence of significant overstocking and of any negligence or malpractice (see also overlap with SFI No. 25 Disposals and Condemnations, Losses and Special Payments). Procedures for the disposal of obsolete stock shall follow the procedures set out for disposal of all surplus and obsolete goods.

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Section C: Standing Financial Instructions 25.3

Goods supplied by NHS Supply Chain

25.3.1

For goods supplied via the NHS Supply Chain central warehouses, the Chief Executive shall identify those authorised to requisition and accept goods from the store. The authorised person shall check receipt against the delivery note before forwarding this to the Chief Finance Officer who shall satisfy himself that the goods have been received before accepting the recharge.

26.

DISPOSALS AND CONDEMNATIONS, LOSSES AND SPECIAL PAYMENTS

26.1 ` 26.1.1

Disposals and Condemnations Procedures The Chief Finance Officer must prepare detailed procedures for the disposal of assets including condemnations, and ensure that these are notified to managers.

26.1.2

When it is decided to dispose of a Trust asset, the Head of Department or authorised deputy will determine and advise the Chief Finance Officer of the estimated market value of the item, taking account of professional advice where appropriate.

26.1.3

All unserviceable articles shall be: (a)

condemned or otherwise disposed of by an employee authorised for that purpose by the Chief Finance Officer;

(b)

recorded by the Condemning Officer in a form approved by the Chief Finance Officer which will indicate whether the articles are to be converted, destroyed or otherwise disposed of. All entries shall be confirmed by the countersignature of a second employee authorised for the purpose by the Chief Finance Officer.

26.1.4

The Condemning Officer shall satisfy himself as to whether or not there is evidence of negligence in use and shall report any such evidence to the Chief Finance Officer who will take the appropriate action.

26.2

Losses and Special Payments

26.2.1

Procedures The Chief Finance Officer must prepare procedural instructions on the recording of and accounting for condemnations, losses, and special payments.

26.2.2

Any employee or officer discovering or suspecting a loss of any kind must either immediately inform their head of department, who must immediately inform the Chief Executive and the Chief Finance Officer or inform an officer charged with responsibility for responding to concerns involving loss. This officer will then appropriately inform the Chief Finance Officer and/or Chief Executive. Where a criminal offence is suspected, the Chief Finance Officer must immediately inform the police and/or the LSMS, if theft or arson is involved. In cases of fraud and corruption or of anomalies which may indicate fraud or corruption, the Chief Finance Officer must inform the relevant LCFS and and/or the AAFS, in accordance with Secretary of State for Healthâ&#x20AC;&#x2122;s Directions. The Chief Finance Officer must notify NHS Protect, the Audit and Assurance Committee and the External Auditor of all frauds.

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Section C: Standing Financial Instructions 26.2.3

For losses apparently caused by theft, arson, neglect of duty or gross carelessness, except if trivial, the Chief Finance Officer must immediately notify: (a)

the Board,

(b)

the LSMS; and

(c)

the External Auditor.

The Chief Finance Officer will inform the Board of losses written off and special payments authorised by officers. 26.2.4

The Chief Finance Officer shall be authorised to take any necessary steps to safeguard the Trustâ&#x20AC;&#x2122;s interests in bankruptcies and company liquidations.

26.2.5

For any loss, the Chief Finance Officer should consider whether any insurance claim can be made.

25.2.6

The Chief Finance Officer shall maintain a Losses and Special Payments Register in which write-off action is recorded.

26.2.7

Any novel, contentious or repercussive cases should be referred to DH for approval. If any general losses emerge from a loss or special payment which would be of interest to others, then the Department of Health should be informed.

26.2.8

All losses and special payments must be reported to the Audit and Assurance Committee periodically..

27.

INFORMATION TECHNOLOGY

27.1

Responsibilities and duties of the Chief Finance Officer

27.1.1

The Chief Finance Officer, who is responsible for the accuracy and security of the computerised financial data of the Trust, shall:

27.1.2

(a)

devise and implement any necessary procedures to ensure adequate (reasonable) protection of the Trustâ&#x20AC;&#x2122;s data, programs and computer hardware for which the Director is responsible from accidental or intentional disclosure to unauthorised persons, deletion or modification, theft or damage, having due regard for the Data Protection Act 1998;

(b)

ensure that adequate (reasonable) controls exist over data entry, processing, storage, transmission and output to ensure security, privacy, accuracy, completeness, and timeliness of the data, as well as the efficient and effective operation of the system;

(c)

ensure that adequate controls exist such that the computer operation is separated from development, maintenance and amendment;

(d)

ensure that an adequate management (audit) trail exists through the computerised system and that such computer audit reviews as the Director may consider necessary are being carried out.

The Chief Finance Officer shall need to ensure that new financial systems and amendments to current financial systems are developed in a controlled manner and thoroughly tested prior to implementation. Where this is undertaken by another organisation, assurances of adequacy must be obtained from them prior to implementation.

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Section C: Standing Financial Instructions 27.2

Responsibilities and duties of other Directors and Officers in relation to computer systems of a general application

27.2.1

The Director responsible for Information Technology shall publish and maintain a Freedom of Information (FOI) Publication Scheme, or adopt a model Publication Scheme approved by the Information Commissioner. A Publication Scheme is a complete guide to the information routinely published by a public authority. It describes the classes or types of information about our Trust that we make publicly available.

27.2.2

In the case of computer systems which are proposed General Applications (i.e. normally those applications which the majority of Trustâ&#x20AC;&#x2122;s in the Region wish to sponsor jointly) all responsible directors and employees will send to the Chief Finance Officer:

27.3

(a)

details of the outline design of the system;

(b)

in the case of packages acquired either from a commercial organisation, from the NHS, or from another public sector organisation, the operational requirement.

Contracts for Computer Services with other health bodies or outside agencies The Chief Finance Officer shall ensure that contracts for computer services for financial applications with another health organisation or any other agency shall clearly define the responsibility of all parties for the security, privacy, accuracy, completeness, and timeliness of data during processing, transmission and storage. The contract should also ensure rights of access for audit purposes. Where another health organisation or any other agency provides a computer service for financial applications, the Chief Finance Officer shall periodically seek assurances that adequate controls are in operation.

27.4

Risk Assessment The Chief Finance Officer and the Director of Information and Facilities shall ensure that financial risks to the Trust arising from the use of IT are effectively identified and considered and appropriate action taken to mitigate or control risk..

27.5

Requirements for Computer Systems which have an impact on corporate financial systems Where computer systems have an impact on corporate financial systems the Chief Finance Officer shall need to be satisfied that: (a)

systems acquisition, development and maintenance are in line with corporate policies such as an Information Technology Strategy;

(b)

data produced for use with financial systems is adequate, accurate, complete and timely, and that a management (audit) trail exists;

(c)

Finance staff have access to such data;

(d)

such computer audit reviews as are considered necessary are being carried out.

28.

PATIENTS' PROPERTY

28.1

The Trust has a responsibility to provide safe custody for money and other personal property (hereafter referred to as "property") handed in by patients, in the

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Section C: Standing Financial Instructions possession of unconscious or confused patients, or found in the possession of patients dying in hospital or dead on arrival. 28.2

The Chief Executive is responsible for ensuring that patients or their guardians, as appropriate, are informed before or at admission by: -

notices and information booklets; (notices are subject to sensitivity guidance) hospital admission documentation and property records; the oral advice of administrative and nursing staff responsible for admissions,

that the Trust will not accept responsibility or liability for patients' property brought into Health Service premises, unless it is handed in for safe custody and a copy of an official patients' property record is obtained as a receipt. 28.3

The Chief Finance Officer must provide detailed written instructions on the collection, custody, investment, recording, safekeeping, and disposal of patients' property (including instructions on the disposal of the property of deceased patients and of patients transferred to other premises) for all staff whose duty is to administer, in any way, the property of patients. Due care should be exercised in the management of a patient's money in order to maximise the benefits to the patient.

28.4

Where Department of Health instructions require the opening of separate accounts for patients' moneys, these shall be opened and operated under arrangements agreed by the Chief Finance Officer.

28.5

In all cases where property of a deceased patient is of a total value in excess of £5,000 (or such other amount as may be prescribed by any amendment to the Administration of Estates, Small Payments, Act 1965), the production of Probate or Letters of Administration shall be required before any of the property is released. Where the total value of property is £5,000 or less, forms of indemnity shall be obtained.

28.6

Staff should be informed, on appointment, by the appropriate departmental or senior manager of their responsibilities and duties for the administration of the property of patients.

28.7

Where patients' property or income is received for specific purposes and held for safekeeping the property or income shall be used only for that purpose, unless any variation is approved by the donor or patient in writing.

29.

FUNDS HELD ON TRUST

29.1

Corporate Trustee

(1) Standing Order No. 2.8 outlines the Trust’s responsibilities as a corporate trustee for the management of funds it holds on trust, along with SFI 4.8.3 that defines the need for compliance with Charities Commission latest guidance and best practice. As corporate trustee of the Charitable funds, its responsibilities are governed by the law applicable to Trusts, principally the Trustee Act 2000 and the Charities Act2006.

(2) The discharge of the Trust’s corporate trustee responsibilities are distinct from its responsibilities for exchequer funds and may not necessarily be discharged in the same manner, but there must still be adherence to the overriding general principles of financial regularity, prudence and propriety. Trustee responsibilities cover both charitable and non-charitable purposes.

(3) The NHS Trust Board has devolved responsibility for the on-going management of charitable funds to the Charitable Funds Committee, which administers the

Page 84 of 187

Section C: Standing Financial Instructions funds on behalf of the Corporate Trustee. As such the Committee acts independently of the Board. Members of the Committee are not individual trustees under charity law but act as agents on behalf of the Corporate Trustee. The Chief Finance Officer shall ensure that each trust fund which the Trust is responsible for managing is managed appropriately with regard to its purpose and to its requirements. 29.2

Accountability to Charity Commission and Secretary of State for Health

(1) The trustee responsibilities must be discharged separately and full recognition given to the Trust’s dual accountabilities to the Charity Commission for charitable funds held on trust and to the Secretary of State for all funds held on trust.

(2) The Schedule of Matters Reserved to the Board and the Scheme of Delegation make clear where decisions regarding the exercise of discretion regarding the disposal and use of the funds are to be taken and by whom. All Trust Board members and Trust officers must take account of that guidance before taking action. 29.3

Applicability of Standing Financial Instructions to funds held on Trust (1) In so far as it is possible to do so, most of the sections of these Standing Financial Instructions will apply to the management of funds held on trust. (See overlap with SFI No 17.16). (2) The over-riding principle is that the integrity of each Trust must be maintained and statutory and Trust obligations met. Materiality must be assessed separately from Exchequer activities and funds.

30.

ACCEPTANCE OF GIFTS BY STAFF AND LINK TO STANDARDS OF BUSINESS CONDUCT (see overlap with SO No. 6 and SFI No. 21.2.6 (d)) The Chief Finance Officer shall ensure that all staff are made aware of the Trust Policy on the Standards of Business Conduct on the acceptance of gifts and other benefits in kind by staff. This Policy references the Bribery Act 2010 and the Counter Fraud and Bribery Policy and Response Plan and follows the guidance contained in the Department of Health circular HSG (93) 5 “Standards of Business Conduct for NHS Staff (the guidance contained within this document referring to the ‘Prevention of Corruption Acts 1889 - 1916’ has been superseded by the ‘Bribery Act 2010’). It is also deemed to be an integral part of these Standing Orders and Standing Financial Instructions (see overlap with SO No. 6). Staff should make themselves aware of, and comply with, the Bribery Act 2010, the Code of Conduct for NHS Managers 2002, and the ABPI ‘The Code of Practice for the Pharmaceutical Industry Second 2012 Edition’ relating to hospitality/gifts from pharmaceutical / external industry.

31.

Blank Blank

32.

RETENTION OF RECORDS

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Section C: Standing Financial Instructions 32.1

The Chief Executive shall be responsible for maintaining archives for all records required to be retained in accordance with Department of Health Records Management NHS Code of Practice Parts 1 and 2.

32.2

The records held in archives shall be capable of retrieval by authorised persons.

32.3

Records held in accordance with latest Department of Health guidance shall only be destroyed at the express instigation of the Chief Executive or delegated Information Asset Manager. Detail shall be maintained of records so destroyed.

33.

RISK MANAGEMENT AND INSURANCE

33.1

Programme of Risk Management The Chief Executive shall ensure that the Trust has a programme of risk management, in accordance with current Department of Health assurance framework requirements, which must be approved and monitored by the Board. The programme of risk management shall include: a)

a process for identifying and quantifying risks and potential liabilities;

engendering among all levels of staff a positive attitude towards the control of risk;

management processes to ensure all significant risks and potential liabilities are addressed including effective systems of internal control, cost effective insurance cover, and decisions on the acceptable level of retained risk;

contingency plans to offset the impact of adverse events;

audit arrangements including; Internal Audit, clinical audit, health and safety review;

a clear indication of which risks shall be insured;

arrangements to review the Risk Management programme.

The existence, integration and evaluation of the above elements will assist in providing a basis to make an Annual Governance Statement within the Annual Report and Accounts as required by current Department of Health guidance. 33.2

Insurance: Risk Pooling Schemes administered by NHSLA The Board shall decide if the Trust will insure through the risk pooling schemes administered by the NHS Litigation Authority or self insure for some or all of the risks covered by the risk pooling schemes. If the Board decides not to use the risk pooling schemes for any of the risk areas (clinical, property and employers/third party liability) covered by the scheme this decision shall be reviewed annually.

33.3

Insurance arrangements with commercial insurers

33.3.1

There is a general prohibition on entering into insurance arrangements with commercial insurers. There are, however, three exceptions when Trustâ&#x20AC;&#x2122;s may enter into insurance arrangements with commercial insurers. The exceptions are: (1) Trustâ&#x20AC;&#x2122;s may enter commercial arrangements for insuring motor vehicles owned by the Trust including insuring third party liability arising from their use;

Page 86 of 187

Section C: Standing Financial Instructions (2) where the Trust is involved with a consortium in a Private Finance Initiative contract and the other consortium members require that commercial insurance arrangements are entered into; and (3) where income generation activities take place. Income generation activities should normally be insured against all risks using commercial insurance. If the income generation activity is also an activity normally carried out by the Trust for a NHS purpose the activity may be covered in the risk pool. Confirmation of coverage in the risk pool must be obtained from the Litigation Authority. In any case of doubt concerning a Trustâ&#x20AC;&#x2122;s powers to enter into commercial insurance arrangements the Finance Director should consult the Department of Health. 33.4

Arrangements to be followed by the Board in agreeing Insurance cover

(1) Where the Board decides to use the risk pooling schemes administered by the NHS Litigation Authority the Chief Finance Officer shall ensure that the arrangements entered into are appropriate and complementary to the risk management programme. The Chief Finance Officer shall ensure that documented procedures cover these arrangements.

(2) Where the Board decides not to use the risk pooling schemes administered by the NHS Litigation Authority for one or other of the risks covered by the schemes, the Chief Finance Officer shall ensure that the Board is informed of the nature and extent of the risks that are self insured as a result of this decision. The Chief Finance Officer will draw up formal documented procedures for the management of any claims arising from third parties and payments in respect of losses which will not be reimbursed.

(3) All the risk pooling schemes require Scheme members to make some contribution to the settlement of claims (the â&#x20AC;&#x2DC;deductibleâ&#x20AC;&#x2122;). The Chief Finance Officer should ensure documented procedures also cover the management of claims and payments below the deductible in each case.

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Section D

Scheme of Reservation and Delegation Corporate Governance Manual 2013/14 onwards

Comments and enquiries concerning the manual may be sent to: The Trust Board Administrator Trust Headquarters Maple House East Surrey Hospital Canada Avenue REDHILL Surrey RH1 5RH Tel: Fax:

01737 768511 Ext 1817 01737 231771

The manual is also available on the Trust internet site www.surreyandsussex.nhs.uk

Page 88 of 187

Page

Contents SECTION D

Scheme of Reservation and Delegation (i)

Reservation of Matters to the Board

90 90 90 90 90 91 91 91 91

General Enabling Provision Regulations and Control Appointments/Dismissal Strategy Plans and Budgets Policy Determination Audit Annual Reports and Accounts Monitoring (ii)

Decisions/Duties Delegated by the Board to Committees: Audit and Assurance Committee Remuneration Committee Safety and Quality Committee Charitable Funds Committee Finance and Workforce Committee

92 92 92 92 93

(iii)

Scheme of Delegation Derived from The Accountable Officer Memorandum

(iv)

Scheme of Delegation Derived from the Codes of Conduct and Accountability

(v)

Scheme of Delegation (Standing Orders) â&#x20AC;&#x201C; specific duties delegated

(vi)

Scheme of Delegation (Standing Financial Instructions) â&#x20AC;&#x201C; specific duties delegated Appendices: Schedules

Board Committee Terms of Reference Delegated financial limits

107 186

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Section D: Scheme of Reservation and Delegation SECTION D - SCHEME OF RESERVATION AND DELEGATION REF

THE BOARD THE BOARD

RESERVATION OF MATTERS RESERVED TO THE BOARD General Enabling Provision The Board may determine any matter, for which it has delegated or statutory authority, it wishes in full session within its statutory powers.

THE BOARD

Regulations and Control 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.

THE BOARD

Appointments/ Dismissal 1. 2. 3. 4. 5. 6.

THE BOARD

Approve Standing Orders (SOs), a schedule of matters reserved to the Board and Standing Financial Instructions for the regulation of its proceedings and business. Suspend Standing Orders. Vary or amend the Standing Orders. Ratify any urgent decisions taken by the Chairman and Chief Executive in public session in accordance with SO 5.2 Approve a scheme of delegation of powers from the Board to committees. Require and receive the declaration of Board members’ interests that may conflict with those of the Trust and determining the extent to which that member may remain involved with the matter under consideration. Require and receive the declaration of officers’ interests that may conflict with those of the Trust. Approve arrangements for dealing with complaints. Adopt the organisation structures, processes and procedures to facilitate the discharge of business by the Trust and to agree modifications thereto. Receive reports from committees including those that the Trust is required by the Secretary of State or other regulation to establish and to take appropriate action on. Confirm the recommendations of the Trust’s committees where the committees do not have executive powers. Approve arrangements relating to the discharge of the Trust’s responsibilities as a corporate trustee for funds held on trust. Establish terms of reference and reporting arrangements of all committees and subcommittees that are established by the Board. Approve arrangements relating to the discharge of the Trust’s responsibilities as a bailer for patients’ property. Authorise use of the seal. Ratify or otherwise instances of failure to comply with Standing Orders brought to the Chief Executive’s attention in accordance with SO 5.6. Discipline members of the Board or employees who are in breach of statutory requirements or SOs.

Appoint the Vice Chairman of the Board. Appoint and dismiss committees (and individual members) that are directly accountable to the Board. Appoint, appraise, discipline and dismiss Executive Directors (subject to SO 2.2). Confirm appointment of members of any committee of the Trust as representatives on outside bodies. Appoint, appraise, discipline and dismiss the Secretary (if the appointment of a Secretary is required under Standing Orders). Approve proposals of the Remuneration Committee regarding directors and senior employees and those of the Chief Executive for staff not covered by the Remuneration Committee.

Strategy, Plans and Budgets 1. 2. 3. 4. 5. 6. 7. 8.

Define the strategic aims and objectives of the Trust. Approve proposals for ensuring quality and developing clinical governance in services provided by the Trust, having regard to any guidance issued by the Secretary of State. Approve the Trust’s policies and procedures for the management of risk. Approve Outline and Final Business Cases for Capital Investment. Approve budgets. Approve annually Trust’s proposed organisational development proposals. Ratify proposals for acquisition, disposal or change of use of land and/or buildings. Approve PFI proposals.

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Section D: Scheme of Reservation and Delegation REF

THE BOARD

RESERVATION OF MATTERS RESERVED TO THE BOARD 9. Approve the opening of bank accounts. 10. Approve proposals on individual contracts (other than NHS contracts) of a capital or revenue nature amounting to, or likely to amount to over ÂŁ100,000 over a 3 year period or the period of the contract if longer. 11. Approve proposals in individual cases for the write off of losses or making of special payments above the limits of delegation to the Chief Executive and Chief Finance Officer (for losses and special payments) previously approved by the Board. 12. Approve individual compensation payments. 13. Approve proposals for action on litigation against or on behalf of the Trust. 14. Review use of NHSLA risk pooling schemes (LPST/CNST/RPST).

THE BOARD

Policy Determination 1. 2.

THE BOARD

Audit 1.

THE BOARD

Approve the appointment (and where necessary dismissal) of External Auditors and advise the Audit Commission on the appointment. Approval of external auditorsâ&#x20AC;&#x2122; arrangements for the separate audit of funds held on trust, and the submission of reports to the Audit and Assurance Committee meetings who will take appropriate action. Receive of the annual management letter received from the

external auditor and agreement of proposed action, taking account of the advice, where appropriate, of the Audit and Assurance Committee.

Receive an annual report from the Internal Auditor and agree action on recommendations where appropriate of the Audit and Assurance Committee.

Annual Reports and Accounts 1. 2.

THE BOARD

Approve management policies including personnel policies incorporating the arrangements for the appointment, removal and remuneration of staff. Policies so adopted shall be listed and appended to this document [by the Secretary]

Receipt and approval of the Trust's Annual Report and Annual Accounts. Receipt and approval of the Annual Report and Accounts for funds held on trust.

Monitoring 1. 2.

3. 4.

Receive of such reports as the Board sees fit from committees in respect of their exercise of powers delegated. Continuous appraisal of the affairs of the Trust by means of the provision to the Board as the Board may require from directors, committees, and officers of the Trust as set out in management policy statements. All monitoring returns required by the Department of Health and the Charity Commission shall be reported, at least in summary, to the Board. Receive reports from Chief Finance Officer on financial performance against budget and Local Delivery Plan. Receive reports from CE on actual and forecast income from SLA.

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Section D: Scheme of Reservation and Delegation DECISIONS/DUTIES DELEGATED BY THE BOARD TO COMMITTEES REF

COMMITTEE

SO 4.8

AUDIT AND ASSURANCE COMMITTEE

The Committee will: 1. Advise the Board on internal and external audit services; 2. The Committee shall review t h e establishment a n d maintenance o f an e f f e c t i v e system o f integrated governance, risk management and internal control, across the whole of the organisation’s activities (both clinical and non-clinical), that supports the achievement of the organisation’s objectives; 3. Monitor compliance with Standing Orders and Standing Financial Instructions; 4. Review schedules of losses and compensations and making recommendations to the Board. 5. Review the annual financial statements prior to submission to the Board. 6. Review the adequacy and assurances behind risk and control declarations, including the Board Assurance Framework (BAF) 7. investigate any activity within its terms of reference and seek any information it requires from any employee. 8. Obtain outside legal or other independent professional advice and to secure the attendance of persons external to the Trust with relevant experience and expertise if it considers this necessary.

REMUNERATION COMMITTEE

The Committee will: 1. Investigate any activity within its terms of reference. 2. Advise the Board about appropriate remuneration and terms of service for the Chief Executive, other Executive Directors and other senior employees including: i All aspects of salary (including any performance-related elements/bonuses); ii Provisions for other benefits, including pensions and cars; iii Arrangements for termination of employment and other contractual terms; iv Make recommendations to the Board on the remuneration and terms of service of executive directors and senior employees to ensure they are fairly rewarded for their individual contribution to the Trust - having proper regard to the Trust's circumstances and performance and to the provisions of any national arrangements for such staff; v Proper calculation and scrutiny of termination payments taking account of such national guidance as is appropriate advise on and oversee appropriate contractual arrangements for such staff; 3. The Committee shall report in writing to the Board the basis for its recommendations.

SAFETY AND QUALITY COMMITTEE

The Committee will: 1. oversee the on-going development and delivery of the Trust’s Safety and Quality Strategy; 2. ensure the Trust has appropriate arrangements in place to deliver the highest standards of quality governance, including clear roles and accountabilities; 3. advise of potential and actual risks to safety and quality (as described in more detail in the committee’s terms of reference); 4. promote a safety and quality focused culture throughout the Trust;; 5. ensure the provision of appropriate safety and quality information; 6. advise on all aspects of safety and quality and providing assurance that Trust policies reflect latest guidance and legislation; 7. ensure that there are clearly defined, well understood processes for escalating safety and quality issues and managing performance; 8. require all investigations into Serious Untoward Incidents (SUIs) to be conducted in an effective and timely manner and that their recommendations are acted upon; 9. review the safety and quality impact of efficiency and other transformation programmes ; 10. ensure that all recommendations of relevant national groups (like NICE) are considered and, if appropriate, implemented and that the Trust acts upon all relevant national safety alerts; 11. receive information on trends and themes from clinical negligence claims, incident reporting and complaints; 12. review the Trust’s compliance with the Care Quality Commission’s registration standards; 13. at the time of its application for NHS foundation trust status to Monitor, advising the Board whether it should sign the self-certification on quality governance and sign-off

SFI 11.1.1

SO 4.8 SFI 18.6.1

SO 4.8

DECISIONS/DUTIES DELEGATED BY THE BOARD TO COMMITTEES

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Section D: Scheme of Reservation and Delegation REF

COMMITTEE

DECISIONS/DUTIES DELEGATED BY THE BOARD TO COMMITTEES the Quality Account; 14. assuring that effective action plans are developed and implemented following reviews or investigations into safety and quality by healthcare regulators, inspectorates or accrediting bodies; 15. receive assurance that the Trust is participating in all relevant clinical audits and demonstrating that recommendations are being implemented; 16. review the Trust’s compliance with the attainment requirements for Information Governance including the Information Governance toolkit and data protection compliance; 17. review the Trust’s participation in clinical research; 18. receive assurance from the Clinical Chiefs of Divisions that the CQUIN quality and safety improvement initiatives relevant to their Divisions are being delivered as set out in the Trust’s contract with its commissioners.

SO 4.8

CHARITABLE FUNDS COMMITTEE

The Committee will: 1. Be autonomous and act independently of the Trust Board but shall report to it for information (please see constitution). 2. Delegate authority to give permission: i to spend above £2,000 to the Chief Finance Officer and the Chair of the Committee; ii to establish new funds to the Chief Finance Officer subject to published procedures;. iii to perform day to day management and administrative functions, including changes to Fund Managers to the Head of Financial Accounts subject to published procedures 3. Oversee the management, investment and disbursement of charitable funds within the regulations provided by the Charities Commission and to ensure compliance with the laws governing charitable funds and according to the committee’s terms of reference. 4. Act on behalf of the trust in satisfying the duties and responsibilities of trustees in managing the funds 5. Review legacies received and ensure that the Trust complies with the terms of the legacy. 6. establish an investment strategy and monitor the performance of investments. 7. agree the annual return and the annual accounts in line with the requirements of the Charities Commission and the laws governing charitable funds

SO 4.8

FINANCE AND W ORKFORCE COMMITTEE

The Committee will: 1. Investigate any activity within its terms of reference and seek any information it requires from any employee of the Trust in order to perform its duties; 2. appoint external professional advisors, and commission or purchase any relevant reports, surveys or information which it deems necessary to fulfil its duties, within budgetary limits described in the SOFIs. 3. provide oversight of the Trust’s business planning and recommend to the Board the sign off of the integrated business plan and annual operating plans. 4. approve: i All relevant supporting strategies and policies, with the exception of the Clinical Strategy (which is signed off by the Board) – see below for workforce ii The business planning timetable 5. provide oversight of the Board’s financial policies, management and reporting and will approve: i the financial policies of the Trust annually and make appropriate recommendations to the Board of Directors; ii the Trust’s medium and long-term financial strategy, in relation to both revenue and capital, including overseeing the development of financial plans for the Trust’s foundation trust application; iii the Trust’s annual financial targets; and iv the preparation of the annual budget prior to its submission to the Board of Directors. 6. provide oversight of the Board’s workforce strategy, plans, management and will approve: i the workforce strategy and relevant supporting policies that are relevant to the Committee (the Executive Committee will sign off most supporting policies) ii the organisational development strategy iii as part of the Trust’s annual financial budget, the preparation of its

Page 93 of 187

Section D: Scheme of Reservation and Delegation REF

COMMITTEE

DECISIONS/DUTIES DELEGATED BY THE BOARD TO COMMITTEES establishment prior to the budget’s submission to the Board of Directors. approve and review the Trust’s investment strategy and policy and maintain oversight of the Trust’s investments, ensuring compliance with the policy. The Committee shall: i establish the overall methodology, processes and controls which govern investments; ii ensure that robust processes are followed; and iii evaluate, scrutinise and monitor investments; iv approve and review the Trust’s treasury management and working capital policy annually or as required; 8. approve proposals for major business cases with a capital value of over £1m or which require a revenue budget virement of over £1m. The Committee shall monitor the work of the Capital Group, which reports to the Executive Committee, for lower value investments (for the avoidance of doubt, the Committee can authorise spend with the same limits as the Board); 9. approve the initiation of projects greater than £1m on the information provided in the Project Initiation Document and Project Plan and other key project documents; 10. monitor implementation of major projects (>£2.0m). 7.

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Section D: Scheme of Reservation and Delegation SCHEME OF DELEGATION DERIVED FROM THE ACCOUNTABLE OFFICER MEMORANDUM REF

DELEGATED TO

CHIEF EXECUTIVE (CE)

CE AND CFO (CHIEF FINANCE OFFICER)

CHIEF EXECUTIVE

Sign a statement in the accounts outlining responsibilities as the Accountable Officer. Sign a statement in the accounts outlining responsibilities in respect of Internal Control.

12 & 13

CHIEF EXECUTIVE

Ensure effective management systems that safeguard public funds and assist the Trust Chairman to implement requirements of corporate governance including ensuring managers:

DUTIES DELEGATED Accountable through NHS Accounting Officer to Parliament for stewardship of Trust resources. Ensure the accounts of the Trust are prepared under principles and in a format directed by the SofS. Accounts must disclose a true and fair view of the Trust’s income and expenditure and its state of affairs. Sign the accounts on behalf of the Board.

• • • 12

CHAIRMAN

CHIEF EXECUTIVE

“have a clear view of their objectives and the means to assess achievements in relation to those objectives be assigned well defined responsibilities for making best use of resources have the information, training and access to the expert advice they need to exercise their responsibilities effectively.”

Implement requirements of corporate governance. Achieve value for money from the resources available to the Trust and avoid waste and extravagance in the organisation's activities. Follow through the implementation of any recommendations affecting good practice as set out on reports from such bodies as the Audit Commission and the National Audit Office (NAO).

CHIEF FINANCE OFFICER

Operational responsibility for effective and sound financial management and information.

CHIEF EXECUTIVE

Primary duty to see that Chief Finance Officer discharges this function.

CHIEF EXECUTIVE

Ensuring that expenditure by the Trust complies with Parliamentary requirements.

CE and Chief Finance Officer

Chief Executive, supported by Chief Finance Officer, to ensure appropriate advice is given to the Board on all matters of probity, regularity, prudent and economical administration, efficiency and effectiveness.

CHIEF EXECUTIVE

If CE considers the Board or Chairman is doing something that might infringe probity or regularity, he should set this out in writing to the Chairman and the Board. If the matter is unresolved, he/she should ask the Audit and Assurance Committee to inquire and if necessary the Trust Development Authority and Department of Health.

CHIEF EXECUTIVE

If the Board is contemplating a course of action that raises an issue not of formal propriety or regularity but affects the CE’s responsibility for value for money, the CE should draw the relevant factors to the attention of the Board. If the outcome is that you are overruled it is normally sufficient to ensure that your advice and the overruling of it are clearly apparent from the papers. Exceptionally, the CE should inform the Trust Development Authority and the DH. In such cases, and in those described in paragraph 24, the CE should as a member of the Board vote against the course of action rather than merely abstain from voting.

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Section D: Scheme of Reservation and Delegation SCHEME OF DELEGATION DERIVED FROM THE CODES OF CONDUCT AND ACCOUNTABILITY

REF

DELEGATED TO

AUTHORITIES/DUTIES DELEGATED

1.3.1.7

BOARD

Approve procedure for declaration of hospitality and sponsorship.

1.3.1.8

BOARD

Ensure proper and widely publicised procedures for voicing complaints, concerns about misadministration, breaches of Code of Conduct, and other ethical concerns.

1.31.9 & 1.3.2.2

ALL BOARD

1.3.2.4

BOARD

1.3.2.4

CHAIR AND NON EXECUTIVE /

Subscribe to Code of Conduct.

MEMBERS

OFFICER MEMBERS

Board members share corporate responsibility for all decisions of the Board. Chair and non-executive officer members are responsible for monitoring the executive management of the organisation and are responsible to the SofS for the discharge of those responsibilities.

1.3.2.4

BOARD

The Board has six key functions for which it is held accountable by the Department of Health on behalf of the Secretary of State: 1. To ensure effective financial stewardship through value for money, financial control an financial planning and strategy; 2. To ensure that high standards of corporate governance and personal behaviour are maintained in the conduct of the business of the whole organisation; 3. to appoint, appraise and remunerate senior executives; 4. to ratify the strategic direction of the organisation within the overall policies and priorities of the Government and the NHS, define its annual and longer term objectives and agree plans to achieve them; 5. to oversee the delivery of planned results by monitoring performance against objectives and ensuring corrective action is taken when necessary; 6. to ensure effective dialogue between the organisation and the local community on its plans and performance and that these are responsive to the community's needs.

1.3.24

BOARD

It is the Boardâ&#x20AC;&#x2122;s duty to: 1. act within statutory financial and other constraints; 2. be clear what decisions and information are appropriate to the Board and draw up Standing Orders, a schedule of decisions reserved to the Board and Standing Financial Instructions to reflect these, 3. ensure that management arrangements are in place to enable responsibility to be clearly delegated to senior executives for the main programmes of action and for performance against programmes to be monitored and senior executives held to account; 4. establish performance and quality measures that maintain the effective use of resources and provide value for money; 5. specify its requirements in organising and presenting financial and other information succinctly and efficiently to ensure the Board can fully undertake its responsibilities; 6. establish Audit and Remuneration Committees on the basis of formally agreed terms of reference that set out the membership of the sub-committee, the limit to their powers, and the arrangements for reporting back to the main Board.

1.3.2.5

CHAIRMAN

It is the Chairman's role to: 1. provide leadership to the Board; 2. enable all Board members to make a full contribution to the Board's affairs and ensure that the Board acts as a team; 3. ensure that key and appropriate issues are discussed by the Board in a timely manner, 4. ensure the Board has adequate support and is provided efficiently with all the necessary data on which to base informed decisions; 5. lead Non-Executive Board members through a formally-appointed Remuneration Committee of the main Board on the appointment, appraisal and remuneration of the Chief Executive and (with the latter) other Executive Board members; 6. appoint Non-Executive Board members to an Audit and Assurance Committee of the main Board; 7. advise the Secretary of State on the performance of Non-Executive Board members.

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Section D: Scheme of Reservation and Delegation REF

DELEGATED TO

AUTHORITIES/DUTIES DELEGATED

1.3.2.5

CHIEF EXECUTIVE

The Chief Executive is accountable to the Chairman and Non-Executive members of the Board for ensuring that its decisions are implemented, that the organisation works effectively, in accordance with Government policy and public service values and for the maintenance of proper financial stewardship. The Chief Executive should be allowed full scope, within clearly defined delegated powers, for action in fulfilling the decisions of the Board. The other duties of the Chief Executive as Accountable Officer are laid out in the Accountable Officer Memorandum.

1.3.2.6

NON-EXECUTIVE DIRECTORS

Non-Executive Directors are appointed by Appointments Commission to bring independent judgement to bear on issues of strategy, performance, key appointments and accountability through the Department of Health to Ministers and to the local community.

1.3.2.8

CHAIR AND DIRECTORS

1.3.2.9

BOARD

Declaration of conflict of interests. NHS Boards must comply with legislation and guidance issued by the Department of Health on behalf of the Secretary of State, respect agreements entered into by themselves or in on their behalf and establish terms and conditions of service that are fair to the staff and represent good value for taxpayers' money.

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Section D: Scheme of Reservation and Delegation SCHEME OF DELEGATION

SO REF

DELEGATE D TO

AUTHORITIES/DUTIES DELEGATED

1.1

CHAIRMAN

2.4

BOARD

3.1

CHAIRMAN

Call meetings.

3.9

CHAIRMAN

Chair all Board meetings and associated responsibilities.

3.10

CHAIRMAN

Give final ruling in questions of order, relevancy and regularity of meetings.

3.12

CHAIRMAN

Having a second or casting vote

3.13

BOARD

Suspension of Standing Orders

3.13

AUDIT AND ASSURANCE COMMITTEE

3.14

BOARD

Variation or amendment of Standing Orders

4.1

BOARD

Formal delegation of powers to sub committees or joint committees and approval of their constitution and terms of reference. (Constitution and terms of reference of sub committees may be approved by the Chief Executive.)

5.2

CHAIRMAN & CHIEF EXECUTIVE

The powers which the Board has retained to itself within these Standing Orders may in emergency be exercised by the Chair and Chief Executive after having consulted at least two Non-Executive members.

5.4

CHIEF EXECUTIVE

The Chief Executive shall prepare a Scheme of Delegation identifying his/her proposals that shall be considered and approved by the Board, subject to any amendment agreed during the discussion.

5.6

ALL

7.1

THE BOARD

Declare relevant and material interests.

7.2

CHIEF EXECUTIVE

Maintain Register(s) of Interests.

7.4

ALL STAFF

Comply with national guidance contained in HSG 1993/5 “Standards of Business Conduct for NHS Staff”.

7.4

ALL

Disclose relationship between self and candidate for staff appointment. (CE to report the disclosure to the Board.)

8.1/8.3

CHIEF EXECUTIVE

Keep seal in safe place and maintain a register of sealing.

8.4

CHIEF EXECUTIVE/

Approve and sign all documents which will be necessary in legal proceedings.

Final authority in interpretation of Standing Orders (SOs). Appointment of Vice Chairman

Audit and Assurance Committee to review every decision to suspend Standing Orders (power to suspend Standing Orders is reserved to the Board)

Disclosure of non-compliance with Standing Orders to the Chief Executive as soon as possible.

EXECUTIVE DIRECTOR * Nominated officers and the areas for which they are responsible should be incorporated into the Trust’s Scheme of Delegation document.

Page 98 of 187

Section D: Scheme of Reservation and Delegation SCHEME OF DELEGATION SFI REF

DELEGATED TO

AUTHORITIES/DUTIES DELEGATED

10.1.3

CHIEF FINANCE OFFICER

Approval of all financial procedures.

10.1.4

CHIEF FINANCE OFFICER

Advice on interpretation or application of SFIs.

10.1.6

ALL MEMBERS OF THE BOARD AND

10.2.4

CHIEF EXECUTIVE

Responsible as the Accountable Officer to ensure financial targets and obligations are met and have overall responsibility for the System of Internal Control.

10.2.4

CHIEF EXECUTIVE & CHIEF FINANCE OFFICER

Accountable for financial control but will, as far as possible, delegate their detailed responsibilities.

10.2.5

CHIEF EXECUTIVE

To ensure all Board members, officers and employees, present and future, are notified of and understand Standing Financial Instructions.

10.2.6

CHIEF FINANCE OFFICER

Responsible for: a) Implementing the Trust's financial policies and coordinating corrective action; b) Maintaining an effective system of financial control including ensuring detailed financial procedures and systems are prepared and documented; c) Ensuring that sufficient records are maintained to explain Trustâ&#x20AC;&#x2122;s transactions and financial position; d) Providing financial advice to members of Board and staff; e) Maintaining such accounts, certificates etc. as are required for the Trust to carry out its statutory duties.

10.2.7

ALL MEMBERS OF THE BOARD AND

Responsible for security of the Trust's property, avoiding loss, exercising economy and efficiency in using resources and conforming to Standing Orders, Financial Instructions and financial procedures.

Have a duty to disclose any non-compliance with these Standing Financial Instructions to the Director of Performance and Finance as soon as possible.

EMPLOYEES

10.2.8

CHIEF EXECUTIVE

Ensure that any contractor or employees of a contractor who is empowered by the Trust to commit the Trust to expenditure or who is authorised to obtain income are made aware of these instructions and their requirement to comply.

11.1.1

AUDIT AND ASSURANCE COMMITTEE

11.1.2

CHAIR

11.1.3 & 11.2.1

CHIEF FINANCE OFFICER

11.2.1

CHIEF FINANCE OFFICER

Decide at what stage to involve police and the LSMS in cases of misappropriation and other irregularities not involving fraud or corruption.

11.3

HEAD OF INTERNAL AUDIT

Review, appraise and report in accordance with NHS Internal Audit Manual and best practice.

11.4

AUDIT AND ASSURANCE COMMITTEE

11.5

CHIEF EXECUTIVE & CHIEF FINANCE OFFICER

Monitor and ensure compliance with SofS Directions on fraud and corruption including the appointment of the Local Counter Fraud Specialist.

11.6

CHIEF EXECUTIVE

Monitor and ensure compliance with Directions issued by the Secretary of State for Health on NHS security management including appointment of the Local Security Management Specialist.

Provide independent and objective view on internal control and probity.

Raise the matter at the Board meeting where Audit and Assurance Committee considers there is evidence of ultra vires transactions or improper acts. Ensure an adequate internal audit service, for which he/she is accountable, is provided (and involve the Audit and Assurance Committee in the selection process when/if an internal audit service provider is changed.)

Ensure cost-effective External Audit.

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Section D: Scheme of Reservation and Delegation SFI REF

DELEGATED TO

AUTHORITIES/DUTIES DELEGATED

12.1

CHIEF FINANCE OFFICER

Preparation of annual accounts and reports.

13.1

CHIEF FINANCE OFFICER

Managing banking arrangements, including provision of banking services, operation of accounts, preparation of instructions and list of cheque signatories. (Board approves arrangements.)

14.

CHIEF FINANCE OFFICER

Income systems, including system design, prompt banking, review and approval of fees and charges, debt recovery arrangements, design and control of receipts, provision of adequate facilities and systems for employees whose duties include collecting or holding cash.

14.2.3

ALL EMPLOYEES

Duty to inform Chief Finance Officer of money due from transactions which they initiate/deal with.

15.3.1

CHIEF EXECUTIVE

Must ensure the Trust enters into suitable Contract with service commissioners for the provision of NHS services The CE, as the Accountable Officer, must ensure that regular reports are provided to the Board detailing actual and forecast income from the Contract. The Chief Finance Officer has responsibility for providing those reports

15.4.1

CHIEF EXECUTIVE & CHIEF FINANCE OFFICER

15.4.2

CHIEF FINANCE OFFICER

15.5.1

EMPLOYEES MAKING HEALTHCARE DECISIONS

Duty not to commit Trust resources for work/procedures that are not covered or restricted by Commissioners contracts

16.1.1

CHIEF EXECUTIVE

Compile and submit to the Board a Business Plan which takes into account financial targets and forecast limits of available resources. The Plan will contain: • a statement of the significant assumptions on which the plan is based; • details of major changes in workload, delivery of services or resources required to achieve the plan.

16.1.2 & 16.1.3

CHIEF FINANCE OFFICER

Submit budgets to the Board for approval. Monitor performance against budget; submit to the Board financial estimates and forecasts.

16.2

CHIEF FINANCE OFFICER

Specifying the criteria allowing an individual to be a budget holder and control of that permission;

Devise and maintain systems of contractual control (for Commissioners contracts)

Ensure adequate training is delivered on an on-going basis to budget holders. 16.3.1

CHIEF EXECUTIVE

Delegate budget to budget holders.

16.3.2

CHIEF EXECUTIVE & BUDGET HOLDERS

16.3.5

CHIEF EXECUTIVE

Approval of annual revenue budget increase (above the budgets approved by the Board at the start of the year) below £1.0M.

16.3.5

THE BOARD

Approval of annual revenue budget increase (above the budgets approved by the Board at the start of the year) above £1.0M

16.4.1

CHIEF FINANCE OFFICER

16.4.2

BUDGET HOLDERS

Must not exceed the budgetary total or virement limits set by the Board.

Devise and maintain systems of budgetary control. Ensure that a) no overspending or reduction of income which cannot be met by virement within the budgetary total is incurred without the prior consent of the Chief Executive; b) action plans are provided to correct any overspending/under-collection of income in their budgets; c) the amount provided in the approved budget is not used in whole or in part for any purpose other than that specifically authorised subject to the rules of virement; d) any income included within their budget is subject to a formal written contractual agreement;

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Section D: Scheme of Reservation and Delegation SFI REF

DELEGATED TO

AUTHORITIES/DUTIES DELEGATED e) f)

no permanent employees are appointed without the approval of the Chief Executive other than those provided for within the available resources and manpower establishment as approved by the Board. Financial savings agreed in budgets at the start of the year are delivered and that any overspending elsewhere in the budget that reduces those savings is compensated by additional savings, virement or permission to overspend.

16.4.3

CHIEF EXECUTIVE

Identify and implement cost improvements and income generation activities in line with the LTFM.

16.6.1

CHIEF EXECUTIVE

Submit monitoring returns

17.

CHIEF EXECUTIVE

Tendering and contract procedure.

17.5.3

CHIEF EXECUTIVE

Waive formal tendering procedures.

17.5.3

CHIEF EXECUTIVE

Report waivers of tendering procedures to the Board.

17.5.5

CHIEF FINANCE OFFICER

17.6.2

CHIEF EXECUTIVE

Responsible for the receipt, endorsement and safe custody of tenders received.

17.6.3

CHIEF EXECUTIVE

Shall maintain a register to show each set of competitive tender invitations despatched.

17.6.4

CHIEF EXECUTIVE AND CHIEF FINANCE OFFICER

17.6.6

CHIEF EXECUTIVE

17.6.8

CHIEF EXECUTIVE

Will appoint a manager to maintain a list of approved firms.

17.6.9

CHIEF EXECUTIVE

Shall ensure that appropriate checks are carried out as to the technical and financial capability of those firms that are invited to tender or quote.

17.7.2

CHIEF EXECUTIVE

The Chief Executive or his nominated officer should evaluate the quotation and select the quote which gives the best value for money.

17.7.4

CHIEF EXECUTIVE or CHIEF FINANCE OFFICER

17.10

CHIEF EXECUTIVE

17.10

BOARD

17.11

CHIEF EXECUTIVE

The Chief Executive shall nominate an officer who shall oversee and manage each contract on behalf of the Trust.

17.12

CHIEF EXECUTIVE

The Chief Executive shall nominate officers with delegated authority to enter into contracts of employment, regarding staff, agency staff or temporary staff service contracts.

17.15

CHIEF EXECUTIVE

The Chief Executive shall be responsible for ensuring that best value for money can be demonstrated for all services provided on an in-house basis.

17.15.5

CHIEF EXECUTIVE

The Chief Executive shall nominate an officer to oversee and manage the contract on behalf of the Trust.

18.1.1

BOARD

18.1.2

REMUNERATION COMMITTEE

Where a supplier is chosen that is not on the approved list the reason shall be recorded in writing to the CE.

Where one tender is received will assess for value for money and fair price.

No quotation shall be accepted which will commit expenditure in excess of that which has been allocated by the Trust and which is not in accordance with these Instructions except with the authorisation of the Chief Executive. The Chief Executive shall demonstrate that the use of private finance represents value for money and genuinely transfers risk to the private sector. All PFI proposals must be agreed by the Board.

Establish a Remuneration & Terms of Service Committee Advise the Board on and make recommendations on the remuneration and terms of service of the CE, other officer members and senior employees to ensure they are fairly rewarded having proper regard to the Trustâ&#x20AC;&#x2122;s circumstances and any national agreements; Monitor and evaluate the performance of individual senior employees; Advise on and oversee appropriate contractual arrangements for such staff, including proper

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Section D: Scheme of Reservation and Delegation SFI REF

DELEGATED TO

AUTHORITIES/DUTIES DELEGATED

18.1.3

REMUNERATION COMMITTEE

18.1.4

BOARD

18.2.2

CHIEF EXECUTIVE

Approval of variation to funded establishment of any department.

18.3

CHIEF EXECUTIVE

Staff, including agency staff, appointments and re-grading.

18.4.1 and 18.4.2

CHIEF FINANCE OFFICER

18.4.3

NOMINATED MANAGERS*

18.4.4

CHIEF FINANCE OFFICER

Ensure that the chosen method for payroll processing is supported by appropriate (contracted) terms and conditions, adequate internal controls and audit review procedures and those suitable arrangements are made for the collection of payroll deductions and payment of these to appropriate bodies.

18.5

NOMINATED MANAGER*

Ensure that all employees are issued with a Contract of Employment in a form approved by the Board and which complies with employment legislation; and deal with variations to, or termination of, contracts of employment.

19.1

CHIEF EXECUTIVE

Determine, and set out, level of delegation of non-pay expenditure to budget managers, including a list of managers authorised to place requisitions, the maximum level of each requisition and the system for authorisation above that level.

19.1.3

CHIEF EXECUTIVE

Set out procedures on the seeking of professional advice regarding the supply of goods and services.

19.2.1

REQUISITIONER*

In choosing the item to be supplied (or the service to be performed) shall always obtain the best value for money for the Trust. In so doing, the advice of the Trust's adviser on supply shall be sought.

19.2.2

CHIEF FINANCE OFFICER

Shall be responsible for the prompt payment of accounts and claims.

19.2.3

CHIEF FINANCE OFFICER

calculation and scrutiny of termination payments. Report in writing to the Board its advice and its bases about remuneration and terms of service of directors and senior employees. Approve proposals presented by the Chief Executive for setting of remuneration and conditions of service for those employees and officers not covered by the Remuneration Committee.

Payroll: a) specifying timetables for submission of properly authorised time records and other notifications; b) final determination of pay and allowances; c) making payments on agreed dates; d) agreeing method of payment; e) issuing instructions (as listed in SFI 10.4.2). Submit time records in line with timetable. Complete time records and other notifications in required form. Submitting termination forms in prescribed form and on time.

b) c) d) e) f) g) 19.3.4

APPROPRIATE EXECUTIVE DIRECTOR

Advise the Board regarding the setting of thresholds above which quotations (competitive or otherwise) or formal tenders must be obtained; and, once approved, the thresholds should be incorporated in standing orders and regularly reviewed; Prepare procedural instructions [where not already provided in the Scheme of Delegation or procedure notes for budget holders] on the obtaining of goods, works and services incorporating the thresholds; Be responsible for the prompt payment of all properly authorised accounts and claims; Be responsible for designing and maintaining a system of verification, recording and payment of all amounts payable; A timetable and system for submission to the Chief Finance Officer of accounts for payment; provision shall be made for the early submission of accounts subject to cash discounts or otherwise requiring early payment; Instructions to employees regarding the handling and payment of accounts within the Finance Department; Be responsible for ensuring that payment for goods and services is only made once the goods and services are received

Make a written case to support the need for a prepayment.

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Section D: Scheme of Reservation and Delegation SFI REF

DELEGATED TO

19.3.4

CHIEF FINANCE OFFICER

19.3.4

BUDGET HOLDER

Ensure that all items due under a prepayment contract are received (and immediately inform Chief Finance Officer if problems are encountered).

19.5

CHIEF EXECUTIVE

Authorise who may use and be issued with official orders.

19.5

MANAGERS AND OFFICERS

19.5

CHIEF EXECUTIVE

AUTHORITIES/DUTIES DELEGATED

Approve proposed prepayment arrangements.

Ensure that they comply fully with the guidance and limits specified by the Chief Finance Officer.

CHIEF FINANCE OFFICER

Ensure that the arrangements for financial control and financial audit of building and engineering contracts and property transactions comply with the guidance contained within CONCODE and ESTATECODE. The technical audit of these contracts shall be the responsibility of the relevant Director.

19.6

CHIEF FINANCE OFFICER

Lay down procedures for payments to local authorities and voluntary organisations made under the powers of section 28A of the NHS Act.

22.1.1

CHIEF FINANCE OFFICER

The Chief Finance Officer will advise the Board on the Trustâ&#x20AC;&#x2122;s ability to pay dividend on PBC and report, periodically, concerning the PDC debt and all loans and overdrafts.

22.1.2

BOARD

Approve a list of employees authorised to make short term borrowings on behalf of the Trust. (This must include the CE and Chief Finance Officer.)

22.1.3

CHIEF FINANCE OFFICER

22.1.4

CHIEF EXECUTIVE OR CHIEF FINANCE OFFICER

22.2.2

CHIEF FINANCE OFFICER

Will advise the Board on investments and report, periodically, on performance of same.

22.2.3

CHIEF FINANCE OFFICER

Prepare detailed procedural instructions on the operation of investments held.

CHIEF FINANCE OFFICER

Ensure that Board members are aware of the Financial Framework and ensure compliance

24.1.1 &2

CHIEF EXECUTIVE

Capital investment programme: a) ensure that there is adequate appraisal and approval process for determining capital expenditure priorities and the effect that each has on plans b) responsible for the management of capital schemes and for ensuring that they are delivered on time and within cost; c) ensure that capital investment is not undertaken without availability of resources to finance all revenue consequences; d) ensure that a business case is produced for each proposal.

24.1.2

CHIEF FINANCE OFFICER

Certify professionally the costs and revenue consequences detailed in the business case for capital investment.

24.1.3

CHIEF EXECUTIVE

24.1.4

CHIEF FINANCE OFFICER

Assess the requirement for the operation of the construction industry taxation deduction scheme.

24.1.5

CHIEF FINANCE OFFICER

Issue procedures for the regular reporting of expenditure and commitment against authorised capital expenditure.

24.1.6

CHIEF EXECUTIVE

Issue manager responsible for any capital scheme with authority to commit expenditure, authority to proceed to tender and approval to accept a successful tender.

Prepare detailed procedural instructions concerning applications for loans and overdrafts. Be on an authorising panel comprising one other member for short term borrowing approval.

Issue procedures for management of contracts involving stage payments.

Issue a scheme of delegation for capital investment management.

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Section D: Scheme of Reservation and Delegation SFI REF

DELEGATED TO

AUTHORITIES/DUTIES DELEGATED

24.1.7

CHIEF EXECUTIVE

24.1.8

CHIEF FINANCE OFFICER

Approval of capital projects and purchases up to a value of ÂŁ0.5m, within the budget and programme approved by the Board Issue procedures governing financial management, including variation to contract, of capital investment projects and valuation for accounting purposes.

24.2.1

CHIEF FINANCE OFFICER

Demonstrate that the use of private finance represents value for money and genuinely transfers significant risk to the private sector.

24.2.1

BOARD

24.3.1

CHIEF EXECUTIVE

24.3.5

CHIEF FINANCE OFFICER

Approve procedures for reconciling balances on fixed assets accounts in ledgers against balances on fixed asset registers.

24.3.8

CHIEF FINANCE OFFICER

Calculate and pay capital charges in accordance with Department of Health requirements.

24.4.1

CHIEF EXECUTIVE

24.4.2

CHIEF FINANCE OFFICER

24.4.4

BOARD, EXECUTIVE MEMBERS AND ALL

Proposal to use PFI must be specifically agreed by the Board. Maintenance of asset registers (on advice from Chief Finance Officer).

Overall responsibility for fixed assets. Approval of fixed asset control procedures. Responsibility for security of Trust assets including notifying discrepancies to Chief Finance Officer, and reporting losses in accordance with Trust procedure.

SENIOR STAFF

25.2

CHIEF EXECUTIVE

25.2

CHIEF FINANCE OFFICER

25.2

DESIGNATED PHARMACEUTICAL

Delegate overall responsibility for control of stores (subject to Chief Finance Officer responsibility for systems of control). Further delegation for day-to-day responsibility subject to such delegation being recorded. Responsible for systems of control over stores and receipt of goods. Responsible for control of pharmaceutical stocks.

OFFICER

25.2

DESIGNATED ESTATES OFFICER

Responsible for control of stocks of fuel oil and coal.

25.2

NOMINATED OFFICERS*

25.2

CHIEF FINANCE OFFICER

Set out procedures and systems to regulate the stores.

25.2

CHIEF FINANCE OFFICER

Agree stocktaking arrangements.

25.2

CHIEF FINANCE OFFICER

Approve alternative arrangements where a complete system of stores control is not justified.

25.2

CHIEF FINANCE OFFICER

Approve system for review of slow moving and obsolete items and for condemnation, disposal and replacement of all unserviceable items.

25.2

NOMINATED OFFICERS*

Operate system for slow moving and obsolete stock, and report to Chief Finance Officer evidence of significant overstocking.

25.3.1

CHIEF EXECUTIVE

26.1.1

CHIEF FINANCE OFFICER

Prepare detailed procedures for disposal of assets including condemnations and ensure that these are notified to managers.

26.2.1

CHIEF FINANCE OFFICER

Prepare procedures for recording and accounting for losses, special payments and informing police and/or the LSMS in cases of suspected arson or theft.

26.2.2

ALL STAFF

Discovery or suspicion of loss of any kind must be reported immediately to either head of department or nominated officer. The head of department / nominated officer should then

Security arrangements and custody of keys.

Identify persons authorised to requisition and accept goods from NHS Supplies stores.

Page 104 of 187

Section D: Scheme of Reservation and Delegation SFI REF

DELEGATED TO

AUTHORITIES/DUTIES DELEGATED inform the CE and Chief Finance Officer.

26.2.2

CHIEF FINANCE OFFICER

Where a criminal offence is suspected, Chief Finance Officer must inform the LSMS and/or police if theft or arson is involved. In cases of fraud and corruption Chief Finance Officer must inform the relevant LCFS and NHS Protect Regional Team in line with SofS directions.

26.2.2

CHIEF FINANCE OFFICER

Notify NHS Protect and External Audit of all frauds.

26.2.3

CHIEF FINANCE OFFICER

Notify Board LSMS and External Auditor of losses caused theft, arson, neglect of duty or gross carelessness (unless trivial).

26.2.4

BOARD

26.2.6

CHIEF FINANCE OFFICER

Consider whether any insurance claim can be made.

26.2.7

CHIEF FINANCE OFFICER

Maintain losses and special payments register.

27.1

CHIEF FINANCE OFFICER

Responsible for accuracy and security of computerised financial data.

27.1

CHIEF FINANCE OFFICER

Satisfy himself that new financial systems and amendments to current financial systems are developed in a controlled manner and thoroughly tested prior to implementation. Where this is undertaken by another organisation assurance of adequacy must be obtained from them prior to implementation.

27.1.3

DIRECTOR RESPONSIBLE

Approve write off of losses (within limits delegated by DH).

Shall publish and maintain a Freedom of Information Scheme.

FOR INFORMATION

27.2.1

RELEVANT OFFICERS

27.3

CHIEF FINANCE OFFICER

Send proposals for general computer systems to Chief Finance Officer Ensure that contracts with other bodies for the provision of computer services for financial applications clearly define responsibility of all parties for security, privacy, accuracy, completeness and timeliness of data during processing, transmission and storage, and allow for audit review. Seek periodic assurances from the provider that adequate controls are in operation.

27.4

CHIEF FINANCE OFFICER

Ensure that risks to the Trust from use of IT are identified and considered and that disaster recovery plans are in place.

27.5

CHIEF FINANCE OFFICER

Where computer systems have an impact on corporate financial systems satisfy himself that: a) systems acquisition, development and maintenance are in line with corporate policies; b) data assembled for processing by financial systems is adequate, accurate, complete and timely, and that a management rail exists; c) Chief Finance Officer and staff have access to such data; d) Such computer audit reviews are being carried out as are considered necessary.

28.2

CHIEF EXECUTIVE

Responsible for ensuring patients and guardians are informed about patients' money and property procedures on admission.

28.3

CHIEF FINANCE OFFICER

Provide detailed written instructions on the collection, custody, investment, recording, safekeeping, and disposal of patients' property (including instructions on the disposal of the property of deceased patients and of patients transferred to other premises) for all staff whose duty is to administer, in any way, the property of.

28.6

DEPARTMENTAL

Inform staff of their responsibilities and duties for the administration of the property of patients.

MANAGERS

29.1

CHIEF FINANCE OFFICER

Shall ensure that each trust fund which the Trust is responsible for managing is managed appropriately.

CHIEF FINANCE OFFICER

Ensure all staff are made aware of the Trust policy on the acceptance of gifts and other benefits in kind by staff

Page 105 of 187

Section D: Scheme of Reservation and Delegation SFI REF

DELEGATED TO

AUTHORITIES/DUTIES DELEGATED

CHIEF EXECUTIVE

Retention of document procedures in accordance with HSC 1999/053.

33.1

CHIEF EXECUTIVE

Risk management programme.

33.1

BOARD

Approve and monitor risk management programme.

33.2

BOARD

Decide whether the Trust will use the risk pooling schemes administered by the NHS Litigation Authority or self-insure for some or all of the risks (where discretion is allowed). Decisions to self-insure should be reviewed annually.

33.4

CHIEF FINANCE OFFICER

Where the Board decides to use the risk pooling schemes administered by the NHS Litigation Authority the Chief Finance Officer shall ensure that the arrangements entered into are appropriate and complementary to the risk management programme. The Chief Finance Officer shall ensure that documented procedures cover these arrangements. Where the Board decides not to use the risk pooling schemes administered by the NHS Litigation Authority for any one or other of the risks covered by the schemes, the Chief Finance Officer shall ensure that the Board is informed of the nature and extent of the risks that are self insured as a result of this decision. The Chief Finance Officer will draw up formal documented procedures for the management of any claims arising from third parties and payments in respect of losses that will not be reimbursed.

33.4

CHIEF FINANCE OFFICER

Ensure documented procedures cover management of claims and payments below the deductible.

* Nominated officers and the areas for which they are responsible should be incorporated into the Trustâ&#x20AC;&#x2122;s Scheme of Delegation document.

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Section D: Scheme of Reservation and Delegation Audit and Assurance Committee: Terms of Reference

1. 1.1

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

2. 2.1

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

2.2

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

3. 3.1

Membership The Committee shall be appointed by the Board from the non-executive directors of the Trust and shall consist of not less than three members.

3.2

A quorum shall be two members.

3.3

The Board will appoint one of the members to be Chair of the Committee.

3.4

The Chairman of the organisation shall not be a member of the Committee.

4. 4.1

Attendance The Chief Finance Officer and the Director of Corporate Affairs and appropriate internal and external Audit representatives shall normally attend meetings. However, at least once a year the Committee should meet privately with the external and internal auditors.

4.2

The Committee shall request the attendance of the Executive Directors when discussing risk or requiring assurance in relation to their areas of responsibilities.

4.3

As Accountable Officer, the Chief Executive has an open invitation to attend each Board sub-committee and should attend to discuss with the Committee the process for assurance that supports the agreeing of accounts and the Annual Governance Statement.

The Corporate governance Manager shall be secretary to the Committee and shall attend to take minutes of the meeting and provide appropriate support to the Chairman and committee members.

5. 5.1

Frequency Meetings shall be held not less than four times a year and normally will take place every two months.

5.2

The External Auditor or Head of Internal Audit or Counter Fraud may request of the Chair a meeting is held if they consider that one is necessary.

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Section D: Scheme of Reservation and Delegation 6. 6.1

Authority The Committee is authorised by the Board to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Committee.

6.2

The Committee is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of persons external to the Trust with relevant experience and expertise if it considers this necessary.

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

7.1

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

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

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

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

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

7.2

In carrying out this work the Committee will primarily utilise the work of internal audit, external audit and other assurance functions (for example the Trustâ&#x20AC;&#x2122;s clinical audit function) to ensure review is external, but will not be limited to these. It will also seek reports and assurances from directors and managers as appropriate, concentrating on the overarching systems of integrated governance, risk management and internal control, together with indicators of their effectiveness.

7.3

In relation to the Board Assurance Framework the committee will use this to guide its work and will provide assurance that the controls and actions taken to address any gaps are robust and support the delivery of corporate objectives.

8. 8.1

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

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

Page 108 of 187

Section D: Scheme of Reservation and Delegation

9. 9.1

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

ensuring the internal audit function is adequately resourced

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

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

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

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

10. Other Assurance Functions 10.1 The Committee shall review the findings of other significant assurance functions, both internal and external to the organisation, and consider the implications to the governance of the organisation. These will include, but will not be limited to, any reviews by Department of Health Arms Length Bodies or Regulators/Inspectors (e.g. CQC, NHS Litigation Authority, etc.), professional bodies with responsibility for the performance of staff or functions (e.g. Royal Colleges, accreditation bodies, etc.), reports by the Trust’s local counter fraud specialist.

10.2 In addition, the Committee will review the work and function of other committees, working groups and senior responsible officers within the organisation, whose work can provide relevant assurance to the Committee’s own scope of work.

10.3 In reviewing work of around clinical risk management, the Committee will wish to satisfy itself on the assurance that can be gained from the clinical audit function and outcome measures from the Trusts clinical benchmarking systems.

11. Management 11.1 The Committee shall request and review reports and positive assurances from directors and managers on the overall arrangements for governance, risk management and internal control. They may also request specific reports from individual functions within the organisation (e.g. clinical audit) as appropriate.

12. Financial Reporting 12.1 The Committee shall review the annual report and financial statements before submission to the Board, focusing particularly on: -

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

changes in, and compliance with, accounting policies and practices

unadjusted mis-statements in the financial statements

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Section D: Scheme of Reservation and Delegation

12.2

major judgmental areas

significant adjustments resulting from the audit

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

13. Reporting 13.1 The minutes of the Committee meetings shall be formally recorded by the Trust Secretary and submitted to the Board. The Chair of the Committee shall draw to the attention of the Board any issues that require disclosure to the full Board, or require executive action.

13.2 The Committee will report to the Board annually on its work in support of the Statement on Internal Control, specifically commenting on the fitness for purpose of the assurance framework, the completeness and embedding of risk management in the organisation, the integration of governance arrangements and the appropriateness of the self-assessment of provider compliance with CQC regulations.

14. Other Matters 14.1 The Trust Secretary, whose duties in this respect will include the following, shall support the Committee administratively: -

Agreement of agenda with Chairman and attendees and collation of papers

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

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

Advising the Committee on pertinent matters

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Section D: Scheme of Reservation and Delegation Audit and Assurance Committee : Standing Agenda

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

Risk Management Board Assurance Framework Risk Management Systems

Internal Control Systems Review annual governance statement Review internal controls Note business of other committees Specific Duties Review annual accounts Review losses, waviers and special payments

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

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

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Section D: Scheme of Reservation and Delegation Remuneration Committee: Terms of Reference 1. Constitution The Board hereby resolves to establish a Committee of the Board to be known as the Remuneration and Terms of Service Committee (The Committee). 2. Membership The Committee comprises: • The Board Chair • All Non-Executive Directors The Chief Executive, or other Executive Directors, will be invited to attend the Committee in an advisory capacity but will withdraw when a matter concerning his/her remuneration package or other matter of individual confidentiality is being discussed or documented. The Director of Human Resources will also attend the Committee as adviser. The Director of Human Resources will be responsible for minuting the Meetings. 3. Quorum No business shall be transacted at a meeting unless the Chair of the Board or Deputy Chair and two Non-Executive Directors are present for the whole meeting. 4. Frequency The Committee will meet as required by the Chair of the Board and at least twice per year. 5. Authority The Committee is authorised by the Board to investigate any activity within its terms of reference. In particular it may: • Seek advice from whatever source it deems to be appropriate. •

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

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

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

•

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

•

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

•

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

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Section D: Scheme of Reservation and Delegation 7. Reporting Formal minutes will be recorded of each meeting of the Committee and will be distributed to those present at meetings. All recipients will hold minutes securely and Auditors may access the official Minute Book held by the Secretary with the prior approval of the Chair of the Board. The Committee will report in writing to the Board at least once annually the basis for its decisions and recommendations. 8. Review Date The Terms of Reference of the Committee will be reviewed annually.

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Section D: Scheme of Reservation and Delegation Safety and Quality Committee:

Terms of Reference

1. Background •

The Safety and Quality Committee (“the Committee”) is constituted as a standing committee of the Board of Directors. These terms of reference can only be amended by the Board of Directors.

•

The purpose of the Committee is to assist the Board of Directors in monitoring the overall development and delivery of the Trust’s Safety and Quality Strategy.

2. Authority •

The Board of Directors has delegated to the Committee the authority to deal with the matters set out in paragraph 6 below.

•

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

3. Membership and Attendance •

The members of the Committee shall be: (i)

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

(ii)

Chief Executive;

(iii) Chief Medical Officer; (iv) Chief Nurse or Deputy; (v) Chief Operating Officer or Deputy; (vi) Chief Finance Officer or Deputy. (vii) Clinical Chiefs of Service •

Members of the Board of Directors not specified in paragraph 3.1 above shall have the right of attendance. The Secretary shall circulate minutes of meetings of the Safety and Quality Committee to all members of the Board of Directors.

•

The Chairman of the Committee shall be a non-executive director appointed by the Board of Directors.

•

The following individuals are required to attend part or all of the meetings as required by the Chairman of the Committee but shall have no voting rights: (i)

Divisional Chief Nurses

(ii)

Risk and Patient Safety Lead;

(iii)

Director of Informatics, Estates and Facilities – by invitation only when required;

(iv)

Director of Corporate Affairs - by invitation only when required;

(v)

Clinical Governance Compliance Manager

(vi)

any other clinicians, nursing and midwifery staff and allied health professionals as appropriate to the business of the meeting concerned; and

(vii)

Accountable Officer for Controlled Drugs - by invitation only when required;

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Section D: Scheme of Reservation and Delegation

4. Quorum •

The quorum necessary for the transaction of business shall be five members, which shall include two non-executive directors, the Chief Medical Officer or Chief Nurse, two Chiefs of Service or their deputies and two Divisional Nurses.

•

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

•

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

•

Where a Committee meeting: (i) is not quorate under paragraph 4.1 within one half hour from the time appointed for the meeting; or (ii) becomes inquorate during the course of the meeting,

•

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

5. Meetings •

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

•

Risk and Patient Safety Lead (or their nominee) shall act as the Secretary of the Committee of the Committee.

•

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

•

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

•

Supporting papers shall be sent to Committee members and to other attendees, as appropriate five days ahead of the date of the meeting.

6. Duties 6.1

The Committee shall support the Board of Directors with:

STRATEGY The Committee will review and approve the Safety and Quality Strategy and the Quality Account following its development through EC and prior to presentation to the Board for approval. 6.2

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

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Section D: Scheme of Reservation and Delegation • • • • • • • • •

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

6.3

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

6.4

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

6.5

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

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Section D: Scheme of Reservation and Delegation 6.6 •

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

Reporting arrangements •

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

•

The Committee shall make whatever recommendations to the Board of Directors and/or Executive Committee that it deems appropriate on any area within its remit where action or improvement is needed. In particular, the Committee shall refer any substantive issues or concerns on delivery of the Safety and Quality Strategy to the Audit & Assurance Committee, the Executive Committee for Quality & Risk or to the Board of Directors for wider consideration in light of its overall responsibility for ensuring the safety and quality of services provided by the Trust.

•

The Committee shall prepare an annual report on the implementation of the Trust’s Safety and Quality Strategy and on related priorities (a quality account) which shall be published separately.

Review •

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

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Section D: Scheme of Reservation and Delegation Charitable Funds Committee: Terms of Reference

Background

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

Constitution

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

Relationships

Board upwards for information only. No sub committees.

Membership

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

2 x Non Executive Directors Chief Finance Officer (CFO) Chief Nurse (links to patient experience) Director of Corporate Affairs Director of Information and Facilities Head of Financial Accounts Fundraising Co-ordinator

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Section D: Scheme of Reservation and Delegation Head of Communications

Attendance •

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

•

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

Administration •

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

•

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

•

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

•

Review Date July 2013

Frequency •

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

•

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

•

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

•

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

Authority

The Group is autonomous and acts independently of the Trust Board but shall report to the Board for information (please see constitution). The Committee delegates authority as follows: •

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

•

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

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Section D: Scheme of Reservation and Delegation •

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

•

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

•

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

Monitoring Effectiveness

9. •

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

Core Duties 1.

Safe Custody •

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

•

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

•

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

Compliance •

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

•

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

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Section D: Scheme of Reservation and Delegation

•

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

•

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

•

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

Investments & fund raising •

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

•

Consider future charitable campaigns including the nature of events and objectives

•

To improve strategy, monitor implementation and functionality of the fund-raising operational group

•

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

Accounts and similar requirements •

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

•

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

•

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

•

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

Other functions •

To consider matters requested by the Trust Board.

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Section D: Scheme of Reservation and Delegation Finance and Workforce Committee:

Terms of Reference

1: Background The Finance and Workforce Committee (“the Committee”) is a standing Committee of the Board of Directors. These terms of reference can only be amended by the Board of Directors. The purpose of the Committee is to assist the Board of Directors in exercising its business planning, financial and workforce and investment governance procedures in four key areas: i) Monitoring Financial Performance ii) Business planning, including strategic financial and workforce planning; iii) approving investment decisions, as defined in these terms of reference, including capital projects, treasury and working capital management, and; iv) monitoring delivery of significant projects and investments, and any potential business combinations..

2: Authority The Committee is authorised by the Board of Directors to investigate any activity within its terms of reference. The Committee is authorised by the Board of Directors to seek any information it requires from any employee of the Trust in order to perform its duties. In connection with its duties, the Committee is authorised by the Board of Directors, at the Trust’s expense, within any budgetary restraints imposed by the Board of Directors, to appoint external professional advisors, and to commission or purchase any relevant reports, surveys or information which it deems necessary to fulfil its duties. 3: Membership and Attendance The members of the Committee shall be appointed by the Board of Directors. The members of the Committee shall be: (i)

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

(ii)

Chief Executive; and

(iii)

Chief Finance Officer

(iv)

Director of Corporate Affairs

(v)

Director of Human Resources

(vi)

Director of Information and Estates

(vii)

Chief Nurse

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Section D: Scheme of Reservation and Delegation (viii)

Chief Operating Officer

As Accountable Officer, the Chief Executive has an open invitation to attend each Board sub-committee The following shall be invited to attend meetings as and when appropriate but shall have no voting rights: (i)

all other corporate members of the Executive Committee; and

(ii) (iii)

all other non-executives and executive members of the Board of Directors.

The Committee may invite other Trust staff to attend its meetings as appropriate. 4: Quorum Where a Committee meeting: The quorum necessary for the transaction of business shall be three, which shall include one non-executive director. A duly convened meeting of the Committee at which a quorum is present shall be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the Committee. In the absence of the Committee Chairman and/or an appointed Deputy, the remaining non-executive members present shall elect one of themselves to chair the meeting. Where a Committee meeting: (i)

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

(ii)

becomes inquorate during the course of the meeting,

the Committee members present may determine to adjourn the meeting to such time, place and date as may be determined by the members present. 5: Meetings The Committee shall meet monthly and at such other times as the Chairman of the Committee shall require. The Chief Finance Officer or their nominee shall act as the Secretary of the Committee. Meetings of the Committee shall be summoned by the Secretary of the Committee at the request of the Chairman and/or Chief Executive. Unless otherwise agreed, notice of each meeting confirming the venue, time and date together with an agenda of items to be discussed, shall be forwarded to each member of the Committee no later than five days before the date of the meeting. Supporting papers shall be sent to Committee members and to other attendees, as appropriate, at the same time. Minutes of the Committee shall be circulated to Committee members and attendees, and the Board of Directors.

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Section D: Scheme of Reservation and Delegation 6: Duties 6.1

Financial Performance

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

(i)

The volume and complexity of activity and performance against Plans

(ii)

Reasons for variances, the impact financially and delivery of actions to correct adverse performance

(iii)

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

(iv)

Effectiveness of contractual processes, contractual notices and outputs with commissioners

(v)

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

(vi)

Cashflow management and Working Capital planning

(vii)

Major judgmental areas

The Committee shall consider and review financial reports focusing on:

6.2

(i)

Delivery to plans

(ii)

Reasons for variances and delivery of actions to correct adverse performance

(iii)

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

(iv)

Delivery of Trust savings plans

(v)

Operation of Trust budgetary procedures and compliance with SOFIs

(vi)

Major judgmental areas

Business planning The Committee shall provide oversight of the Trustâ&#x20AC;&#x2122;s business planning and will recommend to the Board of Directors the sign off of the integrated business plan and annual operating plans. The Committee will also take stock of market and environmental analysis reports and make itself aware of developments in the local health economy and through transformation programmes and QIPP schemes. In doing so, the Committee shall approve:

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Section D: Scheme of Reservation and Delegation i) All relevant supporting strategies and policies, with the exception of the Clinical Strategy i.e. Clinical Effectiveness, Safety and Patient Experience (which is approved by the Safety & Quality Committee) – see below for workforce ii) The business planning timetable 6.3

Financial policy, management and reporting The Committee shall provide oversight of the Board of Directors’ financial policies, management and reporting with consideration to the overall financial performance of the Trust by ensuring the development and implementation of high levels of financial control are embedded into operational management of the Trust and financial plans are disseminated and understood across the Trust. In doing so, the Committee shall approve: (i)

the financial policies of the Trust annually and make appropriate recommendations to the Board of Directors;

(ii)

the Trust’s medium and long-term financial strategy, in relation to both revenue and capital, including overseeing the development of financial plans for the Trust’s foundation trust application;

(iii)

the Trust’s annual financial targets; and

(iv)

the preparation of the annual budget prior to its submission to the Board of Directors.

6.4 Workforce strategy The Committee shall provide oversight of the Board of Directors’ workforce strategy to deliver Trust objectives and direction, workforce plans, management and reporting with consideration to the overall flexibility of resources, total staff costs and staff development. In doing so, the Committee shall approve:

6.5

(i)

the 3-5 year workforce strategy and relevant supporting policies that are relevant to the Committee (the Executive Committee will sign off most supporting policies)

(ii)

the organisational development strategy and annual plan

(iii)

the annual workforce plan including, the preparation of its establishment prior to the budget’s submission to the Board of Directors.

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

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Section D: Scheme of Reservation and Delegation (i)

establish the overall methodology, processes and controls which govern investments;

(ii)

ensure that robust processes are followed; and

(iii)

evaluate, scrutinise and monitor investments;

(b) approve and review the Trust’s treasury management and working capital policy annually or as required; (c) approve proposals for major business cases with a capital value of over £1m or which require a revenue budget virement of over £1m. The Committee shall monitor the work of the Capital Group, which reports to the Executive Committee, for lower value investments; (d) approve the initiation of projects greater than £1m on the information provided in the Project Initiation Document and Project Plan Outline Business Case and Full Business Case and other key project documents; (e)

monitor implementation of major projects (>£2.0m). include:

This shall

(i) developing sub-groups as needed and approving their terms of reference; (i) assisting in the evaluation of the bids at each stage or identifying the expert advice needed; (ii) giving approval to the Project Director to start each necessary stage of work upon completion of the necessary tasks from the previous stages; (iii) approving major alterations in the project plan; (iv) ensuring key areas are communicated across all stakeholder organisations; (v) (vi)

ensuring the project is appropriately evaluated; ensuring propriety in placing and management of contracts; and (vii) ensuring risk assessment and management strategies are in place. (f) evaluate the implementation and delivery of the business benefit of projects > £1m via a post implementation review. 7: Other duties The Committee shall: 1.

make any arrangements necessary to ensure that all members of the Board of Directors maintain an appropriate level of knowledge and understanding of key financial issues affecting the Trust;

examine any other matter referred to the Committee by the Board of Directors.

meet privately to consider commercially sensitive matters e.g. potential partnerships, marketing strategy

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Section D: Scheme of Reservation and Delegation 4.

see assurances that governance controls are reviewed to provide assurance that the trusts internal control framework systemâ&#x20AC;&#x2122;s design, function and performance is satisfactory.

External advice

The Committee shall be exclusively responsible for establishing the selection criteria, selecting, appointing and setting the terms of reference for any external professional advisors who advise the Committee in the course of its work. Where external professional advisors are appointed, a statement shall be made available of whether they have any other connection with the Trust. 9.

Reporting arrangements

The Committee Chairman shall report formally to the Board of Directors on its proceedings after each meeting on all matters within its duties and responsibilities. The Committee shall make whatever recommendations to the Board of Directors and/or Management Board that it deems appropriate on any area within its remit where action or improvement is needed. The Committee shall produce an annual report of the Trustâ&#x20AC;&#x2122;s financial, investment, project, procurement, and estates policies and practices which shall form part of the Trustâ&#x20AC;&#x2122;s annual report. The Committee shall review reports previously considered and approved by the Executive Committee , the Workforce Group and the Capital Group. 10.

Review

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Section D: Scheme of Reservation and Delegation Schedule 1:

Authority to commit or spend Trust money - delegated limits Responsibilities set out in Standing Financial Instructions The Trust’s Standing Financial Instructions are very clear about staff requiring formal authority to commit or spend Trust money. Staff who commit or spend Trust money must read the Standing Financial Instructions - specific areas to be aware of (this is not an exhaustive list) are as follows:

Section 15.5 covers staff making decisions about healthcare procedures, and states that staff should not commit resources to do work not covered, or restricted by, Commissioners Contracts.

Section 16 covers budget holders and states that Trust resources should be spent according to what the budget has been allocated for;

Section 18 covers pay expenditure (revenue);

Section 19 covers non pay expenditure (revenue)

Section 24 covers capital.

It is each individual’s responsibility to make themselves aware of their responsibilities as stated in the Standing Financial Instructions. Formal authorisation This schedule provides the limits to be applied. Not every person at each level will have delegated authority - specific authority is provided by an individual signing, and an (authorised) senior signing to confirm, an authorised signatory pro-forma. If you do not have a signed authorised signatory form saying so you do not have delegated authority to commit or spend Trust money. Automated Trust financial and purchasing processes The Trust uses NHS Shared Business Services (SBS) to provide its financial accounting and purchasing systems. The system is highly automated, web based and electronic. Staff must ensure they are (a) trained to use it, (b) use it properly and (c) do not let the system emails generated build up, they must be dealt with promptly. Within the system authority levels for posts are set such that •

Post holders who requisition goods and services are unable to approve those purchases, the requisition moves electronically to the next line manager level for approval.

•

If that requisition is above the next levels approval limit it moves electronically to the next level.

•

This is repeated until the requisition is approved or it gets to the Chief Executive.

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Section D: Scheme of Reservation and Delegation •

The purpose of the detailed bandings is to facilitate a smooth progression upwards and avoid significant ‘limit’ bottlenecks.

•

The process operates similarly for approval of non-purchase order expenditure where invoicing is sent electronically through the same approvals hierarchy.

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Section D: Scheme of Reservation and Delegation

Delegated limits Capital expenditure All capital expenditure project/procurement above £5,000 requires sign off by the Executive Team meeting,or the Capital Group – all representing the Chief Executive and the Board) or directly by the Board (if not part of the Board approved budget) prior to any requisition. The delegated limits for approval of projects/items are: -

Amounts over £1m – Finance and Workforce Committee and the Trust board.

Amounts upto £1m –, Executive Commitee

Amounts up to £0.25m – the Capital Investment Group

If a scheme’s cost exceeds its budget formal approval of that overrun must be obtained from the Capital Group or other named committee according to the delegated authority of that committee. In terms of authorising payments in respect of approved schemes/items the delegated limits are below. Level

Staff with authority

1 2

Chief Executive Chief Finance Officer

3 4

Director of Estates & Information Other Directors, Head of Capital or Deputy Chief Finance Officer nd 2 line reports to Directors, e.g.: Divisional ADO’s, Assistant Directors (not Clinical Directors)

Requisitions Purchase Non orders – purchase limit (£000) orders – limit (£000)

Invoices - limit (£000)

Any amount over 250

250 100

Where the CFO is absent then the Deputy CFO will be delegated their approval limits. Revenue expenditure The delegated limits for approval of annual recurrent or non recurrent revenue expenditure are: -

Amounts over £1.0m – the Board

Amounts below £1.0m – the Executive Team meeting or the Programme Management Office.

In terms of authorising payments in respect of approved expenditure the delegated limits are below.

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Section D: Scheme of Reservation and Delegation Level

Staff with authority

1 2

Chief Executive Chief Finance Officer

Other Directors and nominated senior finance staff nd 2 line reports to Directors, e.g.: ADO’s, Chief Nurse, Associate Directors (not Clinical Directors) rd 3 line reports to Directors: e.g.: senior managers, Heads of Department Includes Head of Procurement Other budget holders

4 5 6

Requisitions Purchase Non orders – purchase limit (£000) orders – limit (£000)

Invoices - limit (£000)

Any amount over 250 250

2.5

Where the CFO is absent then the Deputy CFO will be delegated their approval limits. Contracts Standing Orders (at para 8.4) describe that the Chief Executive and Executive Directors (and the Deputy Chief Finance Officer in the absence of the CFO) can sign legally binding documents and Section 5 and the scheme of delegation provides for the delegation of functions and authority allowing other members of staff to do so, within the criteria provided by approval of the expenditure.

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Section E

Codes of Accountability and Conduct & for NHS Boards (as published by the Department of Health and the Appointments Commission)

Appendix 1 â&#x20AC;&#x201C; The Nolan Principles Corporate Governance Manual 2013/14 onwards

Contents CODE OF CONDUCT

CODE OF ACCOUNTABILITY

Public Service Values

Status

General Principles

Code of Conduct

Openness and Public Responsibilities

Statutory Accountability The Board of Directors

Public Service Values in Management

The Role of the Chair

Public Business and Private Gain Hospitality and Other Expenditure Relations with Suppliers Staff

Non-Executive Directors Reporting and Controls Declaration of Interests Employee Relations

Compliance

The manual is also available on the Trust internet site www.surreyandsussex.nhs.uk

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CODE OF CONDUCT FOR NHS BOARDS Public service values must be at the heart of the National Health Service. High standards of corporate and personal conduct based on a recognition that patients come first, have been a requirement throughout the NHS since its inception. Moreover, since the NHS is publicly funded, it must be accountable to Parliament for the services it provides and for the effective and economical use of taxpayers’ money. There are three crucial public service values which must underpin the work of the health service.

Accountability – everything done by those who work in the NHS must be able to stand the test of parliamentary scrutiny, public judgements on propriety and professional codes of conduct.

Probity – there should be an absolute standard of honesty in dealing with the assets of the NHS: integrity should be the hallmark of all personal conduct in decisions affecting patients, staff and suppliers, and in the use of information acquired in the course of NHS duties.

Openness – there should be sufficient transparency about NHS activities to promote confidence between the NHS organisation and its staff, patients and the public.

General Principles Public service values matter in the NHS and those who work in it have a duty to conduct NHS business with probity. They have a responsibility to respond to staff, patients and suppliers impartially, to achieve value for money from the public funds with which they are entrusted and to demonstrate high ethical standards of personal conduct. The success of this Code depends on a vigorous and visible example from boards and the consequential influence on the behaviour of all those who work within the organisation. Boards have a clear responsibility for corporate standards of conduct and acceptance of the Code should inform and govern the decisions and conduct of all board directors. Openness and Public Responsibilities Health needs and patterns of provision of health care do not stand still. There should be a willingness to be open with the public, patients and with staff as the need for change emerges. It is a requirement that major changes are consulted upon before decisions are reached. Information supporting those decisions should be made available, in a way that is understandable, and positive responses should be given to reasonable requests for information and in accordance with the Freedom of Information Act 2000. NHS business should be conducted in a way that is socially responsible. As a large employer in the local community, NHS organisations should forge an open and positive relationship with the local community and should work with staff and partners to set out a vision for the organisation in line with the expectations of patients and the public. NHS organisations should demonstrate to the public that they are concerned with the wider health of the population including the impact of the organisation’s activities on the environment. The confidentiality of personal and individual patient information must, of course, be respected at all times. Public Service Values in Management It is unacceptable for the board of any NHS organisation, or any individual within the organisation for which the board is responsible, to ignore public service values in achieving results. Chairs and board directors have a duty to ensure that public funds are properly safeguarded and that at all times the board conducts its business as efficiently and effectively as possible. Proper stewardship of public monies requires value for money to be high on the agenda of all NHS boards. Accounting, tendering and employment practices within the NHS must reflect the highest professional standards. Public statements and reports issued by the board should be clear, comprehensive and balanced, and should fully represent the facts. Annual and other key reports should be issued in good time to all individuals and groups in the community who have a legitimate interest in health issues to allow full consideration by those wishing to attend public meetings on local health issues.

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Public Business and Private Gain Chairs and board directors should act impartially and should not be influenced by social or business relationships. No one should use their public position to further their private interests. Where there is a potential for private interests to be material and relevant to NHS business, the relevant interests should be declared and recorded in the board minutes, and entered into a register which is available to the public. When a conflict of interest is established, the board director should withdraw and play no part in the relevant discussion or decision. Hospitality and Other Expenditure Board directors should set an example to their organisation in the use of public funds and the need for good value in incurring public expenditure. The use of NHS monies for hospitality and entertainment, including hospitality at conferences or seminars, should be carefully considered. All expenditure on these items should be capable of justification as reasonable in the light of the general practice in the public sector. NHS boards should be aware that expenditure on hospitality or entertainment is the responsibility of management and is open to be challenged by the internal and external auditors and that ill-considered action can damage respect for the NHS in the eyes of the community. Relations with Suppliers NHS boards should have an explicit procedure for the declaration of hospitality and sponsorship offered by, for example, suppliers. Their authorisation should be carefully considered and the decision should be recorded. NHS boards should be aware of the risks in incurring obligations to suppliers at any stage of a contracting relationship. Suppliers should be selected on the basis of quality, suitability, reliability and value for money. The Department of Health has issued guidance to NHS organisations about standards of business conduct (ref: HSG(93)5). Staff NHS boards should ensure that staff have a proper and widely publicised procedure for voicing complaints or concerns about maladministration, malpractice, breaches of this code and other concerns of an ethical nature. The board must establish a climate:

that enables staff who have concerns to raise these reasonably and responsibly with the right parties;

that gives a clear commitment that staff concerns will be taken seriously and investigated; and

where there is an unequivocal guarantee that staff who raise concerns responsibly and reasonably will be protected against victimisation.

(Ref: Whistleblowing in the NHS, letter dated 25 July 2003 from the Director of HR in the NHS) Compliance Board directors should satisfy themselves that the actions of the board and its directors in conducting board business fully reflect the values in this Code and, as far as is reasonably practicable, that concerns expressed by staff or others are fully investigated and acted upon. All board directors of NHS organisations are required, on appointment, to subscribe to the Code of Conduct.

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CODE OF ACCOUNTABILITY FOR NHS BOARDS This Code of Practice is the basis on which NHS organisations should seek to fulfil the duties and responsibilities conferred upon them by the Secretary of State for Health. Status NHS organisations, such as NHS trusts, Clinical Commissioning Groups, National Commissioning Board, Trust Development Authority and special health authorities, are established under statute as corporate bodies so ensuring that they have separate legal personality. Statutes and regulations prescribe the structure, functions and responsibilities of the boards of these bodies and prescribe the way chairs and directors of boards are to be appointed. Code of Conduct All board directors of NHS organisations are required, on appointment, to subscribe to the Code of Conduct. Breaches of this Code of Conduct by the chair or a non-executive director of the board should be drawn to the attention of the appropriate Regional Commissioner of the NHS Appointments Commission. NHS managers are required to take all reasonable steps to comply with the requirements set out in the Code of Conduct for NHS Managers. Chairs and non-executive directors of NHS boards are responsible for taking firm, prompt and fair disciplinary action against any executive director in breach of the Code of Conduct for NHS Managers. Statutory Accountability The Secretary of State for Health has statutory responsibility for the health of the population of England and uses statutory powers to delegate functions to NHS organisations who are thus accountable to the Secretary of State and to Parliament. The Department of Health is responsible for directing the NHS, ensuring national policies are implemented and for the effective stewardship of NHS resources. NHS trusts provide services to patients (these may be acute services, ambulance services, mental health or other special services, e.g. for children). Other main functions are to:

ensure services are of high quality and accessible;

lead the development of new ways of working to fully engage patients and ensure a patient-centred service;

Clinical Commissioning Groups are expected to identify the health needs of the population, to work to improve the health of the community and to secure the provision of a full range of services. Other main functions are to:

maintain an effective public health function;

lead local planning;

manage and develop primary healthcare services;

develop and improve local services;

lead the integration of health and social care; and

deliver services within their remit.

Trust Development Authorities provide strategic leadership to ensure the maintenance of provision and the delivery of improvements in local health and health services by primary care trusts and NHS trusts, within the national framework of developing a patient-centred NHS and supported by effective controls and clinical governance systems. Other main functions for which the Trust Development Authority is responsible are to:

lead the development and empowerment of uniformly excellent frontline NHS organisations committed to innovation and improvement;

consider the overall needs of the health economy across primary, community, secondary and tertiary care, and working with primary care trusts and NHS trusts to deliver a programme to meet these needs;

performance manage and ensure accountability of local primary care trusts and NHS trusts; Surrey and Sussex Healthcare NHS Trust ~ Corporate Governance Manual 2012/13 onwards Page 135 of 187

lead on the creation and development of clinical and public health networks;

create capacity through the preparation and delivery of strategies for capital investment, information management and workforce development;

ensure effective networks and joint working exists between NHS organisations for the provision of health and social care; and

ensure the development and training of an adequate workforce of competent clinical personnel.

NHS trust, Commissioners and Trust Development Authority finances are subject to external audit by Grant Thornton and, for the value for money element, by the Care Quality Commission. NHS boards must co-operate fully with the Department of Health, Grant Thornton and the Care Quality Commission when required to account for the use they have made of public funds, the delivery of patient care and other services, and compliance with statutes, directions, guidance and policies of the Secretary of State. The Chief Executive/ Permanent Secretary of the Department of Health, as Accounting Officer for the NHS, is accountable to Parliament. The work of the Department of Health and its associated bodies is examined by the House of Commons Health Committee. Its remit is to examine the expenditure, administration and policy of the Department of Health. Two other Parliamentary Committees, the Public Accounts Committee and the Public Administration Select Committee, scrutinise the work of the Department of Health and the health service. The Board of Directors NHS boards comprise executive directors together with non-executive directors and a chair who are appointed by the Trust development Authority on behalf of the Secretary of State. Together they share corporate responsibility for all decisions of the board. There is a clear division of responsibility between the chair and the chief executive; the chair’s role and board functions are set out below; the chief executive is directly accountable to the board for meeting their objectives, and as Accountable Officer, to the Chief Executive of the NHS for the performance of the organisation. Boards are required to meet regularly and to retain full and effective control over the organisation; the chair and non-executive directors are responsible for monitoring the executive management of the organisation and are responsible to the Secretary of State for the discharge of these responsibilities. NHS Trust Development Authorities generally provide the line of accountability from local NHS organisations to the Secretary of State for the performance of the organisation the TDA will always be available to chairs and nonexecutive directors on matters of concern to them relating to the personal effectiveness of individual chairs and non-executives. The duty of an NHS board is to add value to the organisation, enabling it to deliver healthcare and health improvement within the law and without causing harm. It does this by providing a framework of good governance within which the organisation can thrive and grow. Good governance is not restrictive but an enabling ingredient to underpin change and modernisation. The role of an NHS board is to:

be collectively responsible for adding value to the organisation, for promoting the success of the organisation by directing and supervising the organisation’s affairs

provide active leadership of the organisation within a framework of prudent and effective controls which enable risk to be assessed and managed

set the organisation’s strategic aims, ensure that the necessary financial and human resources are in place for the organisation to meet its objectives, and review management performance

set the organisation’s values and standards and ensure that its obligations to patients, the local community and the Secretary of State are understood and met.

Further details may be obtained from Governing the NHS: A Guide for NHS Boards at www.dh.gov.uk

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The Role of the Chair The overall role of the chair is one of enabling and leading so that the attributes and specific roles of the executive team and the non-executives are brought together in a constructive partnership to take forward the business of the organisation. The key responsibilities of the chair are:

leadership of the board, ensuring its effectiveness on all aspects of its role and setting its agenda;

ensuring the provision of accurate, timely and clear information to directors;

ensuring effective communication with staff, patients and the public;

arranging the regular evaluation of the performance of the board, its committees and individual directors; and

facilitating the effective contribution of non-executive directors and ensuring constructive relations between executive and non-executive directors.

A complementary relationship between the chair and chief executive is important. The chief executive is accountable to the chair and non-executive directors of the board for ensuring that the board is empowered to govern the organisation and that the objectives it sets are accomplished through effective and properly controlled executive action. The chief executive should be allowed full scope, within clearly defined delegated powers, for action in fulfilling the decisions of the board. Further details may be obtained from Governing the NHS: A Guide for NHS Boards at www.dh.gov.uk. Non-Executive Directors Non-executive directors are appointed by the NHS Trust Development Authority on behalf of the Secretary of State to bring an independent judgement to bear on issues of strategy, performance, key appointments and accountability through the Department of Health to Ministers and to the local community. The duties of non-executive directors are to:

constructively challenge and contribute to the development of strategy;

scrutinise the performance of management in meeting agreed goals and objectives and monitor the reporting of performance;

satisfy themselves that financial information is accurate and that financial controls and systems of risk management are robust and defensible;

determine appropriate levels of remuneration of executive directors and have a prime role in appointing, and where necessary, removing senior management and in succession planning; and

ensure the board acts in the best interests of the public and is fully accountable to the public for the services provided by the organisation and the public funds it uses.

Non-executive directors also have a key role in a small number of permanent board committees such as the Audit and Assurance Committee, Remuneration Committee, Safety & Quality Committee and Investment & Workforce Committee. Further details may be obtained from Governing the NHS: A Guide for NHS Boards at www.dh.gov.uk. Reporting and Controls It is the boardâ&#x20AC;&#x2122;s duty to present through the timely publication of an annual report, annual accounts and other means, a balanced and readily-understood assessment of the organisationâ&#x20AC;&#x2122;s performance to:

the Department of Health, on behalf of the Secretary of State

the Audit Commission and its appointed auditors, and

the local community.

Detailed financial guidance, including the role of internal and external auditors, issued by the Department of Health must be observed. (Ref: the NHS Finance Manual at www.info.doh.gov.uk/doh/finman).The Standing Orders of boards should prescribe the terms on which Surrey and Sussex Healthcare NHS Trust ~ Corporate Governance Manual 2012/13 onwards Page 137 of 187

committees and sub-committees of the board may be delegated functions, and should include the schedule of decisions reserved for the board. Declaration of Interests It is a requirement that chairs and all board directors should declare any conflict of interest that arises in the course of conducting NHS business. All NHS organisations maintain a register of member’s interests to avoid any danger of board directors being influenced, or appearing to be influenced, by their private interests in the exercise of their public duties. All board members are therefore expected to declare any personal or business interest which may influence, or may be perceived to influence, their judgement. This should include, as a minimum, personal direct and indirect financial interests, and should normally also include such interests of close family members. Indirect financial interests arise from connections with bodies which have a direct financial interest, or from being a business partner of, or being employed by, a person with such an interest. Employee Relations NHS boards must comply with legislation and guidance from the Department of Health on behalf of the Secretary of State, respect agreements entered into by themselves or on their behalf and establish terms and conditions of service that are fair to the staff and represent good value for taxpayers’ money. Fair and open competition should be the basis for appointment to posts in the NHS. The terms and conditions agreed by the board for senior staff should take full account of the need to obtain maximum value for money for the funds available for patient care. The board should ensure through the appointment of a remuneration and terms of service committee that executive board directors’ remuneration can be justified as reasonable. Board directors’ remuneration for the NHS organisation should be published in its annual report.

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APPENDIX 1 TO SECTION E The Trust places high importance on appropriate accountability and openness in its working practices and endorses the recommended seven principles of conduct that underpin the work of public authorities NOLAN PRINCIPLES – SEVEN PRINCIPLES OF PUBLIC LIFE

‘Seven Principles of Public Life’ which should apply to all in the public service are: Selflessness Holders of public office should act solely in terms of the public interest. They should not do so in order to gain financial or other benefits for themselves, their family or their friends. Integrity Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might seek to influence them in the performance of their official duties. Objectivity In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit. Accountability Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office. Openness Holders of public office should be as open as possible about all the decisions and actions that they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands. Honesty Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest. Leadership Holders of public office should promote and support these principles by leadership and example. In addition to this members of NHS boards and governing bodies in England are expected to adhere to the New standards for NHS leaders. They put respect, compassion and care for patients at the centre of leadership and good governance. These standards are published by the Professional Authority for Health and Social Care. Copies of the standards are available at http://www.chre.org.uk/media/18/502/

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SECTION F

Anti-Fraud and Corruption Policy & Response Plan Subject: Policy Number Ratified By: Date Ratified: Version: Policy Executive Owner: Designation of Author: Name of Assurance Committee: Date Issued: Review Date: Target Audience: