May 2017 board papers by Surrey and Sussex Healthcare NHS Trust

Surrey and Sussex Healthcare NHS Trust Board papers

May 2017

Trust Board Meeting – IN PUBLIC Thursday 25th May – 11:00 to 13:00 AD77, Trust Headquarters, East Surrey Hospital, Canada Avenue, Redhill, RH1 5RH

AGENDA 1. 11.00

GENERAL BUSINESS 1.1 Welcome and apologies for absence

A McCarthy

Verbal

1.2 Declarations of Interests & Annual Declarations of Interests For approval

A McCarthy

Paper

A McCarthy

Paper

A McCarthy

Paper

A McCarthy

Verbal

M Wilson

Paper

G FrancisMusanu

Paper

2.1 Patient Story For assurance

D Holden/

Paper

2.2 Safety & Quality Committee Chair Update For assurance

R Shaw

Paper

2.3 Safer Staffing report & Care Hours Per Patient Day For assurance

F Allsop

Paper

2.4 Nasogastric Tube Safety Alert For assurance

F Allsop

2.5 Safety & Quality Indicators For assurance

F Allsop/ D Holden

Paper

A Stevenson

Paper

1.3 Minutes of the last meeting held on 25th April 2017 For approval 1.4 Action tracker & Matters arising For assurance 1.5 Chairman’s Report For assurance 1.6 Chief Executive’s Report For assurance 1.7 Board Assurance Framework & Significant Risk Register For approval 2. 11.30

3. 12.15

QUALITY OF CARE

Paper

OPERATIONAL PERFORMANCE 3.1 Integrated Performance Report (M01) For assurance 3.2 Operational & Access Performance Indicators For assurance

4. 12.30

5. 13:00

FINANCE AND USE OF RESOURCES 4.1 Finance and Workforce Committee Chair Update For assurance

R Durban

Paper

4.2 Workforce performance Indicators For assurance

M Preston

Paper

4.3 Finance & Use of Resources Performance Indicators For assurance

P Simpson

Paper

STRATEGIC CHANGE 5.1 Revisions to the Integrated Performance Report For approval

6. 13:15

13.25

A Stevenson

Paper

6.1 Retention Strategy – Progress Update For assurance & approval

M Preston

Paper

6.2 The Single Oversight Framework NHS provider licence – Self Certification – For approval

G FrancisMusanu

Paper

6.3 Updated Standards of Business Conduct Policy For approval

G FrancisMusanu

Paper

OTHER ITEMS 7.1 Minutes from Board Committees to receive & note

A McCarthy

LEADERSHIP & IMPROVEMENT CAPABILITY

7.1.1 Finance and Workforce Committee

Paper

7.1.2 Safety & Quality Committee

Paper

7.2

ANY OTHER BUSINESS

7.3

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 7.4

Review of Meeting

A McCarthy

7.5

DATE OF NEXT MEETING 29th June 2017 at 11.00am

A McCarthy

Verbal

TRUST BOARD IN PUBLIC

Date: 25th May 2017

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

Agenda Item: 1.2 TRUST BOARD ANNUAL DECLARATION OF INTERESTS Gillian Francis-Musanu Director of Corporate Affairs Gillian Francis-Musanu Director of Corporate Affairs N/A

Action Required: Approval (â&#x2C6;&#x161; )

Discussion ( )

Assurance (â&#x2C6;&#x161;)

Purpose of Report: To provide assurance to the Board on its statutory and regulatory requirements. Summary of key issues Under the Standing Orders of the Corporate Governance Manual and Standards of Business Conduct Policy, all staff including Board members have a statutory obligation to declare all external interests relating to their own or that of their partner which are relevant and material to the Trust. This report is the current Trust Board Annual Register of Interests as at 25th May 2017. Recommendation: The board is asked to receive and approve the report. Relationship to Trust Strategic Objectives & Assurance Framework: SO5: Well led - To be a high quality employer of choice and deliver financial and clinical sustainability around a patient centred, clinically led leadership model Corporate Impact Assessment: Legal and regulatory impact

Each member of the Board has a statutory obligation of declare all external interests

Financial impact

A requirement of Trust Standing Orders

Patient Experience/Engagement

N/A

Risk & Performance Management

None identified in the report

NHS Constitution/Equality & Diversity/Communication

This report will be available on the Trust website and is subject to Freedom of Information requests.

Attachment: BOARD MEMBERSâ&#x20AC;&#x2122; ANNUAL REGISTER OF INTERESTS: May 2017

2 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT – 25TH May 2017 ANNUAL BOARD DECLARATIONS OF INTEREST – May 2017 1.

Introduction

The purpose of this paper is to ensure good governance and transparency. On an annual basis members of the Board of Directors are required to update their declarations in relation to interests held. In accordance with Standing Order 7.1 ‘Declaration of Interests’ in the Trust’s Corporate Governance Manual. “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”. “The Code of Accountability requires declarations to be made in respect of “close family members” where it is possible that there may be a perception that judgement could be influenced. For the purposes of these orders, close family members is to include, as a minimum, spouses and/or partners”. As an NHS Trust and in accordance with the trust’s Standards of Business Conduct Policy requires that “the trust shall have a register of interests of the directors”. Furthermore, paragraph is states that “the trust shall make the registers available for inspection by members of the public…. The updated register for 2017-18 is included at appendix 1 and all members of the board have agreed for these details to be made available on the trust’s website. These interests will also be reported in the Trust’s Annual Report. In addition, at each meeting of the Board of Directors, and its Committees, members are asked to declare any further interests since the date of the last declaration and to notify the Chair of any conflicts of interest in relation to the agenda items for discussion (for which they may need to abstain). Any such declaration is recorded in the minutes. 2. Recommendation & Board action The Board of Directors is asked to receive this report and register the declarations of interest made by members of the Surrey & Sussed Healthcare NHS Trust Board.

Gillian Francis-Musanu Director of Corporate Affairs & Company Secretary 25th May 2017

APPENDIX 1 - BOARD MEMBERS’ REGISTER OF INTERESTS AS AT 31st MAY 2017

Name

Position held

Interests

Date of last declaration

Chair of Charity Commissioning Performance for “Sick” Festival Trustee of Brighton Dome and Festival Board Vice Chair Brighton Aldridge Community Academy Trustee of Albion in the Community Magistrate (Justice of the Peace) on the Surrey bench

20.04.17

Governor of Brooklands College of Further Education Non-executive Director W&J Linney Ltd Non-executive Director CAF Bank Trustee, Macfarlane Trust Part-time Clinical Paediatric Safeguarding Named Nurse at Queen Victoria Hospital NHS Foundation Trust Owner/Director – David Sadler Advisory Ltd Director Coach Associates Ltd Councilor Tandridge District Council Member Consumer Council for Water Member Fairchildes Academy Community Trust Director of Vaneal Ltd Associate Director of Engagement - UCB (global biopharmaceutical company)

27.04.17 25.04.17

Non-Executive Directors Alan McCarthy

Chairman

Richard Durban Richard Shaw Paul Biddle

Deputy Chairman & Nonexecutive Director Non-executive Director Non-executive Director

Pauline Lambert

Non-executive Director

David Sadler

Non-executive Director

Caroline Warner

Non-executive Director (Designate non-voting)

Daphnee Pushparajah Associate Non-executive Director (non-voting)

27.04.17

26.04.17 24.04.17 17.04.17 26.04.17

Executive Directors Michael Wilson

Chief Executive

Visiting Professor at Surrey University Honorary President of the East Surrey Branch of the NHS Retirement Fellowship CEO representative on the Programme Board for Health Education England for Surrey Acute Providers Special Advisor for the Care Quality Commission Member of the Health Education England Tele-enhanced Learning Programme Member of the National Trust Guiding Board â&#x20AC;&#x201C; Virginia Mason Institute Programme CEO Lead for Sussex & East Surrey STP Interim Chair of NHS STP Finance Group from 1.04.17

Paul Simpson Dr Desmond Holden

Chief Finance Officer & Deputy Chief Executive Medical Director

Fiona Allsop

Chief Nurse

Medical Director of Kent, Surrey & Sussex Academic Health 26.04.17 Science Network (1 day per week) Non-Executive Director of South East Health Technology Alliance Specialist Advisor for the Care Quality Commission 06.04.17

Angela Stevenson

Chief Operating Officer

None to declare

24.04.17

Mark Preston

Director of Organisational Development & People (non-voting)

None to declare

13.04.17

An Associated University Hospital of Brighton and Sussex Medical School

26.04.17

07.04.17

Ian Mackenzie Gillian FrancisMusanu

Director of Information & Facilities (non-voting) Director of Corporate Affairs & Company Secretary (non-voting)

None to declare

05.04.17

Home Office Authorised Person (Marriage Registrar) in London Borough of Hounslow & City of Westminster

17.04.17

An Associated University Hospital of Brighton and Sussex Medical School

Minutes of Trust Board meeting held in Public Thursday 30th March 2017 Room AD77, East Surrey Hospital Present (AM) Alan McCarthy (MW) Michael Wilson (PS) Paul Simpson (FA) Fiona Allsop (DH) Des Holden (AS) Angela Stevenson (RD) Richard Durban (PB) Paul Biddle (RS) Richard Shaw (DS) David Sadler (PL) Pauline Lambert (CW) Caroline Warner (DP) Daphnee Pushparajah

Chairman Chief Executive Deputy Chief Executive & Chief Finance Officer Chief Nurse Medical Director Chief Operating Officer Non-Executive Director and Deputy Chairman Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director (Designate) Associate Non-Executive Director

Chairman Chief Executive Deputy Chief Executive Chief Nurse Medical Director Chief Operating Officer Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Associate Non-Executiv

In Attendance (GFM) Gillian Francis-Musanu (MP) Mark Preston (CP) Colin Pink (SJ) Sue Jenkins 1.

Director of Corporate Affairs Director of Organisational Development and People Head of Corporate Governance Director of Strategy & KPO Lead (agenda Item 5.1)

General Business 1.1

Welcome and Apologies for absence AM opened the meeting by welcoming Trust Board Members, governors, members of the public and staff. AM welcomed Daphnee Pushparajah to the Trust as an Associate NED. Apologies for absence were noted from Ian Mackenzie

1.2

Declarations of Interest â&#x20AC;&#x201C; For approval AM asked whether any Board members had any additional declarations of interest. None were raised.

1.3

Minutes of the last meeting The minutes of the meeting held on 30th March 2017 were reviewed. These were agreed as an accurate record.

1.4

Action Tracker The Board reviewed the action tracker and GFM confirmed that there were no actions for discussion at the meeting.

1.5

There were no other matters arising. Chairmanâ&#x20AC;&#x2122;s Report for Assurance Page 1 of 8

AM reported that he had no issues to discuss with the Board that weren’t already included in the agenda. 1.6

Chief Executives report for Assurance The Board noted the report in advance of the meeting. MW introduced the report highlighting the recently refreshed five year forward view and focus on provision of urgent and emergency care, GP provision, cancer, mental health, frailty health and wellbeing, establishment and delivery of STPs and efficiencies. MW discussed the positive steps that have been identified and are included in the updated NHS ‘Race Equality Standard’. In response to a question from RS, MP highlighted that the Trust had identified that it had work to do to improve equal opportunities for leadership positions and should continue to focus on reducing experience of discrimination. It was also noted that the national report had highlighted that SaSH was one of the organisations where the numbers of BME staff referred for disciplinary action had in fact reduced. MW congratulated Prof Rane for his appointment as adjunct professor at the Icahn School of Medicine at Mount Sinai, New York. Congratulations to Mary Clare Salmon and Kerry Duval therapy rehabilitation assistants for recognition in the KHSS staff awards. AM asked if there are any significant changes in the ‘Five Year Forward View’. MW highlighted that the main focus was ensuring the development and establishment of urgent care models. MW went on to highlight work underway to increase community resource and develop the Trust’s capability to manage urgent care noting the work with the pilot and development of the use of physicians associates in local GP surgeries, the redevelopment of the front of the Emergency department to improve ambulance parking and increase the numbers of GP located within our Accident and Emergency Unit. The Trust is having good conversations with local GPs and CCG to identify what out of hours access needs to look like and in particularly the urgent care provision at local sites. Each of the four local sites provided different urgent care services operating on different models with unlinked IT systems, hence there is room for improvement for both service delivery and public understanding of what these services provide. CW asked for clarity over what percentage of attendances would be reviewed and managed by the GPs working in the emergency department and whether this proposal could increase emergency department attendance. MW stated that the full benefits of increased GP presence would not be known until it was in place. At present the Trust admits circa 90 people a day through its ED and it is key to reduce this number. It is possible that more people will come to ED to access a GP and this is in part linked to the locally reducing numbers of GPs available and as such is a sensible plan. AS commented the current service sees 6% of attendances, The Luton and Dunstable University Hospital has developed a model that sees 28% of its ED attendances seen at the front door by a GP. The Trust would like to increase its services to 20% of attendances. RD reflected that the plan had been discussed at the FWC. The Board went on to discuss the role of local urgent care, public understanding and use of available services and similarly the role of the local providers of Page 2 of 8

ambulance services and the choices they make when transporting patients. The Board congratulated Prof Rane, Mary Clare Salmon and Kerry Duval. The Board duly noted and took assurance from the report. 2.

Quality of Care 2.1 Patient Story for Assurance and approval DH introduced the patient story highlighting the patient, who was a 10 year old girl, and her parents experience as a patient of the Trust, all of which is detailed in the paper. The young girl needed a laparotomy to manage an appendicitis which was not diagnosed on the first two of three presentations at the hospital and is now well. The incident has been recorded as a serious incident because of the additional morbidity suffered by this patient. DH reported that the Trust had met with the family 5 times to discuss the matter, its investigation and to rebuild confidence in the Trust’s services. DH stressed that the diagnosis of appendicitis was difficult and in this case the original picture did not suggest appendicitis, however the continuing presence of symptoms could have been cause to review the initial diagnosis in full and act earlier. DH reported that in this instance the family was not aware that the story was being discussed at Board. The Board asked that the Trust makes the family aware that the story has been discussed and pass on its sincere apologies for their daughter’s and their experience of our care. Action DH PL asked what learning there was for the Trust, DH reflected on the reliance on the initial assessment and how the parents had experienced the Trust’s staff reaction to the incident, in which staff had rallied around the doctor involved and felt the need to discuss the matter regularly which the family had felt was very defensive. The incident has been discussed and shared widely internally. DP reflected on the complex nature of the incident and the number of human factors involved in decision making. RS asked if there was evidence to suggest that the surgical team had committed too early in this case. DH reflected that the cause of abdominal pain is hard to diagnose and in many cases will resolve without intervention, going on to highlight that on the second admission in particularly there was limited evidence to support diagnosis and opportunity to run more diagnostics. FA reflected that 5 local resolution meetings is high and wondered if the Trust could learn from cases where patient of family confidence has been significantly damaged. The Board asked that the Exec team consider the case and what can be learnt for the Trust focussing on the management of the resolution process. AM thanked DH for the presentation. The Board duly noted the report, took assurance and approved the report and action plan. 2.2

Safety & Quality Committee Chair Update for assurance The Board received and noted the report in advance of the meeting. RS introduced the report form the Safety and Quality Committee highlighting positive feedback form the executives’ quality and risk committee on the development of an overall assessment of the Trust’s services in line with the CQC’s key lines of enquiry. The committee had focused on reducing harm, Page 3 of 8

never events and positive movement on falls reduction. The Trust has reported 4 significant pressure ulcers, the Committee received assurance that cases are being reviewed and that actions are being delivered to reduce the rate of occurrence to earlier low levels. The Committee had also sought assurance of the local safeguarding systems by reviewing available feedback from serious case reviews. In both cases the Trust had dealt well with concerns that had been raised. The discussion highlighted the need to continue to increase awareness and vigilance. GFM asked for detail around the plan to attach NED to the CQC domains within the Trust’s compliance review. RS said that this was in the early development stages and is in consideration and would probably be a scrutiny and awareness opportunity. The Board duly noted and took assurance from the report. 2.3

Safety and Quality Indicators for Assurance The Board received and noted the report in advance of the meeting. FA introduced the safety elements of the report highlighting improvements in safety thermometer date the two serious incidents reported in month. DH highlighted the five MRSA blood stream infections reported in year, two of which are considered to be contaminates and not true infections. The infection control team is reviewing competencies for blood sample taking. DH went on to discuss the number of C. diff cases reported by the Trust, noting that the end of year position on lapses in care is yet to be agreed. DH reflected that lapses of care are being attributed when there is no evidence to support clinical judgments for example when the decision not to isolate has not been recorded; there are also human factors. DH reported that the Trust’s HSMR mortality indicator is rising but still below the national average. The Trust is speaking to ‘Dr Foster’ to understand what is driving this rise. The Trust’s SHMI mortality indicator which takes into account patient death up to within 30 days of discharge is the second lowest in Kent, Surrey and Sussex. Ian Wilkinson, Consultant Ortho-geriatrician and fractured neck of femur lead for the AHSN has reviewed the Trust’s management of each patient and has not identified any clinical concerns associated with the increase in fractured neck for femur HSMR, this continues to be reviewed. FA reported that patient experience indicators remain broadly good and that the friends and family test for the emergency department is the 5th best nationally. The Board duly noted and took assurance from the report.

2.4

Safer Staffing and Care Hours Per Patient Day Report for assurance The Board received and noted the report in advance of the meeting. FA presented the report highlighting previous conversations relating to the indicators for Burstow ward. No safety concerns have been raised; during peaks of activity midwives are pulled to Burstow to support the team. This might impact on patient experience but this has not appeared as a strong trend to date. There were no questions raised. Page 4 of 8

The Board duly noted and took assurance from the report. 2.5

Safer Working Guardian Quarterly Report for assurance The Board received and noted the report in advance of the meeting. The Board discussed the report which was presented by MP. The new junior doctors’ contract is being implemented effectively, there have been no issues that have resulted in external fines and exception reporting from individual junior doctors is reducing. Full implementation is expected by August 2017. DH reported that the issue effecting FY1’s in surgery have been resolved and there are lessons to learn about how to manage and resolve concerns raised by individual staff groups. MW, DH speak with the junior doctors regularly at present they are not raising any concerns and are not currently attending the forum set up to discuss the new contracts implementation. The Board duly noted and took assurance from the report.

2.6

Serious Incident Report for assurance The Board received and noted the report in advance of the meeting. FA introduced the report highlighting overall numbers. The Trust reported eight serious incidents in Q4 2016/17. The Trust has eight serious incidents open with the CCG, of which two have been submitted for closure and one downgrade has been requested. FA reported that 54% (19) of the serious incidents that occurred in the last twelve months relate to patient falls. The Trust’s management of the system to support SI investigation is in a good position. FA will include learning from events in future reports. The Board discussed the trends in the report noting that numbers of incidents have raised, specifically the numbers of low or no harm occurrences. FA highlighted that this is a good sign that the reporting culture for the Trust continues to improve. The Board duly noted and took assurance from the report.

Operational Performance Report 3.1

Integrated Performance Report (M12) for assurance The Board received and noted the report in advance of the meeting. AS presented the operational and access performance indicators detailed in the integrated performance report. The ED national standard was met in March. There is an accident and emergency delivery board looking at system wide issues and the Trust is working closely with SECAMB. The risk to ED standard remains significant on the Trust’s system. The Trust has achieved good performance for cancer access standards over the last 9 months. This is impacting on RTT as the Trust focuses on maintaining cancer standards. Capacity issues are affecting delivery of RTT. The Trust is migrating its RTT management systems and has identified 19 patients who have waited longer Page 5 of 8

than 52 weeks for treatment. Each case is reviewed using root cause analysis methodology and learning is shared with NHSI. There is an element of patient choice within this group of patients. AS reported that diagnostic performance is good. The Board duly noted and took assurance from the report. 4.

Operational Performance 4.1

Finance and Workforce Committee Chair Update for Assurance The Board received the report in advance of the meeting. RD introduced the report highlighting that the Committee had taken good assurance from workforce KPIs. The Committee is seeking assurance and greater understanding of the management of recruitment of over-seas nurses. To date circa thirty of the one hundred expected nurses have commenced work with the Trust. FA confirmed that this was being reviewed and the FWC would receive an update in due course. RD reported that the FWC had considered the draft accounts with an end of year position of £3.9 million surplus. The Committee had discussed the associated risk in detail. The Committee had taken assurance on Financial control; the trust has developed good systems for the divisions using service level reporting methodology. The issues that impact on the Trust’s income and expenditure remain the same; the balance between elective and none elective activity, agency use and patient flow. The Committee had considered the plans that are being developed to support the deployment of an electronic patient record once the loan funding is received. The Board will need to understand this plan once developed. Loan funding is expected by August 2017. The Board duly noted and took assurance from the report.

4.2

Workforce performance indicators for Assurance The Board received the report in advance of the meeting. MP highlighted that the sickness rates dropped to 3.5% of which 3% are long term. MP reported that the Trust is considering adjusting its targets for sickness absence and turnover to align with Trust performance and national indicators. For example staff turnover target is 12%, comparing to rates nationally of 14% and 15% in similar Trust’s. The Trust’s performance has not reached 12% for turnover. The Board asked MP to consider applying a stretch target for these indicators. The Board duly noted and took assurance from the report.

4.3

Finance and Use of Resources Performances Indicators for Assurance The Board received the paper in advance of the meeting. Page 6 of 8

PS reported that the Trust has reported a £3.7 million surplus end of year position in its unaudited accounts, which is £0.2 million adverse to its revised forecast position £3.9 million. The Trust did not achieve its 2016/17 control total. March was a good month for activity, income and control of spend within the divisions. The Trust’s cash position is good, supported by the working capital facility. The Trust’s better payment practice indicator is twice as good as the position for March 2016. There is however an income dispute between the Trust and East Surrey CCG. The Trust delivered its capital budget, noting that £1.1 million has been deferred to the 2017/18 financial year to support the national NHS. The Board discussed activity in March. AS noted that there had been two weeks of good performance at the start of March which provided scope to deliver more elective activity throughout the month. DH reflected that the clinical teams had taken steps to support this, cancelling audit half days and taking extra patients in clinics. Clinical teams had positively taken action to support the need to deliver March. PB noted that the Audit and Assurance Committee had requested detailed assurance on the Trust’s ‘Going Concern’ position. The AAC had agreed that the Trust is a ‘Going Concern’ there is a much improved cash and liquidity position, the Trust has a realistic financial plan bolstered by changes to the national tariff and strategic transformation funds and if necessary a credit facility is available. The Board duly noted and took assurance from the report. 5

Strategic Change 5.1 Annual Plan Q4 Update for assurance The Board received the paper in advance of the meeting. SJ presented the report highlighting that of the 71 actions, 80% had been completed in year. Those actions that are not linked to the 2016/17 financial year have been carried forward and the Executive Team is updating the 2017/18 annual plan. The Board discussed the format of the report highlighting the balance between detailed levels of visibility of actions within the plan versus the opportunity to present a smaller number of combined actions for ease of review. GFM and SJ agreed to consider the format before the next (Q1) report. The Executive Team find the report format useful. The Board asked for clarification as to the delays in migration to NHS mail from internal email. PS highlighted that the program was running slower than anticipated due to technical challenges but this was being pursued due to the realisation of quality gains. The Board duly noted and took assurance from the report. 6

Leadership and improvement capability 6.1 Updated Rules of Procedure for assurance The Board received the Rules of Procedure in advance of the meeting. GFM introduced the review of Rules of Procedure which has been updated Page 7 of 8

following changes throughout the year. The Rules of Procedure sets out the Board of Director’s integrated governance systems for the Trust. AM highlighted some minor amendments to details of TOR relating to consistency of language. The Board ratified the Rules of procedure, delegating authority to AM and GFM to make minor amendments. The Board duly noted and took assurance from the report. Other Items 7

7.1

Minutes of Board Committees to receive and note

7.1.1

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

7.1.2

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

7.2

Any Other Business The Board congratulated Trust staff for the delivery of a fantastic financial year for delivery of national standards, staff wellbeing and income and expenditure. No further business was raised.

7.3

Questions from the Public No formal questions from the public received were received.

7.4

Review of the Meeting It was felt that the presentation and discussion of IPR was disjointed and its slot and flow on the agenda need to be re-considered. Both Private and Public Board had detailed agendas and as such the quality of conversation lessened towards the end of the public meeting. Patient’s stories remain key, to ground the overall conversation.

7.5

Date of the next meeting Thursday 25th May 2017 at 11.00am in Room AD77, Trust Headquarters, East Surrey Hospital

Note: This is a public document and therefore will be placed into the public domain via the 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 8 of 8

TRUST BOARD ACTION TRACKER - PUBLIC BOARD MEETING - May 2017 Action Ref

Forum

Subject

Action

TBPU - 21

TB Public

TBPU - 22

TB Public

Workforce performance Indicators IPR

TBPU -23

TB Public

Clinical Presentation

TBPU -24

TB Public

TBPU -25

TBPU -26

Date Open

Date Due

Date Closed

The Board asked that an overview of the retention MP discussion be heard at public board. The Board asked that SQC receive a briefing on the RS/AS RCA process relating to the identification of long waiters within RTT The board asked two receive twice yearly updates on DH / DH the Hospital Pharmacy Transformation Plan

26/01/2017

31/05/2017

CLOSED

23/02/2017

30/06/2017

Open

30/03/2017

30/09/2017

Open

SQC Update

FA to provide the board with an update on Trust' assessment of alignment with CQC guidance

30/03/2017

30/06/2017

Open

TB Public

Review of Staff Survey

The Board noted this and asked for a quarterly update MP on what is being done to resolve the issues of abuse of staff highlighted in the staff survey

30/03/2017

30/06/2017

Open

TB Public

Patient story

DH to contact the family involved to express the Boards apologies for their experience of the Trust's care

27/04/2017

31/05/2017

OPEN

Status

Date: 25th May 2017

TRUST BOARD IN PUBLIC

Agenda Item: 1.6 REPORT TITLE:

CHIEF EXECUTIVE’S REPORT

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

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

Action Required: Approval ( )

Discussion (√)

Assurance (√)

Purpose of Report: To ensure the Board are aware of current and new requirements from a national, regional and local perspective and to discuss any impact on the Trusts strategic direction. Summary of key issues Regional/National:  Funding for next winter to ease pressure on accident and emergency Local:  Trust’s response to the NHS cyber attack  Frontier Pathology Retain UKAS Accreditation  Successful Hot Topic Event on Diabetes  Marathon - Fundraising for SASH Charity 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 - To be a high quality employer of choice and deliver financial and clinical sustainability around a patient centred, clinically led leadership model. Corporate Impact Assessment: Legal and regulatory impact

Ensures the Board are aware of current and new requirements.

Financial impact

N/A

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

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

TRUST BOARD REPORT – 25th May 2017 CHIEF EXECUTIVE’S REPORT 1.

National/Regional Issues

1.1

Funding for next winter to ease pressure on accident and emergency (A&E) departments in England.

The Department of Health has recently announced the allocation of £55.98 million of the £100 million A&E capital funding, outlined in the spring Budget by the Chancellor, to ease pressure on emergency departments in time for next winter. The funding awarded at this stage is being allocated to 70 NHS hospitals. The funding will be used by hospitals to meet the 95% standard of admitting, transferring, or discharging patients within 4 hours by ensuring patients are treated in the most appropriate setting. The Board will be pleased to note that Surrey and Sussex healthcare NHS Trust has been successful in securing funding in this allocation. The plans outlined by trusts include primary care streaming and co-locating GP practices within A&E departments to ensure patients are treated in the most appropriate setting. This investment is one part of the A&E plan being implemented across the NHS this year to get performance to 95% during 2018.

Local Issues

2.1

Trust’s response to the NHS cyber attack

On Friday 12th May a world-wide Ransomware cyber-attack took place. This included a significant attach against the NHS. Whilst there was no evidence that SaSH was included in this attack the Trust took a number of actions to ensure that it remained secure. These included disabling access to internal and external email from Friday evening to Monday morning. All clinical systems remained functional throughout the whole period. At the same time all Trust computers were patched with the latest antivirus and antiransomware updates that became available over the weekend. The Trust had already applied previously released updates that dealt with this know security issue. Approximately forty eight NHS Trusts were affected by this ransomware attack. No patients at SaSH were adversely affected by this event. 2.2

Frontier Pathology Retain UKAS Accreditation

The Board would be interested to note that following an assessment by UKAS (United Kingdom Accreditation Service) we have retained accreditation in meeting the international laboratory quality standard at our microbiology team at based at Crawley Hospital, part of our Frontier Pathology partnership with Brighton and Sussex University Hospitals NHS Trust. This is great news and is recognition of the hard work and effort of the whole team.

2.2

Successful Hot Topic Event on Diabetes

On 27th April we held our latest Hot Topic event hosted by the children’s and adults’ diabetes teams. The event was well-attended and I was delighted to join patients, their friends and family along with colleagues from SASH to hear more about the history of diabetes, the differences between Type 1 and Type 2 diabetes and how, working in partnership, the teams support patients and their families to manage their own diabetes care. It was interesting to also hear more about the wide range of vital national diabetes research that our diabetes teams and many of our patients are involved in. My thanks to everyone involved. 2.3

London Marathon - Fundraising for SASH Charity

Our thanks go to Nikki Tapal, from our phlebotomy team, who successfully completed the London Marathon on 30th April raising nearly £1,500 for SASH Charity. I know that many people also took part and completed the London Marathon, including Kate Knight, nursing assistant, who has now completed an amazing 47 marathons – congratulations and well done to you all. 3.

Recommendation

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

Michael Wilson CBE Chief Executive May 2017

Date: 25th May 2017

TRUST BOARD IN PUBLIC

Agenda Item: 1.7 REPORT TITLE: EXECUTIVE SPONSOR: REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

Board Assurance Framework & Significant Risk Register Gillian Francis-Musanu Director of Corporate Affairs Colin Pink Head of Corporate Governance Private Board 27/04/17 and Executive Team 17/05/17

Action Required: Approval (√ )

Discussion (√)

Assurance (√)

Purpose of Report: The 2017/18 Board Assurance Framework (BAF) highlights potential risks to the Trust’s strategic objectives, mitigating actions and the implementation of its programme of objectives for year two of the five year plan. The Significant Risk Register (SRR) details risks on the Trust risk register system that are recorded as significant which have been considered by the Executive Team and the links to the Board Assurance Framework. Summary of key issues The BAF details 14 risks to the Trust’s strategic objectives as discussed at the April Private Board, 6 of which are recorded as significant risks to delivery of strategy. There are 7 significant risks recorded on the Trust risk register. Recommendation: The Board is asked to discuss and approve the report and consider the following:  Delivery of Trust strategy and annual priorities, assurance, risk, mitigation and action.  Does the Board agree with the recorded controls and assurances listed in the BAF? The Board is asked to note the risks as recorded on the SRR. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe – Deliver safe, high quality care and improving services which pursue perfection and be in the top 25% of our peers SO2: Effective – As a teaching hospital, deliver effective and improving sustainable clinical services within the local health economy SO3: Caring – Work with compassion in partnership with patients, staff, families, carers and community partners SO4: Responsive – To continue to be the secondary care provider of choice for the people of our community

An Associated University Hospital of Brighton and Sussex Medical School

SO5: Well led - To be a high quality employer of choice and deliver financial and clinical sustainability around a patient centred, clinically led leadership model Corporate Impact Assessment: Legal and regulatory impact Financial impact Patient Experience/Engagement

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

Risk & Performance Management

These are highlighted throughout the report.

NHS Constitution/Equality & Diversity/Communication

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

Attachment: May 2017 BAF and the May Public Board SRR

An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT – 25th May 2017 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 strategic 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. 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 BAF was reviewed by the Executive team throughout May and updated to reflect current position, including updates following review at the April private board meeting. 2.1

Overview

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 17/18 BAF (attached) details a total of 14 risks to the 5 Trust strategic objectives which are scored as follows: Objective 1. Safe – Deliver safe, high quality care and improving services which pursue perfection and be in the top 25% of our peers 2.Effective – As a teaching hospital, deliver effective and improving sustainable clinical services within the local health economy 3.Caring – Work with compassion in partnership with patients, staff, families, carers and community partners 4. Responsive – To continue to be the secondary care provider of choice for the people of our community 5. Well led - To be a high quality employer of choice and deliver financial and clinical sustainability around a patient centred, clinically led leadership model Total

Red (15-25)

Amber (8-12)

Green (1-6)

An Associated University Hospital of Brighton and Sussex Medical School

2.2 Headline information by objective (BAF) SO1: Safe – Deliver safe, high quality care and improving services which pursue perfection and be in the top 25% of our peers

Initial Risk Rating: Severity x Likelihood

1.1 There is a risk that the Trust will not be in the top quartile 25% for safety and continue to improve beyond this benchmark if opportunities to innovate and learn from benchmarked outcome data/peer review are not adopted and implemented SO2: Effective – As a teaching hospital, deliver effective and improving sustainable clinical services within the local health economy

S4 x L3 = 12

Initial Risk Rating: Severity x Likelihood

2.1 There is a risk that the Trust will not meet its objective of delivering effective and sustainable care if it does not embed relevant research and education programmes that support the development of local services with the best outcomes. 2.2 There is a risk that the Trust will not meet its annual priority to improve discharge planning if suitable plans are not developed and delivered within year. SO3: Caring – Work with compassion in partnership with patients, staff, families, carers and community partners

SO4: Responsive – To continue to be the secondary care provider of choice for the people of our community

Target Risk Score

S3 x L2 = 6

S3 x L3 = 9

S3 x L1 = 3

Initial Risk Rating: Severity x Likelihood

S4 x L4 = 16

Current Risk Rating: Severity x Likelihood

S4 x L1 = 4

S3 x L3 = 9

4.1 There is a risk that the Trust will not meet its objective of becoming the secondary provider of choice for our catchment area if it does not deliver all national standards including seven day working.

S4 x L2 = 8

Target Risk Score

S4 x L3 = 12

Initial Risk Rating: Severity x Likelihood

3.1 There is a risk that the Trust will not meet its annual priority to promote the conditions that create the best environment for patients if it does not seek to shape patient centered clinical services and learn from all sources of patient feedback.

Current Risk Rating: Severity x Likelihood

S3 x L3 = 9

Current Risk Rating: Severity x Likelihood

S4 x L3 = 12

Target Risk Score

S3 x L2 = 6

Target Risk Score

S4 x L2 = 8

An Associated University Hospital of Brighton and Sussex Medical School

SO4: Responsive – To continue to be the secondary care provider of choice for the people of our community

Initial Risk Rating: Severity x Likelihood

4.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the necessary capacity, which will have an adverse impact on elective care, income, expenditure and ultimately quality objectives. SO5: Well led - To be a high quality employer of choice and deliver financial and clinical sustainability around a patient centred, clinically led leadership model

S5 x L3 = 15

Initial Risk Rating: Severity x Likelihood

5. There is a chance that the Trust may not meet its priority to benefit from the opportunities of strengthening partnerships, collaboration and developing high quality safe and sustainable systems that emerge from the solutions within the STP. 5.1 There is a risk to the Trust’s short term financial stability if the annual income plan is not delivered. 5. 2 There is a risk to the Trust’s short term financial stability if in-year divisional spending exceeds budget 5. 3 There is a risk to the Trust’s longer term financial stability if it is unable to deliver its medium term financial plan. 5. 4 There is a risk to the Trust’s ability to operate if its historic liquidity position restricts its ability to physically pay for expenditure. 5.5 There is a risk that the Trust will not meet its objective of becoming an ‘employer of choice’ if it does not deliver a workforce strategy that drives the recruitment and retention of talent, provides the relevant skill-mix for operational delivery and supports on-going professional education, training and development across all staff groups. 5.6 There is a risk that the Trust will not meet its objective of becoming an ‘employer of choice’ if it does not deliver a workforce strategy that seeks to prioritise staff health, safety, well-being, engagement and inclusion. 5.7. There is a risk that the Trust will not fully realise the benefits available from well embedded IT systems.

Current Risk Rating: Severity x Likelihood

S5 x L3 = 15

Current Risk Rating: Severity x Likelihood

Target Risk Score

S5 x L2 = 10

Target Risk Score

S4 x L3 = 12

S3 x L3 = 9

S5 x L3 = 15

S4 x L2 = 8

S5 x L3 = 15

S3 x L2 = 6

S5 x L3 = 15

S4 x L2 = 8

S5 x L3 = 15

S4 x L3 = 12

S5 x L3 = 15

S3 x L2 = 6

S3 x L3 = 9

S3 x L2 = 6

S5 x L3 = 15

S4 x L3 = 12

S3 x L3 = 9

An Associated University Hospital of Brighton and Sussex Medical School

2.3.

Key risks Strategic risks Identified

The BAF highlights the following 6 key red risks to the Trust objectives that have been identified at time of updating the framework (including the proposed reduction). As follows: Risk description 4.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the necessary capacity, which will have an adverse impact on elective care, income, expenditure and ultimately quality objectives. 5.1 There is a risk to the Trust’s short term financial stability if the annual income plan is not delivered. 5. 2 There is a risk to the Trust’s short term financial stability if in-year divisional spending exceeds budget

Initial rating

5. 3 There is a risk to the Trust’s longer term financial stability if it is unable to deliver its medium term financial plan. 5. 4 There is a risk to the Trust’s ability to operate if its historic liquidity position restricts its ability to physically pay for expenditure. 5.5 There is a risk that the Trust will not meet its objective of becoming an ‘employer of choice’ if it does not deliver a workforce strategy that drives the recruitment and retention of talent, provides the relevant skill-mix for operational delivery and supports on-going professional education, training and development across all staff groups.

Current rating

Target risk

S5 x L3 = 15

S5 x L2 = 10

S5 x L3 = 15

S4 x L2 = 8

S5 x L3 = 15

S3 x L2 = 6

S5 x L3 = 15

S4 x L2 = 8

S5 x L3 = 15

S4 x L3 = 12

S5 x L3 = 15

S3 x L2 = 6

3. Significant Risk Register There are 7 risks on the Trust significant risk register. Each risk is in date and has mitigating actions to reduce the level of risk to an acceptable level. 3.1 SRR Breakdown ID

Initial Rating

Title

Failure to maintain Emergency Department performance 1678 RTT Access Standards 1491

Liquidity: Inability to pay creditors/staff 1604 resulting from insufficient cash due to poor liquid position 1689 Risk of Contract income below plan Risk of not achieving Cost Improvement Plan Risk of potential overspending from 1688 operational pressures Unable to deliver realistic medium term 1603 financial plan 1663

Current Rating

Residual Next Rating Review

31/05/2017

25/08/2017

23/06/2017

An Associated University Hospital of Brighton and Sussex Medical School

4. Discussion/Action The Board is asked to discuss and approve the report and consider the following: ď&#x201A;ˇ Delivery of Trust strategy and annual priorities, assurance, risk, mitigation and action. ď&#x201A;ˇ Does the Board agree with the recorded controls and assurances listed in the BAF. The Board is asked to note the risks as recorded on the SRR. Gillian Francis-Musanu Director of Corporate Affairs May 2017

Colin Pink Head of Corporate Governance

An Associated University Hospital of Brighton and Sussex Medical School

Appendix 1: Risk Appetite â&#x20AC;&#x201C; 2017/18 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 to improve quality are justifiable and the management controls in place are well defined and practicable. Target: Green Innovation: The Trust is highly supportive of service development and innovation and will seek to encourage and support it at all levels with a high degree of earned autonomy. We recognise that innovation is a key enabler of service improvement and drives challenge to current practice both internally and across the wider health economy. Target: Amber Well Led: The Board acknowledges that healthcare and the NHS operates within a highly regulated environment, and that it has to meet high levels of compliance expectations from a large number of regulatory sources. It will meet those expectations within a framework of prudent controls, balancing the prospect of risk reduction and elimination against pragmatic operational imperatives. The Board will seek to innovate and take risks where there is potential to develop inspirational leadership as it recognises that this is key to both becoming the local employer of choice and developing strategic partnerships with new bodies. Target: Green Financial: The Trust is prepared to invest for return and minimise the possibility of financial loss by managing risk to a tolerable level. The Board will take decisions that may result in an adverse financial performance rating in the face of opportunities that balance safety and quality and are of compelling value and benefit to the organisation. The Board acknowledges that financial challenges throughout 2017/18 will be significant and 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 by our internal or external audiences, 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 or has the potential to adversely affect the working lives of our employees will be balanced very carefully against any potential benefits The Board recognises the complications attached to recruitment, retention and skill-mix that are caused by geographical and national position. Target: Green

An Associated University Hospital of Brighton and Sussex Medical School

Appendix 2: SASH risk quantification matrix

An Associated University Hospital of Brighton and Sussex Medical School

Abridged consequence chart Risk Type Patient Safety

Insignificant  No obvious injury / harm

Minor

Moderate

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

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

Extreme

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

 Avoidable death

 Minor harm event involving >5 patients

 Moderate harm event involving >5 patients

 Major harm incident involving >5 patients

 Minor unsatisfactory patient experience related to treatment / care given

 Unacceptable patient experience related to poor treatment / care

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

 Informal complaints raised / PALS contacted

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

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

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

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

Major

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

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

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

 No harm injury

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

 Medical treatment required

 Permanent or extensive injury / ill health / permanent disability or loss of limb (RIDDOR reportable)

 Death (RIDDOR reportable)

Financial Management  Small loss <£1K

 Minor loss £2K to £100k

 Moderate loss, £100k - £1M

 Major loss, £1M-£10M

 Loss > £10M

Governance Arrangements

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

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

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

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

 Adverse Monitor continuity of service rating <1 month

 Adverse Monitor continuity of service rating > 1 month

 A breach of Monitor Terms of authorisation

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

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

Health & Safety

Quality of Service

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

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

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

 Injury / ill health resulting in >7 days absence from work or restricted duties for >7 days (RIDDOR reportable)

An Associated University Hospital of Brighton and Sussex Medical School

Page 1

Objective 1 - Safe –Deliver safe services and be in the top 20% against our peers Priority ID and reference Director responsible 1.A Consistently meet national patient safety standards in all specialties and across divisions Initial Risk Key Action for 2016/17 objectives 1.1 There is a risk that the Trust will Current rating and description of any potential not be in the top quartile 25% for significant risk to this priority safety and continue to improve Target risk score beyond this benchmark if opportunities to innovate and learn Linked to Risk from benchmarked outcome data/peer review are not adopted and implemented

Chief Nurse / Medical Director S4 x L3 = 12 S4 x L2 = 8 S4 x L1 = 4 1009,1055

Controls in place (to manage the risk) 1) Clinical teams in place to implement patient safety plans in the Trust (falls, pressure ulcers, sepsis, AKI and infection control) 2) Regular review of patient safety data including incidents, HSMR, the Safety Thermometer at ward, divisional, executive and board level 3) Work undertaken to deliver ‘5 sign up to safety pledges’ (Monitoring patients for early signs of deterioration, Pain management for Dementia, Duty of Candor, COPD EQ pilot and improve shared learning from incidents) 4) Nursing staffing levels monitored and related issues managed daily 5) National patient safety alerts NICE guidance and other safety related guidance reviewed and implemented where relevant and appropriate 6) Serious incident review group in place to monitor and evaluate investigation progress and demonstrate progress against agreed actions 7) IPCAS Team and Group in place, Weekly taskforce meetings in place 8) Assurance process in place for C. diff / MRSA blood stream infection.

Gaps in Control 1) Developing systems to support safety benchmarking

Potential Sources of Assurance (documented evidence of controls effectiveness) 1) External reports and visits to clinical areas both scheduled and unscheduled (e.g. opportunity walks / CQC /audit) 2) Divisional and Trust Level Dashboards 3) SASH + Program 4) Benchmark reporting 5) Compliance with NICE guidance

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

Page 2

Positive (+) CQC Chief Inspector of Hospitals Report (+) CNST level 2 Maternity (+) Incidence of Hospital Acquired Pressure Damage reduced and sustained (+) EWS audit, action plan in place including development of electronic systems (+) Datix incident reporting and analysis including increase in reporting (+) Datix linkages to audit and strengthening legal affairs systems (+) Monthly trust wide reporting using national benchmarking (+) Falls Training data (+) Strong evidence of improved SI investigation management and closures (+) Improved reporting of patient falls has enabled the Trust to understand fall profile and revised strategy and action plan in development (+) Initiation of ‘Stop, Access, Send’ initiative for the management of loose stool (+) Management of diarrhoea ‘SASH+ Value Streams’ (+) Antimicrobial prescribing audit compliance

(+) NRLS reporting Negative (-) Never events incidence (-) Incidence of CDI 2016/17 (-) MRSA 3 x BSI Gaps in assurance Ability to benchmark in real time and data quality of elements of reporting Mitigating actions underway 1) VMI/SASH plus development program 2) 5 work streams identified in Trusts sign up to Safety Pledges (Monitoring patients for early signs of deterioration, Pain management for Dementia, Duty of Candor, COPD EQ pilot and improve shared learning from incidents) 3) Actions described in the IPCAS strategy Update by

Page 3

FA 08/05/17 DH 19/05/17

Date discussed at board

Assurance Level gained: RAG Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Ongoing 2) Ongoing action plan 3) Ongoing

May 2017

Objective 2 - Effective â&#x20AC;&#x201C;Deliver effective and sustainable clinical services within the local health economy Priority ID and reference Director responsible 2.A Achieve the best possible clinical outcomes for our patients Initial Risk Key Action for 2016/17 objectives 2.1 There is a risk that the Trust will Current rating and description of any potential not meet its objective of delivering significant risk to this priority effective and sustainable care if it Target risk score does not embed relevant research and education programmes that Linked to Risk support the development of local services with the best outcomes. Controls in place (to manage the risk) 1) Oversight training by GMC/RCN/ other professional bodies for AHPs 2) Local Academic Board in place 3) CRN oversight of the research portfolio 4) Practice development model in nursing Potential Sources of Assurance (documented evidence of controls effectiveness) 1) GMC Survey trainees 2) Staff surveys (Qs relating to training/ doing job / appraisal) 3) Benchmarked reports from Academic Health Science Network Enhancing Quality and Recovery Programme 4) NHSE 7 day service returns 5) Reporting on patient recruitment to studies / % achieved recruitment st targets and % studies meeting recruitment of 1 patient from study initiation deadlines 6) Internal Audit review of BAF risk provides assurance 7) R+D and Chief of Education both agreed to reports / position statements for SQC per year

Gaps in assurance Position is known, future state needs to be developed Mitigating actions underway

Page 4

19/05/2017

S4 x L3 = 12 S3 x L3 = 9 S3 x L2 = 6 TBC

Gaps in Control 1) Educational bodies not yet forward looking enough to provide new staffing models. Therefore Education models not aligned with future needs 2) KSS CRN worst performing nationally measured by cost each patient recruited to studies and patient recruitment per 1000 population Actual Assurances: Positive (+) or Negative (-) Positive (+) Met end of year stretch target for recruitment to clinical studies (+) Good benchmark nationally for national metrics relating to the number days to recruit a patient to a study within 70 days of approval. (+) GMC survey improving (for instance gateway 2 dark green flags and reducing red flags in pediatrics) (+) funding received from KSS CRN continues (based on formula that rewards recruitment) (+) HEKSS funding of school of Physicians Associates and Mouth Care Matters programs (+) New COO appointed to KHS CNN with strong track record â&#x20AC;&#x201C; opportunity for new leadership development as job share clinical director as stood down (+) Frist draft of education strategy available for comment and review (+) SASH have recruited more than 300 patients into NIHR adopted studies (10%) of total regional recruitment (+) Research report taken at SQC (+) Education report taken at SQC Negative Narrative: Most of what is currently available relates to/supports traditional structure and expectations that needs to be challenged and changed (see 5YFV, STPs). Challenge needs to focus on smarter strategy and intelligence. (-) NIHR have not renewed contracts for current CRN managing directors Assurance Level gained: RAG Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. TBC

1) Strategic actions being developed Update by

Medical Director

Date discussed at board

May 2017

BAF Risk 2.2 to follow Objective 2 - Effective â&#x20AC;&#x201C;Deliver effective and sustainable clinical services within the local health economy Priority ID and reference Director responsible 2.A Achieve the best possible clinical outcomes for our patients Initial Risk Key Action for 2016/17 objectives 2.2 There is a risk that the Trust will Current rating and description of any potential not meet its annual priority to significant risk to this priority improve discharge planning if Target risk score suitable plans are not developed and delivered within year. Linked to Risk

TBC

Controls in place (to manage the risk)

Gaps in Control

Potential Sources of Assurance (documented evidence of controls effectiveness)

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

Gaps in assurance

Assurance Level gained: RAG

Mitigating actions underway

Update by

Page 5

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

Date discussed at Board

Objective 3 - Caring – Ensure patients are cared for and feel cared about Priority ID and reference 3. Ensure patients are cared for and Director responsible Chief Nurse feel cared about Initial Risk S3 x L3 = 9 Key Action for 2016/17 objectives 3.1 There is a risk that the Trust will Current rating S3 x L3 = 9 and description of any potential not meet its annual priority to Target risk score S3 x L2 = 6 significant risk to this priority promote the conditions that create the best environment for patients if it Linked to Risk TBC does not seek to shape patient centered clinical services and learn from all sources of patient feedback. Controls in place (to manage the risk) Gaps in Control 1. Patient experience committee reviews performance and escalates Hard to reach groups of patients areas of work and concerns to Executive Committee for Quality & Risk Patient listening events (ECQR) and Board 2. ECQR receives reports and provides feedback 3. Quarterly meetings with Surrey and Sussex Healthwatch 4. Opening visiting in place 5. Engagement with the voluntary sector 6. Carers support network, involvement in John’s campaign 7. Open visiting introduced in general ward areas Potential Sources of Assurance (documented evidence of controls Actual Assurances: Positive (+) or Negative (-) effectiveness) 1. Your Care Matters (YCM) results (including free text comments) Positive 2. FFT scores and free text responses (+) Carers passport 3. Staff survey (+) Standards of behavior and feedback from staff 4. National patient surveys (+) National cancer survey 5. Complaints (+) National pediatric survey 6. PALS concerns (+) Patient feedback 7. Duty of Candour (+) Place audit 8. Engagement with representatives from shadow Council of Governors (including patient experience committee) Negative 9. Patient feedback with SASH plus improvement work (-) No clear improvement in YCM or national results relating to discharge or 10. Feedback from open visiting communication around medication and danger signals 11. PROMS rolling out to show we care about patients (-) Outpatient YCM comments 12. Ward improvement linked to access and signage (-) National patient survey, not in top 50% (-) Compliance with Accessible Information Standard (-) Outpatient and Pediatric feedback via YCM Gaps in assurance Assurance Level gained: RAG Trust position known - no identified gaps in assurance Mitigating actions underway 1. Focus groups among recently discharged inpatients 2. Re-procuring the YCM service 3. Developing IT solution for Accessible Information Standard Update by Date discussed at Board FA 08/05/2017

Page 6

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1. Work at early stage – December 16 2. Underway – September 2016 3. TBC May 2017

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 2017/18 objectives and description of any potential significant risk to this priority

Controls in place (to manage the risk) System wide  Transformation Board  SASH System A&E Delivery Board  SASH System Planned Care Board Emergency Care  ED Working Group  Primary Care Streaming Project Build  SASH (internal ) ED Delivery Board  Clinical Pathway review using data Elective Care  Elective Care Board  RTT Recovery Plan  Productivity Board Medicine  Ambulatory pathways  SAFER programme  LOS review Surgery  Day case Unit  SASH@Home  SAFER programme  LoS review Discharge  Patient Focus Board  Integrated Discharge Review  Review of Longest Stay patients Emergency Planning  Business Planning Process  Escalation Plan Page 7

Director responsible

Chief Operating Officer

Initial Risk Current rating

S4 x L4 = 16 S4 x L3 = 12

Target risk score

S4 x L2 = 8

Linked to Risk

1220, 1491

Gaps in Control System Wide  Social Services and CHC capability to effectively reduce and sustain target number of MRD patients  Ineffective alternative pathways of care to ED  Lack of appropriate capacity in the community to effectively manage discharge process Emergency care  Ongoing growth in emergency attendance and ambulance conveyance Elective Care  Increase in referrals particularly from south coast Medicine  GP limitations in supporting ambulatory pathways Seven Day Working  Incremental planned progress to deliver seven day working linked to long term financial plan



Business Continuity Planning (Christmas, Easter, Half terms etc.)

Potential Sources of Assurance (documented evidence of controls effectiveness)  Formal Integrated Delivery Meeting with NHSI  Quality and Performance Dashboard reported to ECQR and EC weekly  Integrated Performance Management reported to Board monthly  Access and Responsiveness Committee  NHSI Daily Sitrep  Daily internal monitoring  Clinical Audit  Benchmarking Reporting  Seven Day Services National Audit Gaps in assurance CCG commitment to increase capacity or alter capacity to meet demand Mitigating actions underway

Actual Assurances: Positive (+) or Negative (-) Positive  ED good performer nationally  RTT Recovery Plan in place and plant to move to Cerner strategic solution in Q3  Strong Cancer performance throughout 16/17  Increase in referrals Negative  MRD remains high driving LOS up  Community capacity does not match demand  Rehab capacity does not match demand  Adult bed occupancy remains high  Increase in ambulance conveyance Assurance Level gained: RAG

Systematic monitoring of actions and outputs described above and ensuring appropriate responsiveness when outputs not delivered. Update by Date discussed at Board AS 19/05/2017

Page 8

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. Ongoing May 2017

Objective 4 - Responsive to people’s needs – Become the secondary care provider of choice for the catchment population Priority ID and reference Director responsible 4. Responsive to people’s needs – Chief Operating Officer Become the secondary care Initial Risk S5 x L3 = 15 provider of choice for the catchment population Key Action for 2016/17 objectives 4.2 There is a risk that if the Trust Current rating S5 x L3 = 15 and description of any potential does not deliver the planned significant risk to this priority efficiencies it will be unable to create Target risk score S5 x L2 = 10 the necessary capacity, which will have an adverse impact on elective Linked to Risk 1221, 1480, 1601, 1405, 1547 care, income, expenditure and ultimately quality objectives. Controls in place (to manage the risk)  CSESA North Accountable Care Leadership Board  Surrey and Sussex Transformation Boards  System Wide A&E Delivery Board  SASH ED Delivery Board  Planned Care Board  Productivity Board  National theatres pilot scheme  CQUIN Board  Patient Focus Board  GIRFT Reviews  Benchmark reporting Potential Sources of Assurance (documented evidence of controls effectiveness) Integrated Performance Report Benchmarking Report

Gaps in assurance CCG commitment to increase capacity or alter capacity to meet demand Mitigating actions underway

Gaps in Control  Ineffective alternative pathways to ED  Community capacity does not match demand  Rehab capacity does not match demand  Adult bed occupancy remains high  Sustained increase in ambulance conveyance

Actual Assurances: Positive (+) or Negative (-) Positive  Delivered surplus in 16/17  Strong elective performance in March 2017  Strong Cancer performance throughout 16/17  Evidence of positive management of performance alerts e.g. Diagnostics Negative  MRD remains high driving LOS up  Community capacity does not match demand  Rehab capacity does not match demand  Adult bed occupancy remains high  Increase in ambulance conveyance Assurance Level gained: RAG

1) Full action plan development for productivity programme (theatres, outpatients, VMI Value streams, LOS) 2) Delivery of internal actions relating to Urgent and Emergency Care Implementation Plan Update by Date discussed at Board AS 19/05/2017 Page 9

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Ongoing 2) Ongoing May 2017

Objective 5 – Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference Director responsible 5. Well Led - become an employer Chief Executive of choice and deliver financial and clinical sustainability around a Initial Risk S4 x L3 = 12 clinical leadership model Key Action for 2014/15 objectives 5. There is a chance that the Trust Current rating S4 x L3 = 12 and description of any potential may not meet its priority to benefit significant risk to this priority Target risk score from the opportunities of S3 x L3 = 9 strengthening partnerships, Linked to Risk N/A collaboration and developing high quality safe and sustainable systems that emerge from the solutions within the STP. Controls in place (to manage the risk) Gaps in Control 1) STP structure and leadership [Exec Board, Programme Board, Finance 1) Financial position across the health system Group]; 2) Clinical group output not on line [group now established, and has met twice] 2) National consultation rules, national publication and national leadership 3) Commissioning reshape in progress but direction not agreed of STPs; 4) BSUH forward plan (as a fixed point in STP – new management contract 3) Very frequent reporting to Board, including Board seminar discussions arrangement now in force with WSNHSFT, additional emergency care capacity every other month; needed, and capacity issue at RSCH site) 4) Trust strategy plans agreed by Board (part of existing Trust process); 5) Infrastructure resourcing below benchmarked levels of other STPs 6) Formal linkage from Boards/Governing bodies into STP governance structure [new structure to be implemented shortly] 7) NHS England actions: locally NHS England is tasking CCGs with the submission of a revised financial plan and has grouped CCGs into categories according to financial risk – all local CCGs are in the worst risk category and are developing plans to restrict expenditure immediately. Potential Sources of Assurance (documented evidence of controls Actual Assurances: Positive (+) or Negative (-) effectiveness) 1) Establishment of STP Board Positive: 2) Agreed leadership of STP Board (+) STP Board and supporting infrastructure in place 3) Meeting the deadlines for submission of plans to NHSE (+) SaSH CEO leader of STP in Sussex & East Surrey 4) SASH involvement in STP work streams (+) All current submission milestones met 5) Board understanding and input into STP solutions (+) New models of care for population-based catchments being explored in [now] four 6) Place based plans “place based areas” 7) Agreed implementation plans across the STP footprint (+) Publication of the STP plan Dec 2016 8) Engagement of relevant stakeholders (+) Engagement and communication plan in place locally and with stakeholders 9) Feedback from NHSE/NHSI on initial submissions 10) Feedback from NHSE/NHI on October 2016 submissions Negative: 11) Publication of the STP (-) Financial gap across the STP footprint 12) Feedback from NHSE/NHSI on current plans (-) Vacancies in senior posts across the footprint 13) Review and strengthening of governance processes being considered (-) National workforce issues in key disciplines by NHS & NHSI (-) Growing and ageing population leading to real underlying growth in demand Gaps in assurance Continued development of next phase – Place Based Plans Mitigating actions underway Page 10

Assurance Level gained: RAG Progress against mitigation (including dates, notes on slippage or controls/ assurance failing.

Development of next phase plans on track Update by

Page 11

GFM 11/05/2017

Actions proceeding to plan. Date discussed at Board

May 2017

Objective 5 – Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference Director responsible 5.A Live within our means to remain Chief Finance Officer financially sustainable Initial Risk S5 x L3 = 15 Key Action for 2014/15 objectives 5.1 There is a risk to the Trust’s Current rating S5 x L3 = 15 and description of any potential short term financial stability if the significant risk to this priority annual income plan is not delivered. Target risk score S4 x L2 = 8 Linked to Risk 1689 Controls in place (to manage the risk) Gaps in Control 1) Business Plans and budgets (activity/ financial) savings & productivity plans. 1) Activity demand continues to be a significant issue, with resultant capacity 2) Agreed contracts in place with main sets of commissioners (NHSE and constraints. CCGs) – all Contracts were signed in January 2017. 2) Strategic management of activity (contract meetings, A&E Delivery & 3) Contract management process in place (this operated effectively in 2016/17). Transformation Boards) not fully effective - partners working to make it so. CEP 4) Financial reporting, including periodic forecast scenarios, is in place and supports joint working over financial risk and activity demand. effective – the first detail forecast will go to Board in July (Q1). 5) A&E Delivery Board and Transformation meetings in place and operating. 6) NHSi/NHS England Performance Meetings: 7) STP capped expenditure process (CEP): as part of the STP the Trust is engaging in work to meet CEP requirements 8) COO is establishing “boards” to oversee productivity delivery, emergency care management & CQUIN Potential Sources of Assurance (documented evidence Actual Assurances: Positive (+) or Negative (-) of controls effectiveness) 1) Financial performance and contractual reporting to Exec Positive Committee, Finance & Workforce Committee and Trust (+) Trust delivered a surplus in 2016/17 (subject to audit) – STF was paid for Q1 and Q2. Board (including CQUIN reporting process). (+) Contract in place requires commissioners to make cash payments for work done prior to the 2) Performance Review (PMO) and Exec Quality and Risk formal reconciliation process process with Divisions, monthly contract cycle with CCGs. (+) Income in line with Plan at M01 Service line reporting process Negative 3) Outputs and reporting from contract and information (-) Commissioners around the Trust have significant financial risk – deficits in 2016/17 that may lead teams to more transactional measures 4) Output and reporting from health system management (-) Too much non elective activity, not enough elective – risk remains over emergency demand (e.g.: A&E Delivery Board/Transformation Board) (-) disputes over 2016/17 income with East Surrey CCG in process but not yet resolved. One dispute 5) Output of Contract Management Process . with Sussex CCGs Gaps in assurance Assurance Level gained: RAG Amber recognizing this is M01 and data describes income in line with Plan. Progress against mitigation (including dates, notes Mitigating actions underway on slippage or controls/ assurance failing. 1) Revised plans to increase elective/outpatient activity implemented from M09 2016/17 and continued Actions proceeding to timetable. into 2017/18; 2) Continue performance management of Divisions to increase income delivery (ongoing) 3) Embed the integrated reablement unit, frailty unit and other measures to manage none elective demand (ongoing). 4) Robust contractual process operated and robust response to CCG challenge (ongoing). Update by Date discussed at Board PS 15/05/2017 May 2017

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Potential Sources of Assurance (documented evidence of controls Actual Assurances: Positive (+) or Negative (-) effectiveness) 1) Financial performance and contractual reporting to Exec Positive Committee, Finance & Workforce Committee and Trust Board UIN (+) Trust delivered a surplus in 2016/17 (subject to audit) – STF was paid for Q1 and Q2. reporting process). (+) Spend in line with Plan at M01 [but with overspending in some areas] 2) Performance Review (PMO) and Exec Quality and Risk (+) 16/17 Internal audit (IA) advises CIP process sound (but notes non-delivery, see below) – process with Divisions, monthly contract cycle with CCGs. Service also Temporary Staffing audit positive (amber rated, noting delivery risk) line reporting process 3) Outputs and reporting from contract and Negative information teams (-) IA advises effectiveness of savings delivery rated red/amber – risk to forecast. 4) Output in financial reporting describes improvement and risk (-) Nurse & Medical agency and ADH CIPs were balanced by the contingency reserve in mitigation. 2016/17 – reduced CIP target in 17/18 but significant risk. 5) Agency and roster PMOs. (-) Emergency activity pressures have continued and some Divisions are overspending (-) Overall agency costs remain very high, with escalation still in use and significant costs across Divisions. Gaps in assurance Amber recognizing this is M01 and data describes spend in line with Plan.

Page 13

Assurance Level gained: RAG

Mitigating actions underway 1) PMO/Performance structure continues (ongoing) 2) Additional PMOs in place for agency control (ongoing ) 3) Controls are being exercised in divisions and centrally â&#x20AC;&#x201C; vacancy restriction and non-clinical procurement. 4) Decisions on business cases taken in light of affordability and contribution. Update by Date discussed at Board PS 15/05/2017

Page 14

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

May 2017

Objective 5 – Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference Director responsible 5.A Live within our means to remain Chief Finance Officer financially sustainable Initial Risk S5 x L3 = 15 Key Action for 2014/15 objectives 5. 3 There is a risk to the Trust’s Current rating S5 x L3 = 15 and description of any potential longer term financial stability if it is significant risk to this priority Target risk score unable to deliver its medium term S4 x L2 = 8 financial plan. Linked to Risk 1603 Controls in place (to manage the risk) Gaps in Control 1) Items referred to in 5.A.1 and 5.A.2 above 1) Items listed above (5.A.1, and 5.A.2) are applicable here 2) NHSi Plan submitted in December 2016, resubmitted (minor cash 2) Reliance on centrally determined rules for tariff & wider NHS finance regime. changes) March 2017..and accepted 3) Risk over capacity from other operational pressures 3) Cost improvement plan process in place (including PMO structure) 4) Overall health system financial view describes significant financial pressures (now 4) Contracts agreed with commissioners in 2017/18 being discussed through STP and capped expenditure process) 5) 2017/18 planning shows recurrent surplus with gain from HRG4+ 5) CCG control totals antagonistic to provider control totals (Trust must increase (tariff pricing change) – but risk in delivering control totals specified. income, CCGs must reduce it), HRG4+ isn’t fully funded for CCGs – net output, 6) STP capped expenditure process (CEP): as part of the STP the substantial unspecified QIPP schemes providing very large financial gap. Trust is engaging in work to meet CEP requirements 6) Central actions over NHS spend may have an adverse impact on Trust because of manner of application (e.g. withholding capital and cash). 7) STP process identifies significant “do nothing” deficit [noting impact of actions reduces that considerably] 8) Need for additional actions to manage STP process and secure financial sustainability. Potential Sources of Assurance (documented Actual Assurances: Positive (+) or Negative (-) evidence of controls effectiveness) 1) Production of 2017/18 budget, revised two year Positive financial model, business plan documentation, and (+)Trust delivered a surplus in 2016/17 (subject to audit) – STF was paid for Q1 and Q2. delivery against them (+) 2017/18 planning shows recurrent surplus with gain from HRG4+ (tariff pricing change). This 2) Agreed contracts with commissioners describing surplus takes into account the underlying position behind the changed forecast. realistic demand and acceptable financial values (+) 2017/18 contracts signed (but significant health system risk behind the contract agreement) 3) Sign off of 2017/18 Plan, sustainability & transformation funding with NHS Improvement in Negative 2017/18 (-) overall health system loss of resource in 2015/16 (to BCF and from CCG non recurrent recovery) and continued financial pressures (notably for CCGs locally) in 2016/17 – 2017/18 describes worsening position, reflected in substantial 2017/18 operating plan risk (-) CCGs do not appear to be fully funded for HRG4+ (tariff) increase in 2017/18 (-) Health system STP footprint in overall deficit – increasing pressure in local health system (all CCGs are now reporting deficits). Gaps in assurance Assurance Level gained: RAG Significant risk and unknown impact of central actions to manage NHS overspending. Mitigating actions underway Please see items above. Update by

Page 15

PS 15/05/2017

Date discussed at Board

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. Progress is on timetable May 2017

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.A Live within our means to remain financially sustainable

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

5.4 There is a risk to the Trust’s ability to operate if its historic liquidity position restricts its ability to physically pay for expenditure.

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

1) No agreement on medium term solution to liquidity – however planned surplus will address. 2) Threat of central cash controls in line with control totals.

NOTE: This risk was reviewed at FWC 22 September 2015 and agreed to be maintained noting working capital facility. Additionally capital loan is now secure. An application for a £12.5m working capital facility has now been agreed and cash drawn down, with a further draw down of £7.0m cash. Potential Sources of Assurance (documented evidence of controls Actual Assurances: Positive (+) or Negative (-) effectiveness) 1) Twice monthly reporting to CFO by finance team, Positive SBS reporting on bank balance (+) Cash targets met in 2016/17 and liquid ratio has followed expectations 2) Monthly finance reporting to Executive Committee, (+) Cash managed well in 2016/17 and to date; Green internal audit report on cash management Finance and Workforce Committee and Trust (+) BPCC has improved month on month to better (but not compliant) levels in 2016/17 Board (+) Adequate working capital facility sufficient to cover cash needs into 2017/18 has been agreed 3) Confirmation of working capital injection (either (+) Have reduced working capital facility by repayment at end of 2016/17. through a loan, working capital facility or, if (+) Planned surplus will improve liquidity position if achieved, at the end of the year available, PDC) Negative (-) No additional cash to resolve underlying liquidity problem – restrictions being applied by NHSi as described in “gaps in control”. (-) Cash flow dependent on regular CCG payments – problematic in 2016/17. Overall rating “red” with risk to forecast I&E. No current cash problem but underlying problem unresolved. Will consider risk rating at M03. Gaps in assurance Assurance Level gained: RAG In terms of cash flow management to end year, no material gaps in assurance. In terms of resolving the actual risk (liquidity), there is no confirmation of additional cash to resolve SoFP weakness. Assurance level “red” noting unresolved underlying cash issue. To be reviewed noting surplus in 2016/17 and planned surplus in 2017/18 Mitigating actions underway Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Day to day cash control is main action, but coupled to action to maintain income and manage spend Actions proceeding to timetable (Ongoing) 2) Detail of cash position issued to NHSi in September 2016 – awaiting feedback from NHSi on likelihood of a new loan agreement (November 2016) Update by Date discussed at Board PS 16/05/2017 May 2017

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Objective 5 - Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference Director responsible 5.E We are an organisation that is Director of Organisational clinically led and managerially Development & People and enabled. Chief Nurse Initial Risk S5 x L3 = 15 Key Action for 2016/17 objectives 5.5 There is a risk that the Trust will Current rating S5 x L3 = 15 and description of any potential not meet its objective of becoming significant risk to this priority an ‘employer of choice’ if it does not Target risk score S3 x L2 = 6 deliver a workforce strategy that drives the recruitment and retention Linked to Risk 1740 of talent, provides the relevant skillmix for operational delivery and supports on-going professional education, training and development across all staff groups Controls in place (to manage the risk) Gaps in Control 1) Reviewed and ‘refreshed’ the Trust’s Workforce Strategy ensuring 1) Operational activity levels in the Trust stated as reason by line managers for nonrelevant objectives in place compliance with Corporate targets 2) Trust-wide and Divisional resourcing plans being devised, implemented and reviewed to ensure the Trust is able to identify and recruit ‘talent’ that compliments the current staff 3) Retention Strategy agreed and now being implemented Trust-wide 4) Multi-disciplinary education and training strategy in development 5) 2017 Achievement Review (ARs) process commenced 6) Divisional HRBPs continue to develop local Workforce Plans Potential Sources of Assurance (documented evidence of controls Actual Assurances: Positive (+) or Negative (-) effectiveness) Positive 1) Progress towards Trust’s Workforce Strategy objectives is reported monthly to the Finance & Workforce Committee. The quarterly Annual Plan (+) Accurate Workforce data being published on a monthly basis report to the Board also includes Workforce Strategy updates (+) Close collaborative working between key internal and external stakeholders (i.e. Workforce, Finance, Nursing, HR Business Partners, BRAP, etc.) 2) Key Workforce Indicators (e.g. recruitment, establishment, sickness, (+) National frameworks in place to support local delivery (e.g. NSS, etc.) turnover, AR compliance, etc.), reported on a monthly basis to the Trust (+) SaSH scored in the top 20% nationally in the 2016 National Staff Survey for 22 of Board the 32 Key Findings (+) Both staff engagement and staff recommending SaSH as a place to work and receive treatment were in the top 20% nationally (+) Quality of appraisals was in the top 20% nationally in 2016 Staff Survey (+) The Trust achieved a 98% completion rate for Achievement Reviews in the 2016/17 AR cycle (+) The multi-professional Education strategy is being worked up and meetings are currently being held with key stakeholders to support the development of this. (+) 5 nurses are scheduled to commence in May 2017 and a further 14 additional offers have been made from Skype events in May 2017 (another Skype event is planned for early June 2017). (+) A total of 10 Continental Travel (CT) agency nurses have successfully transferred to direct employment with SaSH. 13 CT nurses are eligible to transfer and are being actively managed via the resourcing team to facilitate this. (+) There is an active campaign to recruit nursing assistants to the bank and Page 17

interviews are planned on a monthly basis. (+) There was a pediatric nurse recruitment day for newly qualified graduates and 4 offers were made as a result of the event. (+) Trust Retention strategy approved by the Executive Committee and actions plans are now being delivered to support the delivery of this Negative (-) 2016 Staff Survey on appraisal completion in last 12 months was scored as ‘Average’ nationally (-) Nursing recruitment challenging, (including international recruitment issues with Provider organisation), with negative effect on Bank and Agency usage Gaps in assurance

Assurance Level gained: RAG

Some of the individual strategies / work-plans (i.e. Education & Training), which support the over-arching Trust Workforce Strategy are still being developed Mitigating actions underway 1) Individual strategies with objectives and action plans being drafted for approval 2) 2017 AR cascade process commenced to support delivery of 90% compliance rate 3) Pro-active recruitment planning in place including international campaigns th 4) Head of Education, Training & OD appointed to – post holder commences on 15 May Update by

Page 18

MP 08/05/2017 FA 11/05/2017

Date discussed at Board

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Delivery of the Retention Strategy is on-going 2) The AR completion rate is reported on a monthly basis to F&WC and Workforce Committee, as well as the Executive meetings 3) Recruitment & Retention Group set up to support overall R&R in the Trust May 2017

Actual Assurances: Positive (+) or Negative (-) Positive (+) Accurate Workforce data being published on a monthly basis (+) Close collaborative working between key internal and external stakeholders (i.e. Workforce, Finance, Nursing, HR Business Partners, BRAP, etc.) (+) National frameworks in place to support local delivery (e.g. Health CQUIN, WRES, etc.) (+) The Trust exceeded its 2016/17 CQUIN Flu Vaccination target – 77% vaccinated against a target of 75% (+) The Well-being strategy is under development and will link with key CQUIN objectives (+) Overall average monthly sickness rates reduced for 2016/17 compared to 2015/16 rd (+) The SASH BAME Network launched on 23 March Negative (-) SASH was in the lowest 20% nationally in the 2016 Staff Survey for staff experiencing physical violence from patients, relatives or the public

Gaps in assurance Some of the individual strategies / work-plans (i.e. Inclusion, Health & Well-being), which support the over-arching Trust Workforce Strategy are still being developed

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Assurance Level gained: RAG

Mitigating actions underway 1) Individual strategies with objectives and action plans being drafted for approval 2) ‘It’s Not Okay’ campaign being developed to address issues of bullying and harassment 3) 2016/17 Q4 actions for the Health CQUIN delivered 4) 2017/18 HWB CQUIN actions and objectives being finalised Update by

Page 20

MP 08/05/2017 FA 11/05/2017

Date discussed at Board

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) The Inclusion Strategy is being developed in conjunction with BRAP 2) The ‘It’s not Okay’ campaign is being developed for launch 3) HWB CQUIN report submitted highlighting achievements against CQUIN objectives for 2016/17 May 2017

Objective 5 â&#x20AC;&#x201C; Well Led- become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference Director responsible 5.F. Ensure IT support/optimise Director of Information and Facilities patient experience by improving patient interface, sharing and Initial Risk S5 x L3 = 15 capture of patient information and patient communication Key Action for 2016/17 objectives 5.7. There is a risk that the Trust will Current rating S4 x L3 = 12 and description of any potential not fully realise the benefits significant risk to this priority Target risk score available from well embedded IT S3 x L3 = 9 systems Linked to Risk 1428, 999, 1483 Controls in place (to manage the risk) 1) Move to direct contract with Cerner now happened and Trust has exited NPfIT well ahead of schedule 2) IT Strategy aligned with Clinical Strategy, IBP and updated Jan 173) Executive Informatics Board now established 4) Clinical IT leads 5) Various project groups (EPR etc.) 6) Project management controls (Described in Internal Audit of project management) 7) EPR costs identified in capital programme 8) CCIO and CNIO now implemented â&#x20AC;&#x201C; greater clinical buy-in 9) New IT Governance structure agreed 10) EPR Road Map approved by FWC and Executive 11) EPR Roadmap signed-off by Executive November 2015 and Trust working on implementation plan and business case with EPR Provider 12) EPR FBC approved by FWC and Executive and external loan being sort

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

Potential Sources of Assurance (documented evidence of controls effectiveness)

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

Efficiencies being delivered through IT enabled change

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

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Positive (+) Improving infrastructure (e.g. Wi-Fi move to Windows 7) (+) Development of existing EPR platform (e.g. EPMA and move to Cerner) (+) EPR Contract signed and data center move finished (+) Trust moved to latest version of EPR software (+) Business Continuity System now in place (7/24) and well established

Assurance Level gained: RAG

Mitigating actions underway 1. Procurement and implementation of replacement EPR - complete 2. Establishment of Chief clinical Information Officer role - complete 3. New IT governance structure agreed 4. Greater focus on IT in Capital Plan for 2016/17 and future years 5. EPR Roadmap now approved by Executive and approval to proceed agreed 6. EPR Digitise Outline Business Case now approved 7. Move to latest version of Cerner software now taken place 8. Loan being sought to fund EPR Digitise Business Case Update by Date discussed at Board IM 15/05/2017

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Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1. Completed 2. 724 Go-live November 2014. 3. PC Upgrade plan now complete 4. Network review first draft now complete and approval to proceed approved 5. EPR Digitise FBC Approved 6. EPR roadmap approved May 2017

1. Access Policy 2. Weekly PTL / performance meetings to monitor progress. 3. Service Level plans to increase capacity where required. 4. Plan in place for reporting system migration 15

Longer waiting times result in poor patient experience, potential avoidable harm and increase the number of formal and informal complaints Liquidity: Inability to pay Risk of not being able to pay creditors/staff resulting from suppliers from in sufficient cash insufficient cash due to poor liquid due to poor liquidity problem position

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

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

26/01/2017 30/09/2015 28/10/2016 28/10/2016 23/05/2016 22/02/2016

Manage the number of IPs booked on lists to avoid cancellations Upgrade Cerner to full RTT Functionality Roll out RTT Training to Admin Staff 15 Reporting system migration to Cerner / Data Clean up Improve Theatre Utilisation Ring-fencing of Tandridge and Woodland Wards

31/03/2017 31/07/2017 30/06/2017 28/04/2017 20/06/2015 15/05/2015

21/04/2017

As described on the BAF

23/06/2017

05/08/2015 18/09/2015

Next Review

Implementation of divisional escalation plan following key triggers. Escalation bed plan agreed implementation plans in place for each area. Ambulance handover escalation plan agreed and in place with new process for managing handovers agreed to maintain flow. Escalation to division with clear triggers in 16 place. Weekly ED review meeting to review previous weeks performance and implement lessons learnt Plans in place to manage with reduced capacity during January through March 2016 whilst building works are underway. As described on the board assurance framework

31/05/2017

Done date

Residual Rating

Current Rating

Current Likelihood 4

Due date

31/05/2017

Treatment Plan

25/08/2017

Due to demand exceeding capacity, on-going operational pressures and operational process issues, the Trust cannot offer all services within the 18 weeks standards set out in the NHS Constitution.

Current Consequence

Initial Rating

Existing controls

Description

Risk Type Service Access Financial Management

Operations

Angela Stevenson

23/03/2015

18/06/2014 Finance - Fin. Management Simpson, Paul

Responsiveness Executive Committee

1678

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

RTT Access Standards

1604

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

Involvement of Service Users

Executive Risk Owner

Specialty ED - Adult

Angela Stevenson

Open Date 29/08/2013

Committee Responsiveness

ID 1491

Title Failure to maintain Emergency Department performance

i) Output from productivity/LoS work. ii) Discussion with CCGs on 15 resourcing a shared problem. iii) Contingency actions.

Done date

31/03/2017

19/05/2017

Next Review

Due date

Residual Rating

Current Rating

Current Likelihood

Current Consequence 5

Treatment Plan

23/06/2017

Risk the Trust short term financial 1) Business Plans and budgets (activity/ stability if the annual income plan is financial) savings & productivity plans. not delivered. 2) Agreed contracts in place with main sets of commissioners (NHSE and CCGs) – all Contracts were signed in January 2017. 3) Contract management process in place (this operated effectively in 2016/17). 4) Financial reporting, including periodic forecast scenarios, is in place and effective – the first detail forecast will go to Board in July (Q1). 5) A&E Delivery Board and Transformation meetings in place and operating. 6) NHSi/NHS England Performance Meetings: 7) STP capped expenditure process (CEP): as part of the STP the Trust is engaging in work to meet CEP requirements 8) COO is establishing “boards” to oversee productivity delivery, emergency care management & CQUIN

Initial Rating

Existing controls

Description

Risk Type Financial Management

Specialty

Executive Risk Owner Simpson, Paul

Finance - Fin. Management

Open Date 01/04/2015

Committee Executive Committee

ID 1689

Title Risk of Contract income below plan

Treatment plan will vary according to CIP. i) Action plans to reduce 15 shortfall. ii) Contingency within each area.

31/03/2017

Done date

Next Review

Due date

Residual Rating

Current Rating

Current Likelihood

Current Consequence 5

Treatment Plan

23/06/2017

Risk of not achieving financial plan 1) Business Plans & budgets (activity & as a result of non-delivery of Cost financial), CIP/productivity plans Improvement Plans 2) Divisional activity plans 3) Divisional business cases to support correction for overspending areas in 2016/17 (e.g.: WaCH) 4) Internal Performance Review (PMO) process and CEO review 5) ) Financial reporting, including periodic forecast scenarios, is in place and effective – the first detail forecast will go to Board in July (Q1). 6) A&E Delivery Board and Transformation meetings in place and operating. 7) STP capped expenditure process (CEP): as part of the STP the Trust is engaging in work to meet CEP requirements 8) Structure of roster and agency PMOs in place and NHSi agency reduction plan submitted, with weekly NHSi reporting on compliance 9) COO is establishing “boards” to oversee productivity delivery, emergency care management & CQUIN

Initial Rating

Existing controls

Description

Risk Type Financial Management

Specialty

Executive Risk Owner Simpson, Paul

Finance - Fin. Management

Open Date 09/12/2014

Committee Executive Committee

ID 1663

Title Risk of not achieving Cost Improvement Plan

As described on the BAF.

31/03/2017

As described on the BAF

31/03/2017

Next Review

Done date

23/06/2017

Due date

23/06/2017

Treatment Plan

Residual Rating

Current Rating

V8.0 long term financial model (submitted to NHSi June 2016)and integrated business plan completed (submitted to TDA in February 2014) NHSi Plan submitted 2016.

Current Likelihood

Unable to deliver realistic medium As described on the BAF (5.3) term financial plan

Current Consequence

Risk of failure to meet the Trusts 1) Business Plans & budgets (activity & financial plan due to overspending. financial), CIP/productivity plans 2) Divisional activity plans 3) Divisional business cases to support correction for overspending areas in 2016/17 (e.g.: WaCH) 4) Internal Performance Review (PMO) process and CEO review 5) ) Financial reporting, including periodic forecast scenarios, is in place and effective – the first detail forecast will go to Board in July (Q1). 6) A&E Delivery Board and Transformation meetings in place and operating. 7) STP capped expenditure process (CEP): as part of the STP the Trust is engaging in work to meet CEP requirements 8) Structure of roster and agency PMOs in place and NHSi agency reduction plan submitted, with weekly NHSi reporting on compliance 9) COO is establishing “boards” to oversee productivity delivery, emergency care management & CQUIN

Initial Rating

Existing controls

Description

Risk Type Financial Management Financial Management

Specialty

Executive Risk Owner Simpson, Paul

Finance - Fin. Management

Open Date 20/05/2015

18/06/2014 Finance - Fin. Management Simpson, Paul

Committee Executive Committee Executive Committee

ID 1688 1603

Title Risk of potential overspending from operational pressures

TRUST BOARD IN PUBLIC

Date: 25 May 2017 Agenda Item: 2.1

Patient Story

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

Fiona Allsop Chief Nurse Fiona Allsop Chief Nurse N/A

Action Required: Approval ()

Discussion (√)

Assurance ()

Purpose of Report:

To share a patient story with the Board that shows how going ‘above and beyond’ makes a difference for our patients. Summary of key issues

       

The patient, Ms L, had been admitted to one of our orthopaedic wards following a fall off her horse. She sustained soft tissues injuries but no fractures were identified. Two weeks after the fall Ms L remained an inpatient on the ward and had been unable to move from her bed or begin to mobilise. She was losing confidence and belief in herself. She had been assessed by a psychiatrist and a neuro – physio and they were concerned that Ms L was experiencing post-traumatic stress. The ward sister recognized that Ms L needed additional support and asked Ms L what would help. It was arranged for Ms L to visit the stables and see her horse on a Sunday. When Ms L returned she wrote her objectives the following week to help her recover Ms L became fully mobile over the following week and was discharged. Ms L stated that the ward sister was her hero and had given her the support and confidence she needed to progress and leave the hospital.

Recommendation:

To note the report. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe – Deliver safe, high quality care and improving services which pursue perfection and be in the top 25% of our peers SO2: Effective – As a teaching hospital, deliver effective and improving sustainable clinical services within the local health economy SO3: Caring – Work with compassion in partnership with patients, staff, families, carers and community partners SO4: Responsive – To continue to be the secondary care provider of choice for the people of our community SO5: Well led - To be a high quality employer of choice and deliver financial and clinical sustainability around a patient centered, clinically led leadership model

Corporate Impact Assessment: Legal and regulatory impact

Potential positive regulatory impact in relation to CQC standards

Financial impact

Patient Experience/Engagement

Yes â&#x20AC;&#x201C; potential to enhance trust and confidence in the Trust

Risk & Performance Management

NHS Constitution/Equality & Diversity/Communication

Potential â&#x20AC;&#x201C; see above

Attachment:

Page 1

Date: 25th May 2017

TRUST BOARD IN PUBLIC

Agenda Item: 2.2 Safety & Quality Committee Chair 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 discussed at the Safety and Quality Committee in May 2017. Apart from standing items, the main focus of the meeting was on quarterly assurance reports from a range of service areas. Recommendation: The Board is asked to note the report. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe – Deliver safe, high quality care and improving services which pursue perfection and be in the top 25% of our peers SO2: Effective – As a teaching hospital, deliver effective and improving sustainable clinical services within the local health economy SO3: Caring – Work with compassion in partnership with patients, staff, families, carers and community partners 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

Reporting, investigation and learning from serious incidents informs risk management

Attachment:

Trust Board Report in Public – 25th May 2017 Safety and Quality Committee Chair’s Report The Safety and Quality Committee met on 4th May 2017. 1. ECQR and CQRM The Committee received a summary report on the meetings of ECQR and its sub-committees in April. The report continued the focus on deep-dive self-assessments of how services measure up against CQC domains, covering Intensive Care Unit, Estates and Therapies. The Committee took good assurance from the positive findings of the reviews, and from the staff enthusiasm for showcasing their good work. Potentially more could be done to draw out genuinely outstanding work, while it was also important to demonstrate self-awareness and opportunities for further improvement. SQC noted the importance of therapies, especially for patient rehabilitation. We welcomed the development of a therapies strategy requested a presentation to the Committee when it is completed. It was also suggested that the Board should be involved in discussion on the Well-Led Framework, as it had been on its predecessors, BGAF and QGAF. There was no meeting of CQRM in April. 2. Quality Report The Committee explored a number of questions arising from the monthly Quality Report, including:  We discussed the difficult pressures facing the hospital as a result of high demand for services, noting that escalation was in place. We took good assurance from the continuity plans that were working well in managing demand.  We discussed the continuing challenge in meeting RTT targets and sought assurance that the priority given to cancer treatment was not having an adverse impact on other patient treatments and pathways. We welcomed the appointment of the new Director of Outcomes, Richard Brown, who attended the meeting. His role will include analysing whether there may be any longer term impact on patients as a result of steps taken to manage demand. We invited him to present a report to SQC when he has been able to make progress with this valuable work.  We welcomed the ward training on accurate use of the Safety Thermometer tool and data cross checks, which is showing an improvement in data quality and in performance.  There had been five cases of CDiff in March. The Committee took good assurance from the root cause analysis and action reviews that follow each case. We also noted that incidence of CDiff is generally lower at SASH than other Trusts, or in line with them.  In a discussion on mortality, it was noted that the HSMR rolling 12-month graph is showing a gradual trend upwards over the last five years. An external; review by the regional lead orthogeriatrician found no evidence of sub-optimal care, but that there was over-representation of older age groups and of co-morbidities. The committee took good assurance from these findings and welcomed continuing further exploration of potential causes. SQC will be receiving a report on mortality next month.

3. Quality Account The Committee approved a draft Quality Account for circulation to partner organisations and stakeholders seeking their comments. A subsequent version will be submitted to SQC for approval following consultation. 4. Assurance Reports The Committee received seven assurance reports, providing a summary overview of the successes, challenges and risks facing services. The reports now provide a simple grading of assurance, and next quarter Executive Leads will provide a short commentary and indication of relative risk. Overall the picture was of good or adequate assurance, and the comments below reflect discussion of potential areas for further improvement   



  

Patient Experience: reasonable assurance. There can be delays in dealing with concerns raised through PALS and in closing cases. There is an emphasis on dealing with concerns more proactively. Complaints: reasonable assurance, although there is room for further improvement in the quality and timeliness of responses. There is a continuing focus on further improvement. Incidents: good assurance, with continuing progress in reducing the number of incidents overdue for review. Safeguarding of Children: good assurance despite the considerable increase in referrals in the last year or so. We discussed the need for extended level 2 training time and a more appropriate venue; also the need to have a named nurse and doctor for looked after children. Safeguarding of Adults: reasonable assurance and overall good practice in reporting adult safeguarding concerns, with good uptake of training. The main area for improvement is in understanding of MCA and DoLS referral: there are plans in place to address this. Falls: reasonable assurance pending the outcome of the work on pilot wards. The falls rate is below the national average for the last three months, and specific areas of concern are being addressed. Infection Control: reasonable assurance, with performance in line with or better than most peers. A strong focus on infection control through peer reviews with two other organisations and through the VMI workstream on diarrhoea. Mortality: reasonable assurance. The new Director of Outcomes will be taking a close interest in mortality, particularly the M&M meetings and case reviews.

5. AOB The Committee was briefed on a recent national media report about a complaint against maternity services at the Trust. The most recent contact with the patient had been a meeting with her in January 2015 which had appeared to have resolved concerns. We concluded that the case, like many other complaints and concerns raised by patients and their families, highlighted the importance of having open dialogue and honest conversations with patients and their families and setting clear expectations.

Next Meeting The next SQC meeting is at 12.00 noon on Thursday 1st June.

Richard Shaw Non-Executive Director Chair Safety & Quality Committee May 2017

TRUST BOARD IN PUBLIC

Date: 25 May 2017 Agenda Item: 2.3

Safer Staffing Report

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

Fiona Allsop Chief Nurse Fiona Allsop Chief Nurse N/A

Action Required: Approval ()

Discussion (√)

Assurance (√)

Purpose of Report:

To provide monthly Safer Staffing and Care Hours per Patient Day (CHPPD) information and exception reports. Summary of key issues

 

The Safer Staffing report (April 2017 data) indicates that the Trust has delivered the planned versus actual staffing levels in the inpatient areas and maternity unit against existing template. Care Hours Per Patient Day (CHPPD) are reported for April

Recommendation:

To note the report. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe – Deliver safe high quality and improving services which pursue perfection and be in the top 20% against our peers SO2: Effective – As a teaching hospital deliver effective, improving and sustainable clinical services within the local health economy SO3: Caring – Working in partnership with staff, families and carers SO4: Responsive – Become the secondary care provider of choice our catchment population SO5: Well led - Become an employer of choice and deliver financial and clinical sustainability around a patient focused clinical 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: NA

TRUST BOARD REPORT IN PUBLIC – 25TH May 2017 Safer Staffing & Care Hours Per Patient Day 1. Introduction To provide an update to the Board on nursing staffing in relation to planned versus actual staffing, an update regarding safer staffing monitoring and on recruitment activity. 2.

Staffing Planned versus Actual – April 2017

Ward

Ward Specialty

Entries

RN Day

RN Night

NA Day

NA Night

Total Day

Total Night

Overall

Abinger Ward

430 - GERIATRIC MEDICINE

97.62%

96.67%

92.5%

95%

94.94%

95.83%

95.25%

Acute Medical Unit

300 - GENERAL MEDICINE

95.38%

95.57%

97.75%

93.1%

96.08%

94.67%

95.46%

Birthing Centre

501 - OBSTETRICS

88.26%

88.33%

N/A

88.26%

88.33%

88.3%

Bletchingley Ward

430 - GERIATRIC MEDICINE

95%

100%

98.89%

96.67%

98.33%

97.27%

Brockham Ward

502 - GYNAECOLOGY

97.5%

94.44%

98.34%

96.67%

97.78%

95%

96.67%

Brook Ward

100 - GENERAL SURGERY

98.31%

98.33%

96.7%

100%

97.76%

98.44%

98.04%

Buckland Ward

101 - UROLOGY

95%

100%

98.19%

95%

96.38%

97.5%

96.78%

Burstow Ward

501 - OBSTETRICS

90.8%

66.67%

79.28%

86.67%

86.96%

74.67%

81.37%

Capel Annex l Ward

300 - GENERAL MEDICINE

94.77%

100%

94.08%

98.33%

94.48%

99.17%

96.18%

Capel Ward

300 - GENERAL MEDICINE

90.02%

95.56%

99.25%

98.33%

93.07%

96.67%

94.64%

Chaldon Ward

328 - STROKE MEDICINE

90.22%

95%

97.5%

94.44%

93.31%

94.67%

93.78%

Charlwood Ward

301 - GASTROENTEROLOGY

97.5%

98.21%

101.66%

100%

98.89%

99.09%

98.97%

Copthorne Ward

100 - GENERAL SURGERY

91.53%

98.15%

104.24%

96.3%

95.93%

97.22%

96.41%

Coronary Care Unit

320 - CARDIOLOGY

97.78%

100%

N/A

93.33%

97.78%

Delivery Suite

501 - OBSTETRICS

98.12%

97.22%

96.67%

98.33%

97.75%

97.5%

97.63%

Discharge Lounge

300 - GENERAL MEDICINE

100%

97.92%

96.67%

98.97%

98.33%

98.73%

Godstone Ward (Haem)

303 - CLINICAL HAEMATOLOGY

100%

98.33%

100%

N/A

100%

Godstone Ward (Med)

300 - GENERAL MEDICINE

97.98%

98.89%

97.16%

96.67%

97.66%

97.78%

97.71%

Hazelwood

430 - GERIATRIC MEDICINE

98.89%

100%

96.06%

98.33%

97.45%

99.17%

98.13%

Holmwood Ward

320 - CARDIOLOGY

98%

100%

98.33%

98.56%

99.17%

98.78%

ITU/HDU

192 - CRITICAL CARE MEDICINE

98.32%

98.09%

85.53%

96.67%

96.61%

97.98%

97.28%

Leigh Ward

110 - TRAUMA & ORTHOPAEDICS

96.99%

96.67%

97.68%

97.78%

97.26%

97.33%

97.29%

Meadvale Ward

430 - GERIATRIC MEDICINE

92.18%

100%

99.42%

100%

95.98%

100%

97.36%

Neonatal Unit

420 - PAEDIATRICS

94.01%

96.09%

98.34%

93.22%

95.32%

95.19%

95.25%

Newdigate Ward

110 - TRAUMA & ORTHOPAEDICS

93.76%

100%

102.67%

95.56%

97.6%

97.33%

97.5%

Nutfield Ward

430 - GERIATRIC MEDICINE

97.8%

100%

96.27%

100%

97.23%

100%

98.15%

Outwood Ward

420 - PAEDIATRICS

95.17%

100.55%

81.92%

75.86%

93.61%

97.14%

95.28%

Page 1

Rusper Ward

501 - OBSTETRICS

97.5%

96.67%

N/A

97.5%

96.67%

97.22%

Surgical Assessment Unit

100 - GENERAL SURGERY

95%

93.33%

91.67%

94.67%

92.5%

93.7%

Tandridge Ward

430 - GERIATRIC MEDICINE

93.32%

100%

95.33%

100%

94.51%

100%

96.3%

Tilgate Annex

300 - GENERAL MEDICINE

91.57%

98.36%

95.48%

98.33%

93.02%

98.35%

94.81%

Tilgate Ward

340 - RESPIRATORY MEDICINE

93.77%

98.89%

91.84%

100%

93.04%

99.17%

95.08%

Woodland Ward

110 - TRAUMA & ORTHOPAEDICS

97.33%

100%

99.61%

98.33%

98.19%

99.17%

98.51%

95.47%

96.81%

96.51%

96.12%

95.83%

96.55%

96.12%

Total

Planned versus actual commentary The Trust has delivered planned versus actual staffing profile for April at organizational level. The red shifts showing compliance below 80% were managed by the relevant clinical team with no concerns regarding patient safety. Burstow Ward forms part of the maternity unit and staff are managed by the matrons across the service to ensure all areas are staffed appropriately to the clinical need. Care hours per patient day (CHPPD) Only complete sites your organisation is accountable for

Ward name

Mar-17

Day

Main 2 Specialties on each ward

Specialty 1

Specialty 2

Registered midwives/nurses Total monthly planned staff hours

Night Registered midwives/nurses

Care Staff

Day

Night

Care Hours Per Patient Day (CHPPD)

Care Staff

Cumulativ e count Average fill rate Average fill rate over the Registered Total Total Total Total Total Total Total - registered Average fill rate - registered Average fill rate month of midwives/ Care Staff monthly monthly monthly monthly monthly monthly monthly nurses/midwives - care staff (%) nurses/midwives - care staff (%) patients at nurses actual planned actual planned actual planned actual (%) (%) 23:59 each staff hours staff hours staff hours staff hours staff hours staff hours staff hours day

Abinger Ward

430 - GERIATRIC MEDICINE

1302

1245.5

1426

1357

713

95.7%

95.2%

100.0%

699

Acute Medical Unit

300 - GENERAL MEDICINE

3433

3367

1426

1337.5

2495.5

1426

1322.5

98.1%

93.8%

100.0%

92.7%

1052

5.6

2.5

8.1

713

590

690

598

82.7%

100.0%

86.7%

0.0%

18.9

0.4

19.2

1426

1069.5

1000.5

713

690

100.0%

93.5%

100.0%

96.8%

609

3.5

2.8

6.3

Birthing Centre Bletchingley Ward Brockham Ward Brook Ward Buckland Ward Burstow Ward Capel Annex l Ward Capel Ward

501 - OBSTETRICS 430 - GERIATRIC MEDICINE

302 - ENDOCRINOLOGY

2.8

3.0

Overall

5.8

502 - GYNAECOLOGY

1441

1399

748

627

1069.5

1058

356.5

97.1%

83.8%

98.9%

100.0%

555

4.4

1.8

6.2

100 - GENERAL SURGERY

708.5

689.5

356

348.5

713

701.5

97.3%

97.9%

98.4%

0.0%

320

4.3

1.1

5.4

101 - UROLOGY

1433.5

1399

1092

1042

713

690

713

678.5

97.6%

95.4%

96.8%

95.2%

590

3.5

2.9

6.5

501 - OBSTETRICS

1426

1168.5

713

554.5

1069.5

667

713

609.5

81.9%

77.8%

62.4%

85.5%

536

3.4

2.2

5.6

300 - GENERAL MEDICINE

1426

1403

1080

1034.5

713

98.4%

95.8%

100.0%

631

3.4

2.8

6.1

300 - GENERAL MEDICINE

1602.5

681.5

328-STROKE MEDICINE

1454.5

736

1069.5

1058

713

667

90.8%

92.6%

98.9%

93.5%

593

4.2

2.3

6.5

1977.5

1841

1471.5

1387

713

701.5

1058

1035

93.1%

94.3%

98.4%

97.8%

824

3.1

2.9

6.0

Charlwood Ward

301 - GASTROENTEROLOGY

1441

1360.5

754.5

731.5

690

678.5

94.4%

97.0%

100.0%

98.3%

587

3.5

2.4

5.9

Copthorne Ward

100 - GENERAL SURGERY

1426

1353

716.5

693.5

690

678.5

94.9%

96.8%

100.0%

98.3%

594

3.4

2.3

Chaldon Ward

5.7

Coronary Care Unit

320 - CARDIOLOGY

1069.5

1023.5

11.5

713

356.5

322

95.7%

0.0%

100.0%

90.3%

232

7.5

1.4

8.9

Delivery Suite

501 - OBSTETRICS

2139

2035

713

663

2139

2012.5

713

678.5

95.1%

93.0%

94.1%

95.2%

160

25.3

8.4

33.7

688

667

356.5

100.0%

140

7.5

7.3

14.8 9.3

Discharge Lounge Godstone Ward (Haem) Godstone Ward (Med) Holmwood Ward ITU/HDU Leigh Ward Meadvale Ward Neonatal Unit Newdigate Ward Nutfield Ward

300 - GENERAL MEDICINE

713

252

233

713

100.0%

92.5%

100.0%

0.0%

179

8.0

1.3

1782.5

1748

1069.5

954.5

1069.5

1081

1069.5

1035

98.1%

89.2%

101.1%

96.8%

789

3.6

2.5

320 - CARDIOLOGY

303 - CLINICAL HAEMATOLOGY

1782.5

1725

690

644

713

701.5

713

678.5

96.8%

93.3%

98.4%

95.2%

849

2.9

1.6

4.4

192 - CRITICAL CARE MEDICINE

4497.5

4417

711.5

624

4370

4289.5

345

333.5

98.2%

87.7%

98.2%

96.7%

455

19.1

2.1

21.2

110 - TRAUMA & ORTHOPAEDICS

1606

1560.5

1021.5

983

713

724.5

1058

1012

97.2%

96.2%

101.6%

95.7%

838

2.7

2.4

430 - GERIATRIC MEDICINE

1302

1173

1403

1345.5

713

632.5

90.1%

95.9%

100.0%

88.7%

700

2.7

2.8

5.5

420 - PAEDIATRICS

1593

1524

697

1541

1460.5

678.5

586.5

95.7%

100.0%

94.8%

86.4%

410

7.3

3.1

10.4

110 - TRAUMA & ORTHOPAEDICS

1598.5

1507

1185.5

1102

713

1069.5

1023.5

94.3%

93.0%

100.0%

95.7%

792

2.8

2.7

5.5

300 - GENERAL MEDICINE

410 - RHEUMATOLOGY

430 - GERIATRIC MEDICINE

1782.5

1732.5

1072.5

984.5

713

701.5

713

724.5

97.2%

98.4%

101.6%

2.8

2.0

4.8

420 - PAEDIATRICS

3196.5

2946.5

364

260.5

2196.5

2173.5

333.5

195.5

92.2%

71.6%

99.0%

58.6%

560

9.1

0.8

10.0

Rusper Ward

501 - OBSTETRICS

1426

1360.5

11.5

713

95.4%

100.0%

0.0%

262

7.9

0.0

8.0

100 - GENERAL SURGERY

Tandridge Ward

430 - GERIATRIC MEDICINE

Tilgate Annex

300 - GENERAL MEDICINE

Tilgate Ward

340 - RESPIRATORY MEDICINE

Woodland Ward

855

5.1

Outwood Ward Surgical Assessment Unit

91.8%

6.1

1426

1380

356.5

345

713

701.5

713

621

96.8%

98.4%

87.1%

278

7.5

3.5

11.0

340 - RESPIRATORY MEDICINE

1277

1193

1713.5

1564

713

93.4%

91.3%

100.0%

778

2.4

2.9

5.4

1773.5

1720

1076

1026

713

678.5

97.0%

95.4%

100.0%

95.2%

637

3.8

2.7

6.5

340 - RESPIRATORY MEDICINE

1782.5

1736.5

1069.5

954.5

1069.5

379.5

97.4%

89.2%

100.0%

792

3.5

1.7

5.2

1782.5

1058

988.5

724.5

736

100.0%

93.4%

100.0%

101.6%

680

3.7

2.5

6.2

110 - TRAUMA & ORTHOPAEDICS

Apr-17

Abinger Ward

430 - GERIATRIC MEDICINE

1260

1230

1380

1276.5

690

667

690

655.5

97.6%

92.5%

96.7%

95.0%

681

Acute Medical Unit

300 - GENERAL MEDICINE

3323.5

3170

1380

1349

2334.5

2231

1334

1242

95.4%

97.8%

95.6%

93.1%

983

5.5

2.6

8.1

690

609

690

609.5

88.3%

21.0

0.0

21.0

98.9%

100.0%

Birthing Centre Bletchingley Ward

501 - OBSTETRICS

1380

1311

1035

1023.5

690

667

3.4

2.9

6.3

1380

1345.5

693.5

682

1035

977.5

345

333.5

97.5%

98.3%

94.4%

96.7%

542

4.3

1.9

6.2

678.5

667

348.5

337

690

678.5

98.3%

96.7%

98.3%

100.0%

310

4.3

1.2

5.6

101 - UROLOGY

1380

1311

1049.5

1030.5

690

655.5

95.0%

98.2%

100.0%

95.0%

599

3.3

2.8

6.2

501 - OBSTETRICS

1380

1253

690

547

1035

690

598

90.8%

79.3%

66.7%

86.7%

578

3.4

2.0

5.3

Capel Annex l Ward

300 - GENERAL MEDICINE

1387

1314.5

1038.5

977

690

678.5

94.8%

94.1%

100.0%

98.3%

607

3.3

2.7

6.0

Capel Ward

300 - GENERAL MEDICINE

1492.5

1343.5

735.5

730

1035

989

690

678.5

90.0%

99.3%

95.6%

98.3%

587

4.0

2.4

6.4

328-STROKE MEDICINE

1871

1688

1380

1345.5

690

655.5

1035

977.5

90.2%

97.5%

95.0%

94.4%

804

2.9

5.8

301 - GASTROENTEROLOGY

1380

1345.5

693.5

705

644

632.5

621

97.5%

101.7%

98.2%

100.0%

586

3.4

2.3

5.6

719

749.5

609.5

621

Buckland Ward Burstow Ward

Chaldon Ward Charlwood Ward Copthorne Ward

96.7%

586

100 - GENERAL SURGERY

1357

1242

598

91.5%

104.2%

98.1%

96.3%

567

Coronary Care Unit

320 - CARDIOLOGY

1035

1012

690

345

322

97.8%

100.0%

93.3%

229

7.4

1.4

8.8

Delivery Suite

501 - OBSTETRICS

2070

2031

690

667

2070

2012.5

690

678.5

98.1%

96.7%

97.2%

98.3%

161

25.1

8.4

33.5

566

552

540.5

345

333.5

100.0%

97.9%

100.0%

96.7%

9.9

9.5

19.4

100.0%

8.9

Discharge Lounge Godstone Ward (Haem) Godstone Ward (Med) Holmwood Ward ITU/HDU Leigh Ward Meadvale Ward Neonatal Unit Newdigate Ward Nutfield Ward

300 - GENERAL MEDICINE 303 - CLINICAL HAEMATOLOGY

621

95.0%

5.6

100 - GENERAL SURGERY

Brook Ward

302 - ENDOCRINOLOGY

2.8

502 - GYNAECOLOGY

Brockham Ward

430 - GERIATRIC MEDICINE

2.8

3.3

2.4

5.6

690

202.5

690

678.5

11.5

100.0%

98.3%

177

7.7

1.2

1705

1670.5

1072.5

1042

1035

1023.5

1035

1000.5

98.0%

97.2%

98.9%

96.7%

770

3.5

2.7

320 - CARDIOLOGY

1725

1690.5

667

690

678.5

98.0%

100.0%

98.3%

796

3.0

1.7

4.7

192 - CRITICAL CARE MEDICINE

4113

4044

636

544

4209

4128.5

345

333.5

98.3%

85.5%

98.1%

96.7%

412

19.8

2.1

22.0

110 - TRAUMA & ORTHOPAEDICS

1530

1484

971

948.5

690

667

1035

1012

97.0%

97.7%

96.7%

97.8%

811

2.7

2.4

300 - GENERAL MEDICINE

410 - RHEUMATOLOGY

430 - GERIATRIC MEDICINE

6.2

5.1

1252.5

1154.5

1387.5

1379.5

690

92.2%

99.4%

100.0%

683

2.7

3.0

5.7

420 - PAEDIATRICS

1602

1506

693.5

682

1472

1414.5

678.5

632.5

94.0%

98.3%

96.1%

93.2%

405

7.2

3.2

10.5

110 - TRAUMA & ORTHOPAEDICS

1530

1434.5

1163

1194

690

1035

989

93.8%

102.7%

100.0%

95.6%

779

2.7

2.8

5.5 4.9

1728.5

1690.5

1031

992.5

690

97.8%

96.3%

100.0%

827

2.9

2.0

Outwood Ward

420 - PAEDIATRICS

2390

2263

318

260.5

2081.5

2093

333.5

253

94.7%

81.9%

100.6%

75.9%

490

8.9

1.0

Rusper Ward

501 - OBSTETRICS

1380

1345.5

690

667

97.5%

96.7%

259

7.8

0.0

7.8

Surgical Assessment Unit

100 - GENERAL SURGERY

1380

1311

345

322

690

644

690

632.5

95.0%

93.3%

91.7%

280

7.0

3.4

10.4

Tandridge Ward

430 - GERIATRIC MEDICINE

1197

1117

1725

1644.5

690

724.5

93.3%

95.3%

100.0%

790

2.3

3.0

5.3

Tilgate Annex

300 - GENERAL MEDICINE

1731.5

1585.5

1018

972

701.5

690

678.5

91.6%

95.5%

98.4%

98.3%

621

3.7

2.7

6.3

Tilgate Ward

340 - RESPIRATORY MEDICINE

1725

1617.5

1035

950.5

1035

1023.5

345

93.8%

91.8%

98.9%

100.0%

752

3.5

1.7

5.2

1725

1679

1035

1031

690

678.5

97.3%

99.6%

100.0%

98.3%

663

3.6

2.6

6.2

Woodland Ward

430 - GERIATRIC MEDICINE

110 - TRAUMA & ORTHOPAEDICS

340 - RESPIRATORY MEDICINE 340 - RESPIRATORY MEDICINE

Page 2

9.9

The report for April is shown above. The data comparison with March shows that the CHPPD are broadly similar to previous months across the acute inpatient wards. Care hours per patient day are calculated by dividing the total numbers of nursing hours on a ward or unit by the number of patients in beds at the midnight census. This calculation provides the average number of care hours available for each patient on the ward or unit. This tool links with planned versus actual reporting and other data such as safety thermometer, incident reporting, sickness rates, vacancy rates and professional judgement to determine the appropriate staffing levels for a ward or unit. 3.

Recommendation

To note the report Fiona Allsop Chief Nurse May 2017

Page 3

TRUST BOARD IN PUBLIC

Date: 25th May 2017 Agenda Item: Compliance with Nasogastric Tube Misplacement Patient Safety Alert

REPORT TITLE: EXECUTIVE SPONSOR:

Fiona Allsop

REPORT AUTHOR (s):

Kim Rayment

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

Executive Committee & CQRM

Action Required: Approval ( )

Discussion (â&#x2C6;&#x161;)

Assurance (â&#x2C6;&#x161;)

Purpose of Report: The purpose of the report and attachments is to provide assurance to the Trust Board that the actions required by the Patient Safety Alert regarding the continued risk of harm due to nasogastric (NG) tube misplacement have been completed, the alert closed and an appropriate action plan developed to ensure all the safety-critical requirements are met and completion of the actions to achieve this is monitored via the Nutrition Steering Group and the Patient Safety Committee. Summary of key issues The patient safety alert referred to previous alerts sent out in 2005; 2011; 2012; and 2013 regarding the risk of harm relating to NG tube misplacement. Harm resulting from NG tube misplacement is listed as a Never Event (Revised Never Events Policy and Framework March 2015) The alert required completion of an assessment in accordance with a number of safetycritical areas identified from analysis of nationally reported incidents and previous alerts. As a result of the assessment within SASH, a number of areas required action and an action plan has been developed to address these. The areas for action include; review of the previous Trust Policy and development of a revised policy; review of current equipment used for NG tube placement to improve safety and support best practice; competency based training for nurses and doctors; review and revision of clinical documentation; and development of on-going audit of compliance. The action plan will be monitored via the Nutrition Steering Group and the Patient Safety Committee until completion. Recommendation: The Board are asked to take assurance from the report that the requirements of the Patient Safety Alert have been completed and the on-going actions resulting from the assessment have been identified and are being monitored until completion.

Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe â&#x20AC;&#x201C; Deliver safe, high quality care and improving services which pursue perfection and be in the top 25% of our peers SO2: Effective â&#x20AC;&#x201C; As a teaching hospital, deliver effective and improving sustainable clinical services within the local health economy Corporate Impact Assessment: Legal and regulatory impact Financial impact Patient Experience/Engagement Risk & Performance Management NHS Constitution/Equality & Diversity/Communication

Ensures the Board are aware of current and new requirements Impact of patient safety incidents on finances and resources Highlights how best clinical practice improves patient experience Identifies possible future risks which the Board should consider Compliance with NHS Constitution

Attachment:

Combined Baseline NG Tube Patient NHS-PSA-Re-2016-0 NG tube safety assessment against NG tube Safety Safety AlertCritical - Baseline requirements 06 assessment Nasogastric v2Action 090117.pdf TubePlan Misplacement.pdf letter_NHS Apr 17.pdf England and NHS Improvement_ April 2017.pdf

2 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT â&#x20AC;&#x201C; (25th May 2017) Compliance with Nasogastric Tube Misplacement Patient Safety Alert 1. Background Use of misplaced nasogastric and orogastric tubes was first recognised as a patient safety issue by the National Patient safety Agency (NPSA) in 2005 and three further alerts were issued by the NPSA and NHS England between 2011 and 2013. Misplacement and use of a naso- or oro-gastric tube in the pleura or respiratory tract where the misplacement of the tube is not detected prior to commencement of feeding, flush or medication administration is listed as a Never Event by NHS England. Never Events are considered â&#x20AC;&#x2DC;wholly preventable where guidance or safety recommendations that provide strong systemic protective barrier are available at a national level, and should have been implemented by all healthcare providers.â&#x20AC;&#x2122; 1.1 Context National In July 2016 NHS Improvement sent out a patient safety alert regarding the continued risk of harm due to nasogastric (NG) tube misplacement. The alert highlights that despite the number of alerts circulated 95 incidents were reported nationally between September 2011 and March 2016. It is acknowledged that this needs to be considered in the context of over 3 million nasogastric or orogastric tubes being used in the NHS in that period, but concluded that the reported incidents show that risks to patient safety persist. Local During this timeframe SASH reported 1 incident in March 2015, where a child was admitted for replacement of an NG tube after an episode of vomiting at home. The child had complex health needs and was under the care of the Royal Brompton and Royal Marsden hospitals. The main error type identified involved the nursing staff completing incorrect placement checking; poor communication between the nurse and parents; and use of the NG tube which was later found to be misplaced. This resulted in pneumonia and an extended length of stay for the child. As a result of this incident a wide range of learning was identified and actions completed to improve the patient safety processes and reduce the chances of a similar incident occurring. Safety recommendations Analysis of the 95 reported incidents by NHS Improvement reinforced how essential the tube placement checks are in preventing harm. The clinical reviewers of the reported incidents showed that misinterpretation of x-rays by medical staff that did not appear to have received competency-based training was the most common error type. Other error types involved nursing staff and PH tests, unapproved tube placement checking methods and communication failures resulting in tubes not being checked. All of which had been identified as areas of concern in previous alerts and suggested to NHS Improvement problems with organisational processes for implementing recommendations and actions from alerts. In light of these conclusions the Patient Safety Alert circulated in July 2016 was directed at Executive and Board level. 2. Work completed Fiona Allsop, Chief Nurse, was identified as the named Executive Director. A steering group was established to undertake an assessment against the safety-critical

3 An Associated University Hospital of Brighton and Sussex Medical School

requirements identified in the referenced resource set of the alert. The assessment completed by the steering group included adult, paediatric and neonates. The key areas that required action included; review and revision of the Trust policy; review of the equipment currently in use and compliance with safety standards; review of current competency-based training for nurses and doctors, revision of that as required and roll out of new competency-based training for nurses and doctors; review and revision of clinical documentation and roll out of new documentation; and set up of clear audit programme against compliance. An action plan was developed by the steering group which will be monitored via the nutrition steering group and the patient safety committee. The revised combined enteral policy has been approved by the members of the Patient Safety Committee and key stakeholders and ratified by the Executive Committee. The competency-based training for doctors and nurses has been reviewed and a new training programme is being rolled out. There is a proposal paper supporting the change of current NG tubes and equipment to a new device which provides additional safety features and a training package to support nurses and doctors competency training. 3.

Recommendation

The Board are asked to take assurance that the nasogastric tube misplacement risk is being adequately managed, there are appropriate control measures in place and the actions required by the alert have been completed and gaps identified as a result of the work have been developed into an appropriate action plan which is being monitored appropriately.

Fiona Allsop Chief Nurse May 2017

4 An Associated University Hospital of Brighton and Sussex Medical School

Reference:

Action Plan

No: 1.

Recommendation / Issue to be addressed: Policy review and update

Amendment of SI investigation report template to include reference to Patient Safety Alerts as appropriate

Action Plan Lead:

Patient Safety Alert

Record number:

NHS/PSA/RE/2016/006

Suzanne O’Sullivan / Jonathan Nolan / Fiona Allsop

Action(s) to be taken: Action Category (drop-downs) Preventative

Corrective

Action (SMART)

Action owner: (job title)

Deadline for Action:

1.1 Review of current overarching Trust Policy and development into a single combined Enteral Policy

Nutrition Nurse Specialist

10/05/2017

1.2 Neonatal team to review and update their 2 policies and add them as an appendix to the revised combined Enteral Policy

Neonatal Matron / Nutrition Nurse Specialist

31/03/2017

1.3 Inclusion of paediatric policy as an appendix into the revised combined Enteral Policy

Paediatric Matron / Nutrition Nurse Specialist

31/03/2017

2.1 The SI report template has a section entitled ‘Information and Evidence Gathered’ it requires amendment to include specific reference to alerts as appropriate to the incident being investigated

Patient Safety & Risk Facilitator

09/01/2017

Completed

Expected Improvement/ Success Measures:

Evidence of Progress and Completion:

Standardised process and best practice across the Trust. Clarity for all staff in the placement and on-going management of all enteral tubes and their safe use in accordance with best practice

Completed

Raised awareness and compliance with actions from safety alerts and shared learning

SI investigation report template revised

RCA template (08-12-16).docx

The RCA investigation training covers the importance of gathering all sources of information and analysing these as part of the investigation process including any safety alerts relevant to Page 1 of 4

the type of incident. 3.

Ensure use of safe equipment recommended by NHS Improvement and NHS England

Corrective

3.1 Continued use and procurement of CE marked PH testing strips

Nutrition Nurse Specialist / Paediatric Matron / Neonatal Matron / Head of Procurement

31/01/2017

3.2 Supportive paper being developed for a change in the procurement and Trust wide use of current NG tubes to Corflo NG tubes

Nutrition Nurse Specialist / Gastroenterologist / Head of Procurement

30/06/2017

Completed

Standardised use of the recommended PH testing equipment

Standardised use of tube that is fully radio-opaque and regular cm markings as recommended by NHS Improvement and NHS England. New NG tubes have additional safety advantages including; unique distal tip to enable more success in gaining aspirate to confirm safe positioning; dual proximal port to ensure closed system is maintained; internal and external water activated lubricant to allow easy removal of guide wire and avoidance of use of aqueous gels that can occlude distal tip. Soft and more comfortable for patients and therefore reduces likelihood of patient pulling the tube out.

Page 2 of 4

Company support clinicians with education and training both â&#x20AC;&#x2DC;classroomâ&#x20AC;&#x2122; and online / e-learning 4.

Roll out of NG tube competency based training; including placement; PH testing and x-ray check interpretation

Directive

4.1 Development of new trust wide nurse training NG tube placement and checking with PH paper competencies covering both practical and theoretical teaching with on-going assessment at ward level.

Nutrition Nurse Specialist / Paediatric Matron / Neonatal Matron

31/01/2017

4.1.1 Roll out of nursing competency based training to all wards / departments as appropriate

Nutrition Nurse Specialist / Paediatric Matron / Neonatal Matron

31/03/2018 On-going roll out of training over the year

4.1.2 Records of all trained nursing staff will be identified on Health Roster.

Nutrition Nurse Specialist / Health Roster Manager

4.1.3 Yearly competencies updates will be set up

Nutrition Nurse Specialist / Paediatric Matron / Neonatal Matron

4.2 NG tube x-ray position check training will be included in the junior doctor training sessions

Clinical Lead Radiology / Gastroenterologist

4.3 Set up and roll out of training and education package available if business case for switch over to CORFLO NG tube procurement agreed. The company provides;

Nutrition Nurse Specialist / Clinical Lead Radiology / Gastroenterologist

Completed

31/03/2018 On-going in line with roll out of training 31/03/2018 On-going in line with roll out of training 30/06/2017

Page 3 of 4

TBA if change in NG tube supplier agreed

-one hour â&#x20AC;&#x2DC;classroomâ&#x20AC;&#x2122; rolling training programme on placement and confirmation (certificate of attendance) -on-line CORPAK U placement and confirmation with gap analysis for learning improvement (user electronic certificate of completion and pdf sent for printing and own records) -auditable practice -on-line x-ray e-learning course (RCR accredited with certificate of completion) -analytics provided to the trust (learning improvement and training record for auditable practice) 5.

Clinical Documentation formats and checklists

Corrective

Ongoing Audit of Compliance

Detective

5.1 New end of bed documentation with clear pathways has been developed and is being implemented in all wards / departments as appropriate. Checklists in place with care plans

Nutrition Nurse Specialist / Matrons / Ward or Department Managers

31/03/2017

6.1 Audits to demonstrate compliance will be added to the divisional audit programmes and be on-going from 2017/18

Divisional Chiefs / Divisional Audit Facilitators

31/05/2017

6.2 Established audit tool will be used and audits will be facilitated and overseen on a rolling programme for all wards / departments as appropriate

Nutrition Nurse Specialist / Divisional Audit Facilitators

31/03/2018 On-going in line with divisional audit programmes

Page 4 of 4

Completed

OFFICIAL

NHS England & NHS Improvement Skipton House 80 London Road London SE1 6LH

21st April 2017

Dear Chief Executive, Medical and Nursing Directors, Prevention of future deaths: Nasogastric Tubes Patient Safety Alert A recent Coroner’s report on the death of two patients has highlighted the dangers of nasogastric (feeding) tubes. In both cases the tubes were inserted into the lung - not the stomach as intended - and safety checks to confirm tube placement were misread. Approximately 800,000 nasogastric tubes are used in the NHS each year. Fatalities are rare, but there have been 100 incidents and 32 deaths in England over the last 5 years. A national NHS Improvement Patient Safety Alert (NHS/PSA/RE/2016/006) 1 is due for completion 21st April 2017. It asks senior members of Trust Boards, typically the medical and nurse directors or CEO, to take a personal interest in nasogastric tube safety. Key to this is ensuring systematic training for medical and nursing staff of all grades who are required to confirm nasogastric tube placement. It is also vital to ensure all staff, particularly at induction, are aware that they should not be undertaking confirmation of nasogastric placement until they have completed such training. Over and above a plan, safety processes and Trust culture should support every doctor and nurse to confidently manage nasogastric tube safety, even in the early hours on a busy acute ward, mental health unit, or community service. Analysis of incidents shows two major concerns: 1. Misinterpreted X-Rays: more than half of all fatal cases reviewed related to misinterpretation of X-rays, or in some cases failure to review the most upto-date x-ray and predominately involved doctors (of all grades). Causes typically included lack of training in the ‘four criteria2’ technique

NHS Improvement Patient Safety Alert ‘Nasogastric tube misplacement: continuing risk of death and severe harm’ https://improvement.nhs.uk/news-alerts/nasogastric-tube-misplacement-continuing-risk-of-death-severe-harm/ issued via the Central Alerting System July 2016 2 NHS Improvement ‘Resource Set: Initial placement checks for nasogastric and orogastric tubes’ https://improvement.nhs.uk/resources/resource-set-initial-placement-checks-nasogastric-and-orogastric-tubes/ published July 2016.

Health and high quality care for all, now and for future generations

OFFICIAL

2. Misinterpreted pH testing: misinterpreted pH tests, predominately carried out by nurses (of all grades) accounted for about a third of cases. Causes typically included a lack of training or gaps in the content of training. Trusts can find more information and staff support in the resource set2 with the Alert provided by NHS Improvement, but in summary: • • • • • • • •

Embed competency based training for all doctors and nurses of all grades who are required to check nasogastric tube Ensure all staff who have not received this training understand they should not be undertaking these checks Improve X-ray interpretation by using the ‘four criteria’ Better bedside documentation formats to embed safe checking processes Clarifying communication to radiographers and from radiologists Improved pH test interpretation using CE pH strips marked for human gastric aspiration Avoiding outdated methods for safety checks, NEVER use the Whoosh or Bubble test Buying safe equipment; such as fully radio-opaque NG tubes with clear external length markings.

We hope you will support us to ensure every Trust complies with the Alert action to ensure the NHS does all it can to prevent future patient deaths due to misplaced nasogastric tubes. Together we can make the NHS the safest healthcare system in the world. Yours sincerely,

Professor Sir Bruce Keogh National Medical Director NHS England

Professor Jane Cummings Chief Nursing Officer England NHS England

Dr Kathy McLean Executive Medical Director NHS Improvement

Ruth May Executive Director of Nursing & Deputy Chief Nursing Officer NHS Improvement

Health and high quality care for all, now and for future generations

Baseline NG placement Assessment – version 2 09/01/17

Safety-critical area

Implementation issues identified in incident review

Paediatric Review

Neonates Review

Adult Review

Local policies and protocols These need to reflect all the safetycritical requirements summarised.

Some incident investigations suggested that local policies and protocols omitted key aspects of the earlier alerts

Since SI policy has been updated

2 polices –NNU-Gastric Feeding tubes on the Neonatal Unit and Nasogastric Feeding at Home (Outreach).

New policy clearly identifying all aspects of previous alerts. Clear concise policy that reflects all the safety-critical requirements. New documentation on insertion and management of NGT (end of bed) NPSA compliant with identified NEX, point of nostril and continuing care. Trust wide roll out of new Competencies and training for nursing staff with a compliance of two yearly updates.

Both need reviewing and table of safety-critical requirements added. To be ratified at next WaCH Governance meeting ? policy to part of a Trust enteral feeding policy

Some incident investigations suggested policies and protocols were unclear, or too lengthy for frontline staff to realistically be able to read or remember their content. National safety guidance referring to any incident investigations.

Investigation summaries almost never refer to NPSA alerts or actions required within them, and appear to rely on local policy or the investigators’ understanding of good practice.

Safe equipment

Safety equipment appears to have been introduced at the time of the NPSA 2011 alert (if it was not already in use).

Nasogastric tubes are radio-opaque throughout their

The Trust runs RCA investigation training which includes a practical element. Key documentation that requires review as part of the data gathering; mapping and analysis is covered the trainer talks about the inclusion of alerts as appropriate/relevant to the incident; NICE guidance; other National policies/frameworks; local polices etc. The SI investigation report template has a section entitled ‘Information and evidence gathered’ it has been amended to include specifically reference to alerts as appropriate and relevant to the incident being investigated. All naso gastric tubes are radioopaque and have visible length markings pH paper is CE marked

Page 1 of 3

As stated

All Gastric tubes are radioopaque throughout their length and have visible external length markings.

Naso-gastric tubes used within East Surrey Hospital are all NPSA compliant. Procurement only order the ‘Nutricia Flocare Pur tube’, this is the only NGT inserted within the hospital.

Baseline NG placement Assessment – version 2 09/01/17 length and have externally visible length markings. pH paper is CE marked for use on human aspirate. Competency-based training Training needs to reflect all the safety-critical requirements summarised in this resource set.

Clinical documentation formats and checklists These need to reflect all the safety-critical requirements summarised in this resource. Ongoing audit of compliance

Isolated cases when a later decision to change suppliers for cost effectiveness meant that non-compliant nasogastric tubes were re-introduced. Not all trusts appear to have created ongoing training programmes, or levels of training completion had not been routinely monitored and had lapsed.

All staff read the policy, complete a core assessment and practical assessment. Compliance is reviewed by ward managers

From the investigations it was not clear if all trusts provided structured documentation or checklists to record nasogastric tube insertion and subsequent checking requirements.

Paediatric of nasogastric/orogastric tube insertion and correct placement checklist commenced on insertion of ng tube

Some investigations suggested that some policies written after the

Under Divisional Audit programme. Audit planned for February 2017

Page 2 of 3

Using Merck pH indicator papers. 2 types of Merck strips in cupboard – one without CE mark- to ensure all future orders are for the CE marked tubes. Competency undertaken on all new staff – this is retained by them in their portfolio Follow up assessment not practical. To undertake a competency assessment on all staff at next teams with presentation and discussion (Band 4 staff 12/01/17), Band 5 staff – 25/01/2017) and band 6 staff (16/02/2017). Thereafter update to be undertaken annually on team days. No competency for medical staff checking tubes on x-ray Checklists laminated in every care plan. NGT/OGT placement, size and measured entered daily on the Safety Check list. Aspirate/pH entered prior to every feed in allotted column on feed chart Review of policies Evidence of compliance needed in staff files

Transferred patients into the hospital will have to be identified and ensured that the tube insitu is compliant. Merck (Corflo) PH Indicator strips CE marker: only indicator strip used in East Surrey Hospital. New Trust wide competencies training roll out collaborating both practical and theoretical teaching with ongoing assessment at ward level. Records of all trained will be identified on Health Roster. Two yearly competencies updates Doctors: eLearning training regarding X-ray. Any doctor inserting Nasogastric tube would require competency training. This is where an eLearning trust wide package would benefit.

New end of bed documentation, with clear pathways to alert safe use. Rationale for feeding identified with signatures ( further discussion regarding grading) Identified NEX measurement on initial placement, point of nostril, +/- X-ray required. Clear continuation structured format for staff Ongoing yearly audits

Baseline NG placement Assessment â&#x20AC;&#x201C; version 2 09/01/17

Implementation of Patient Safety Alerts

2011 alert had had little impact on clinical areas. Initially good compliance had lapsed over time, but these lapses were only noticed after a Never Event occurred. Following the review of nasogastric tube investigations, omissions in the implementation of safety critical guidance from previous nasogastric tube alerts has become apparent. If there were gaps in organisational systems for ensuring alerts were acted on, these could potentially apply to other alerts.

Ongoing assessments at annual team days

The Trust has a CAS liaison officer in post; there is a Management of Safety Alerts Policy; the use of Datix-web for alerts has been th piloted and is due for launch on 16 January 2017; Divisional chiefs and their representatives and procurement are involved in the receipt; assessment; cascade as relevant and completion of alerts; NHS Patient Safety Alerts are owned by Executive members who have to sign these off; all alerts are monitored for assurance of completion and assurance that recommendations/actions have been completed through the Patient Safety Committee and the Divisional Governance Committeeâ&#x20AC;&#x2122;s; closure of alerts is included on the Trust performance scorecard

Page 3 of 3

As stated

Classification: Official

Patient Safety Alert

Nasogastric tube misplacement: continuing risk of death and severe harm 22 July 2016 Actions

Alert reference number: NHS/PSA/RE/2016/006 Alert stage: Two - Resources Use of misplaced nasogastric and orogastric tubes1 was first recognised as a patient safety issue by the National Patient Safety Agency (NPSA) in 20052 and three further alerts were issued by the NPSA and NHS England between 2011 and 2013.3-5 Introducing fluids or medication into the respiratory tract or pleura via a misplaced nasogastric or orogastric tube is a Never Event. Never Events are considered ‘wholly preventable where guidance or safety recommendations that provide strong systemic protective barrier are available at a national level, and should have been implemented by all healthcare providers.’6 Between September 2011 and March 2016, 95 incidents were reported to the National Reporting and Learning System (NRLS) and/or the Strategic Executive Information System (StEIS) where fluids or medication were introduced into the respiratory tract or pleura via a misplaced nasogastric or orogastric tube. While this should be considered in the context of over 3 million nasogastric or orogastric tubes being used in the NHS in that period,7 these incidents show that risks to patient safety persist. Checking tube placement before use via pH testing of aspirate and, when necessary, x-ray imaging, is essential in preventing harm. Examination of these incident reports by NHS Improvement clinical reviewers shows that misinterpretation of x-rays by medical staff who did not appear to have received the competency-based training required by the 2011 NPSA alert is the most common error type. Other error types involve nursing staff and pH tests, unapproved tube placement checking methods, and communication failures resulting in tubes not being checked. The reports included 32 incidents where the patient subsequently died, although given many patients were critically ill before the tube was introduced, it is not always clear whether the death was directly related to the misplaced tube. Review of local investigations into these incidents suggests problems with organisational processes for implementing previous alerts. This Patient Safety Alert is therefore directed at trust boards (or their equivalent in other providers of NHS funded care) and the processes that support clinical governance. It is NOT directed at frontline staff. Some of the implementation issues identified were: • problems with systems to ensure staff who were checking tube placement had received competency-based training • problems with ensuring bedside documentation formats include all safetycritical checks • problems maintaining safe supplies of equipment, particularly radio-opaque tubes and CE-marked pH test strips. The resource set that accompanies this alert provides a range of support for trust boards (or their equivalents) to assess whether previous nasogastric tube guidance has been implemented and embedded within their organisations improvement.nhs.uk/resources/resource-set-initial-placement-checks-nasogastricand-orogastric-tubes. It includes briefings to help non-executives and governors to understand the issues, summaries of safety-critical requirements of past alerts, self-assessment/assurance checklists, and learning from reported incidents.

Patient Safety

improvement.nhs.uk/resources/patient-safety-alerts NHS Improvement (July 2016)

Who: All organisations where nasogastric or orogastric tubes are used for patients receiving NHS-funded care When: To commence as soon as possible and to be completed by 21 April 2017

4 5

Identify a named executive director* who will take responsibility for the delivery of the actions required in this alert. Using the resources supplied with this alert, undertake a centrally coordinated assessment of whether your organisation has robust systems for supporting staff to deliver safety-critical requirements for initial nasogastric and orogastric tube placement checks. If the assessment identifies any concerns, use the resources supplied with this alert to develop and implement an action plan to ensure all safety-critical requirements are met. Share this assessment and agree any related action plan within relevant commissioner assurance meetings. Share the key findings of this assessment and the main actions that have been taken in the form of a public board paper.**

* For organisations that are not trusts/foundation trusts and do not have executive directors, a role with equivalent senior responsibility should be identified. **For organisations without a board, an equivalent publically available alternative to a board paper should be identified eg a report on a public-facing website.

See page 2 for references

Classification: Official

Alert reference number: NHS/PSA/RE/2016/006 Alert stage: Two - Resources

Resources Patient safety incident reporting For detail of dates and search strategy within the National Reporting and Learning System (NRLS) and the Strategic Executive Information System (StEIS) see page x of the supporting initial placement checks for nasogastric and orogastric tubes resource set on the NHS Improvement website improvement.nhs.uk/resources/resource-set-initialplacement-checks-nasogastric-and-orogastric-tubes References 1. Hanna G, Phillips, L, Priest O & Zhifang N (201) Improving the safety of nasogastric feeding tube insertion A report for the NHS Patient Safety Research Portfolio July 2010 www.birmingham.ac.uk/Documents/college-mds/haps/projects/cfhep/psrp/finalreports/ PS048ImprovingthesafetyofnasogastricfeedingtubeinsertionREVISEDHannaetal.pdf 2. National Patient Safety Agency - Reducing the harm caused by misplaced nasogastric feeding tubes 2005 www. nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59794&p=4 3. National Patient Safety Agency Patient Safety Alert: Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants 2011 www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=129640 4. National Patient Safety Agency Rapid Response Report: Harm from flushing of nasogastric tubes before confirmation of placement 2012 www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=133441 5. NHS England Patient Safety Alert: Stage 1 - Placement devices for nasogastric tube placement DO NOT replace initial placement checks 2013 www.england.nhs.uk/wp-content/uploads/2013/12/psa-ng-tube.pdf 6. NHS England Never Events Policy and Framework 2015 www.england.nhs.uk/patientsafety/never-events/ 7. Page 9 of the supporting initial placement checks for nasogastric and orogastric tubes resouirce set on the NHS Improvement website improvement.nhs.uk/resources/resource-set-initial-placement-checks-nasogastric-andorogastric-tubes Stakeholder engagement • • • •

Medical Specialities Patient Safety Expert Group Children and Young People’s Patient Safety Expert Group Surgical Services Patient Safety Expert Group Patient Safety Steering Group

For details of the membership of the NHS Improvement patient safety expert groups and steering group see www. england.nhs.uk/ourwork/patientsafety/patient-safety-groups/

Patient Safety

improvement.nhs.uk/resources/patient-safety-alerts

Integrated Performance Report M1 â&#x20AC;&#x201C; April 2017 Presented by: Angela Stevenson(Chief Operating Officer) Des Holden (Medical Director) Fiona Allsop (Chief Nurse) Paul Simpson (Chief Financial Officer)

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

Performance – April 2017 Patient Safety • The Trust declared 1 SI in April 2017 • Patient safety indicators continue to show expected levels of performance. • There were no MRSA bloodstream infections and 3 Trust acquired C-Diff case in April 2017. Clinical Effectiveness • Mortality is lower than expected for our patient group when benchmarked against national comparators. • Maternity indicators continue to show expected performance. Access and Responsiveness • The 4hr ED standard was not achieved with performance of 92.9% in April 2017.

• All cancer standards except the Two week rule and Cancer 62 day referral to treatment screening standard were achieved in April 2017. • 18 Weeks RTT - The Trust did not achieve the RTT Incomplete pathways standard with performance of 88.7%. Recovery actions are in place. Patient Experience • The FFT for Inpatients was 96.6% in April 2017; the ED FTT decreased slightly to 96.3%. The Trust continues to rank amongst the top Trusts for ED FFT. Workforce • On-going local and overseas recruitment continues in order to reduce agency usage across the Trust • The Trust continues to monitor ward nursing numbers and skill mix on a daily basis and is assured that adequate staffing is in place.

An Associated University Hospital of Brighton and Sussex Medical School

Performance – April 2017 Finance

• The Trust achieved a £1.0m [adjusted] deficit at the end of April, £0.6m favourable to the month 1 planned £1.6m deficit, due to continued restrictions on discretionary spend, and limited use of contingency reserves. The position includes £0.4m STP funding.

Key Risks • The Significant Risk Register for the Trust includes two quality risks in relation to ED Access standards and RTT Access standards.

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

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

Regulation:

The Care Quality Commission (CQC) regulates patient safety and quality of care and the CQC register and therefore license care services under the Health and Social Care Act 2009 and associated regulations.

Patient experience/ engagement:

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

Risk & performance management

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

NHS constitution; equality & diversity; communication.

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

An Associated University Hospital of Brighton and Sussex Medical School

Patient Safety Patient Safety Indicator Description

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Apr-17

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)

91.5%

94.7%

93.8%

92.3%

89.0%

90.7%

89.0%

89.9%

92.2%

89.9%

93.9%

93.1%

91.1%

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

95.0%

96.5%

97.6%

96.2%

92.6%

96.2%

94.8%

94.4%

96.8%

94.2%

97.9%

98.7%

98.9%

95%

96%

95%

100%

98%

100%

Serious Incidents - No per 1000 Bed Days

0.38

0.16

0.11

0.31

0.32

0.45

0.16

0.00

0.05

0.21

0.11

0.05

Percentage of Patient Safety Incidents causing Severe harm or Death

0.7%

0.4%

0.5%

0.8%

0.9%

0.5%

0.0%

0.5%

0.2%

0.0%

0.2%

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

Number of overdue CAS and NPSA alerts

Trend

100%

• The Trust declared one serious incident in April 2017. • 2017/10931 Failure of inter-provider metastatic spinal cord compression pathway resulting in paralysis • Safety thermometer performance continued to improve for the “New Harm” measure from 98.7% in March to 98.9% in April. Performance for “All Harm” reduced to 91.1% in April. The main driver was community acquired pressure damage. • The percentage of patient safety incidents causing severe harm or death was 0.2% in April 2017, within the expected range.

An Associated University Hospital of Brighton and Sussex Medical School

Patient Safety Infection Control Indicator Description

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Apr-17

MRSA BSI (incidences in month)

CDiff Incidences (in month)

MSSA

E-Coli

Trend

â&#x20AC;¢ There were no cases of MRSA in April 2017 and 3 cases of Trust acquired C.diff.

An Associated University Hospital of Brighton and Sussex Medical School

Clinical Effectiveness Mortality and Readmissions Indicator Description

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

HSMR (56 Monitored diagnoses - 12 Months)

95.8

94.4

93.7

94.8

93.7

92.1

92.9

92.7

94.3

91.1

Emergency readmissions within 30 days (PBR Rules)

6.5%

6.6%

6.8%

7.3%

7.0%

6.3%

6.5%

6.4%

7.5%

6.6%

Feb-17

Mar-17

6.5%

7.0%

Apr-17

Trend

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

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Apr-17

C Section Rate - Emergency

14%

18%

14%

12%

15%

16%

17%

13%

18%

17%

20%

C Section Rate - Elective

11%

10%

11%

14%

11%

12%

13%

11%

10%

14%

11%

Admissions of full term babies to neo-natal care

3.9%

7.0%

2.7%

4.7%

4.5%

5.0%

7.0%

4.9%

7.6%

5.9%

4.5%

5.7%

7.8%

Trend

â&#x20AC;˘ Maternity indicators continue to be monitored and reviewed by the Divisional Governance process as well as the Clinical Effectiveness Committee.

An Associated University Hospital of Brighton and Sussex Medical School

Access and Responsiveness Emergency Department Indicator Description

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Apr-17

91.3%

95.5%

96.4%

95.3%

96.0%

96.4%

95.4%

95.1%

89.8%

87.0%

90.9%

95.1%

92.9%

Ambulance Turnaround - Number Over 30 mins

231

172

168

191

145

189

224

336

253

194

249

188

Ambulance Turnaround - Number Over 60 mins

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

Trend

• The ED 4hr standard was not achieved in April 2017 with performance of 92.9%. • April was a challenging month for emergency care with ED attendances 6% higher than the same period in the prior year and admissions 8% higher. Most notable was the increase in admissions for patients aged 75 and over which was 15% higher than in 2016/17. • Ambulance turnaround performance declined in April 2017 with 27 breaches of the 1hr standard (c.1% of attendances). • The Trust is aligned with the national plans for Ambulance Handover improvement and is part way through an action plan with partners and further improvement is expected in Q1 of 2017/18. • In light of the on-going operational pressures in the Trust, the following risk is on the significant risk register:

• ED Access Standard - Failure to maintain the emergency department standard due to lack of capacity in the health system – Risk score 16 (Likelihood of 4 and consequence of 4)

An Associated University Hospital of Brighton and Sussex Medical School

Access and Responsiveness Cancer Indicator Description

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Apr-17

Cancer - TWR

91.0%

90.3%

91.7%

95.4%

93.0%

95.3%

94.8%

94.3%

94.5%

94.7%

94.4%

95.0%

92.1%

Cancer - TWR Breast Symptomatic

87.1%

91.1%

82.0%

93.9%

97.2%

95.7%

99.0%

95.8%

94.7%

95.4%

93.0%

95.7%

93.0%

Cancer - 31 Day Second or Subsequent Treatment (SURGERY)

95.8%

100.0%

96.0%

98.1%

95.8%

100.0%

94.0%

100.0%

96.2%

100.0%

98.1%

100.0%

Cancer - 31 Day Diagnosis to Treatment

96.7%

98.5%

98.6%

98.8%

97.0%

96.0%

100.0%

97.7%

97.2%

96.8%

99.1%

Cancer - 62 Day Referral to Treatment Standard

86.3%

86.0%

90.0%

86.7%

85.4%

85.6%

89.8%

89.7%

86.6%

87.9%

85.0%

89.0%

Cancer - 62 Day Referral to Treatment Screening

87.5%

100.0%

83.3%

100.0%

93.3%

100.0%

50.0%

Cancer - 31 Day Second or Subsequent Treatment (DRUG)

Trend

• The Two week rule and Cancer 62 day referral to treatment screening standard were not achieved in April 2017. The 62 Day GP and 31 day treatment standards were achieved. • Internal capacity, high referral volumes and patient deferral were a challenge in April resulting in amber performance for TWR target, clinical conversations with patients in relation to the urgency of appointment will happen throughout May & June to support patient care. • Cancer 62 day referral to treatment screening – a total of 4 screening referrals were received in April. Two colorectal patients breached the 62 day target. Both patients were received late on in their pathways due to patient deferrals at the screening centre. Patient 1’s referral was received at SASH day on 40 and was treated on day 67. Patient 2’s referral was received at SASH on day 37 and was treated on day 64. • Ring fencing of capacity for Cancer continues to see a knock on effect on RTT and Diagnostics.

An Associated University Hospital of Brighton and Sussex Medical School

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

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Apr-17

92.6%

92.5%

92.7%

92.6%

92.1%

92.4%

92.1%

92.5%

90.9%

90.5%

90.0%

90.1%

88.7%

RTT Admitted

76%

78%

79%

76%

77%

74%

77%

75%

71%

77%

78%

RTT Non Admitted

86%

87%

84%

82%

83%

82%

79%

77%

81%

86%

Percentage of patients w aiting 6 weeks or more for diagnostic

0.1%

0.5%

0.3%

0.4%

7.7%

10.9%

9.5%

8.3%

4.7%

0.4%

0.3%

0.2%

0.4%

Last Minute Elective Cancellations for non clinical reasons

104

No of operations cancelled on the day not treated within 28 days

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

Trend

• The Trust did not achieve the 92% RTT Incomplete pathway standard with performance of 88.7% in April 2017. • With significant growth in referrals and activity patterns changing to the South of the Trust, capacity challenges remain in a number of specialties and plans continue to be put in place to mitigate. • At the end of April 2017,19 patients were waiting over 52 weeks for treatment. Delay reasons include patient choice, capacity and complex pathways. • The 6 week diagnostic standard was achieved in April 2017 with performance of 0.4% • The following risks are on the significant risk register: • RTT Access Standards - Due to on-going operational pressures and increasing demand for elective services, the Trust cannot offer all services within the 18 weeks standards set out in the NHS Constitution. Longer waiting times result in poor patient experience and increase the number of formal and informal complaints – Risk score 15 (Likelihood of 5 and consequence of 3)

An Associated University Hospital of Brighton and Sussex Medical School

Patient Experience Patient Voice Indicator Description

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Apr-17

Emergency Department FFT - % positive responses

95.4%

94.9%

95.9%

94.9%

96.1%

95.3%

96.1%

96.8%

96.0%

96.3%

96.6%

96.9%

96.3%

Inpatient FFT - % positive responses

95.6%

96.0%

94.7%

95.8%

93.8%

95.4%

94.8%

95.5%

96.7%

96.2%

95.8%

96.6%

Maternity FFT - Antenatal - % positive responses

98.9%

95.4%

93.2%

100.0%

93.6%

97.6%

98.6%

95.6%

93.9%

98.5%

95.2%

95.9%

100.0%

98.8%

99.0%

97.7%

98.7%

95.6%

97.1%

96.9%

98.7%

97.8%

97.3%

98.8%

96.7%

Maternity FFT - Postnatal Ward - % positive responses

95.3%

97.6%

94.0%

91.8%

94.3%

92.8%

86.6%

96.2%

92.3%

89.0%

92.1%

95.8%

Maternity FFT - Postnatal Community Care - % positive responses

97.7%

96.1%

97.1%

98.9%

98.3%

97.5%

96.4%

98.3%

92.5%

100.0%

92.0%

100.0%

97.7%

Outpatient FFT - % positive responses

89.6%

86.7%

89.1%

88.9%

91.7%

90.2%

91.1%

91.2%

88.0%

89.7%

90.7%

90.6%

88.0%

Maternity FFT - Delivery - % positive responses

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

Trend

• ED FFT – The FFT score has decreased slightly to 96.3% in April (from 96.9% in March), it remains well above the national average. The response rate has dropped slightly, but remains high (23% in April compare to 26% in March), • Inpatient FFT - The FFT score for inpatients has increased to 96.6% (95.8% in March). The response rate has dropped slightly to 31% (from 37% in March). • Maternity FFT – The FFT for touchpoint 3 (postnatal ward) has increased to 95.8% (from 92.1% in March). Touchpoint 2 (delivery) has dropped slightly to 96.7% (from 98.8%). Both these scores are based on a 25% response rate. The response rate for touchpoint 1 (antenatal) has dropped to 5% and the postnatal community response rate is 10%, similar to March but lower than expected. The FFT score for these two touchpoints are therefore based on a small number of returns. • Outpatient FFT – The number of responses continues to increase and is the highest to date, at 1086 (compared to 839 in March). The April FFT score has dropped slightly to 88.0% from 90.6% in March.

An Associated University Hospital of Brighton and Sussex Medical School

Workforce Workforce Indicator Description

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Apr-17

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

97.3%

98.1%

97.6%

97.4%

96.9%

97.4%

97.6%

98.7%

96.9%

97.5%

96.7%

95.6%

95.4%

Average fill rate – care staff (%) - Day

98.2%

98.1%

98.2%

93.5%

95.0%

93.4%

91.1%

88.7%

92.4%

91.9%

96.4%

93.0%

96.5%

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

98.8%

98.6%

98.9%

98.3%

97.1%

97.8%

98.3%

97.7%

97.0%

97.3%

97.9%

97.4%

96.7%

Average fill rate – care staff (%) - Night

97.2%

98.2%

98.0%

95.7%

95.8%

95.2%

93.9%

92.8%

92.3%

95.4%

95.0%

94.9%

96.1%

Overall Sickness Rate

3.6%

3.2%

3.5%

3.4%

3.5%

3.3%

3.9%

4.2%

4.3%

4.1%

3.7%

3.5%

2.8%

%age of staff who have had appraisal

0.4%

14.7%

23.8%

41.6%

54.9%

71.0%

86.4%

95.2%

96.4%

97.0%

97.2%

97.6%

1.3%

Staff Turnover rate

14.4%

14.5%

15.3%

15.4%

14.9%

15.6%

15.5%

16.4%

16.1%

15.8%

16.0%

Total Establishment (WTE)

3733

3813

3820

3837

3876

3891

3937

3944

3952

3925

3932

3929

Vacancy Rate (All Staff)

8.4%

10.4%

12.8%

10.8%

11.3%

11.2%

11.5%

11.8%

11.0%

9.8%

9.4%

9.5%

%age of staff who have completed MAST training in the last 12 months

62.0%

64.7%

79.7%

80.8%

80.9%

80.3%

79.9%

80.0%

80.3%

76.8%

78.0%

13.0%

65.8%

Trend

• Vacancy Rates across all staff groups has increased by 0.1% to 9.5% and has also increased in Nursing by 0.2% to 15.9%. • Turnover has increased by 0.2% to 16.0% for all staff groups, but has remained at 16.1% in Nursing. • Sickness has reduced by 0.7% to 2.8%. • MAST figures were recorded as 77% which is Amber on the Trust RAG rating. • Achievement Review completion rates have been reset for the 2017 cycle and completion rates at the end of April were 1.32%. • There is still on-going high usage of Bank & Agency staff, and PMOs are reviewing usage on a weekly basis.

An Associated University Hospital of Brighton and Sussex Medical School

Finance Indicator Description

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Apr-17

Outturn £m Surplus / (Deficit) - Plan

15.2

21.3

Outturn £m Surplus / (Deficit) - Forecast

15.2

0.3

5.0

21.3

YTD £m Surplus / (Deficit) - Plan

(2.3)

(4.0)

(4.9)

(2.1)

(1.9)

1.8

6.2

5.0

6.8

10.1

15.2

(1.6)

YTD £m Surplus / (Deficit) - Actual

(1.3)

(2.5)

(3.0)

(1.8)

0.1

2.8

2.0

3.6

2.0

3.5

(1.0)

Outturn UNDERLYING £m Surplus / (Deficit) - Plan

7.5

12.5

Outturn UNDERLYING £m Surplus / (Deficit) - Actual

7.5

(4.6)

(2.8)

(4.3)

1.4

YTD Savings £m - Actual

0.2

0.5

1.0

1.6

1.9

2.3

3.1

4.4

5.6

6.8

8.0

9.2

0.3

(6.8)

(7.2)

(14.9)

(4.0)

(2.5)

0.0

0.3

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

2.3

2.1

6.3

2.5

5.6

2.7

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

2.7

3.0

3.7

4.9

5.8

4.5

4.8

7.2

5.3

4.4

2.9

5.6

3.8

OT Risk £m Surplus / (Deficit) - Assessment

YTD Liquid ratio - days

(16.0)

(13.0)

(18.0)

(17.0)

(19.0)

(16.0)

(10.0)

(9.0)

(7.0)

(11.0)

(12.0)

(14.0)

YTD BPPC (overall) volume £m

28%

32%

53%

62%

70%

73%

77%

79%

80%

82%

83%

94%

YTD BPPC (overall) value £m

41%

51%

58%

64%

71%

74%

77%

79%

80%

82%

97%

Outturn Capital spend Fav / (Adv) - forecast

9.0

13.1

15.9

12.6

12.4

11.3

11.4

17.9

Trend

• The Trust’s 2017/18 plan has been profiled as below, reflecting the phasing of the £8.8m sustainability funding, clinical activity and cost improvements.

• The Trust achieved a £1.0m [adjusted] deficit at the end of April, £0.6m favourable to the month 1 planned £1.6m deficit, due to

continued restrictions on discretionary spend, and limited use of contingency reserves. The position includes £0.4m STP funding.

An Associated University Hospital of Brighton and Sussex Medical School

Finance • Agency spend in April was £1.2m which was £0.2m lower than the plan but offset by increased bank spend. • The cash balance at the end of April 2017 was £3.8m. The Trust repaid £3.5m working capital facility (RWCF) in April 2017 leaving an outstanding balance of £12.5m. This cash has supported on-going improvement in BPPC performance which is 94% by volume, 97% by value for April 2017. • The planned Capital Resource Limit (CRL) for 2017/18 is £17.9m including £1.1m CRL deferred from 2016/17. In addition to this the Trust secured additional funding of £0.9m in respect of A&E Primary Care Streaming. The capital programme will be funded by £9.8m from depreciation, £7m capital investment loans and other internally generated funds; the Trust will repay £1.3m of existing capital investment loans. Major projects in the 2017/18 capital programme include, Ambulatory Care Unit £2.9m, Pathology Joint Venture £2.7m, EPR Digitise £2.0m, Day Surgery Unit £1.7m , Ophthalmology Day Unit £1.5m and Estates Fixed Allocation £1.5m.

An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD IN PUBLIC

Date: 25 May 17 Agenda Item: 5.1

REPORT TITLE:

IPR Revisions

EXECUTIVE SPONSOR:

Angela Stevenson

REPORT AUTHOR (s):

Ben Emly

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

Board Seminar / Executive Committee

Action Required: Approval (√) Purpose of Report: To confirm proposed changes to the format / content of the Trust Integrated Performance Report Summary of key issues Two changes are being proposed for the IPR  the format/ layout of the report  the measures / KPIs used within the report The proposed changes will help align the report with the “How are we doing?” / “How are we improving?” questions that now form a key element of the performance system in the Trust. Alignment / reporting with the annual priorities will also be supported. Recommendation: The Board is asked to approve the amendments to the report. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe – Deliver safe, high quality care and improving services which pursue perfection and be in the top 25% of our peers SO2: Effective – As a teaching hospital, deliver effective and improving sustainable clinical services within the local health economy SO3: Caring – Work with compassion in partnership with patients, staff, families, carers and community partners SO4: Responsive – To continue to be the secondary care provider of choice for the people of our community SO5: Well led - To be a high quality employer of choice and deliver financial and clinical sustainability around a patient centred, clinically led leadership model Corporate Impact Assessment: Legal and regulatory impact

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

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

The IPR includes reporting on financial performance The IPR includes reporting on patient experience measures The IPR forms part of the Trust Performance management framework, providing Trust level performance reporting to the Board The IPR includes report against NHS Constitution operating standards.

Attachment: IPR Revisions Report

2 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT – May 2017 IPR Revisions 1.

Introduction

•

As part of an on-going review of Trust reporting, the Integrated Performance Report has been reviewed with a number of proposed changes including re-naming the report to be “Delivering our Vision – How are we doing?”

•

Two changes are being proposed for the IPR • the format/ layout of the report • the measures / KPIs used within the report

2. •

•

Layout / Format The changes to the format of the report is proposed to: • Make the document more explicitly aligned to the CQC domains • Include monthly commentary / measures on the annual priorities • Build on the “How are we doing / improving” questions that form part of the Deep dive process in 2017. • Provide a format that is suitable for a number of audiences including Board and staff members Each section will include a page showing the traditional scorecard to ensure on-going visibility of trends etc.

The layout can be seen in the pictures below:

3 An Associated University Hospital of Brighton and Sussex Medical School

3. •

Measures / Indicators The measures to be included in the scorecard element of the report have been reviewed and a number of proposed changes are detailed below. Further meetings are being put in place to discuss some measures for introduction over the course of the year. Indicator

Proposal Safety

No of Never Events in month

Retain

No of medication errors causing Severe Harm or Death

Remove

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

Remove

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

Retain

Percentage of patients who have a VTE risk assessment

Retain

WHO Checklist Usage - % Compliance

Remove

Number of Sis

Retain

Serious Incidents - No per 1000 Bed Days

Retain

Number of Patient Safety Incidents causing Severe harm or Death

Add

Percentage of Patient Safety Incidents causing Severe harm or Death

Retain

Number of overdue CAS and NPSA alerts

Remove

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

Retain - Move to Safe

Average fill rate – care staff (%) - Day

Retain - Move to Safe

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

Retain - Move to Safe

Average fill rate – care staff (%) - Night

Retain - Move to Safe

MRSA BSI (incidences in month)

Retain

CDiff Incidences (in month)

Retain

MSSA

Retain

E-Coli

Retain - Revise to Trust Acquired Safety - Annual Plan - Reduce Avoidable Harm

Falls per '000 Bed Days

Add

Pressure Damage per '000 Bed Days

Add Effectiveness

HSMR (56 Monitored diagnoses - 12 Months)

Retain

SHMI

Add

Emergency readmissions within 30 days (PBR Rules)

Retain

C Section Rate - Emergency

Retain

C Section Rate - Elective

Remove

Admissions of full term babies to neo-natal care

Remove

TBC - Audit

Add

4 An Associated University Hospital of Brighton and Sussex Medical School

TBC - Research

Add Effectiveness - Annual Plan - Improve Discharge Planning

TBC - SAFER Metrics

Add

TBC - Your Care Matters Question

Add Access and Responsiveness

ED 95% in 4 hours

Retain

Patients Waiting in ED for over 12 hours following DTA

Retain

Ambulance Turnaround - Number Over 30 mins

Retain

Ambulance Turnaround - Number Over 60 mins

Retain

Cancer - TWR

Retain

Cancer - TWR Breast Symptomatic

Retain

Cancer - 31 Day Second or Subsequent Treatment (SURGERY)

Retain

Cancer - 31 Day Second or Subsequent Treatment (DRUG)

Retain

Cancer - 31 Day Diagnosis to Treatment

Retain

Cancer - 62 Day Referral to Treatment Standard

Retain

Cancer - 62 Day Referral to Treatment Screening

Retain

RTT Incomplete Pathways - % waiting less than 18 weeks

Retain

RTT Patients over 52 weeks on incomplete pathways

Retain

RTT Admitted

Remove

RTT Non Admitted

Remove

Percentage of patients waiting 6 weeks or more for diagnostic

Retain

No of operations cancelled on the day not treated within 28 days

Retain

Maternity Closures

Add

Access and Responsiveness - Annual Plan - Improve Efficiency of Elective Care TBC - Theatres

Add

Last Minute Elective Cancellations for non clinical reasons

Add

OP Clinic Utilisation

Add

DNA Rate

Add

Appt to Attend Ratio

Add

Day Case Rate

Add

Activity - OPD

Add

Activity - Theatres

Add

Activity - Angio

Add

Activity - Endoscopy

Add Caring

Emergency Department FFT - % positive responses

Retain

Inpatient FFT - % positive responses

Retain

5 An Associated University Hospital of Brighton and Sussex Medical School

Maternity FFT - Antenatal - % positive responses

Retain

Maternity FFT - Delivery - % positive responses

Retain

Maternity FFT - Postnatal Ward - % positive responses

Retain

Maternity FFT - Postnatal Community Care - % positive responses

Retain

Outpatient FFT - % positive responses

Retain

Mixed Sex Breaches

Retain

Complaints (rate per 10,000 occupied bed days)

Retain

Caring - Annual Plan - Create best environment for patients Meeting to discuss Well Led Overall Sickness Rate

Retain

%age of staff who have had appraisal

Retain - Revise to YTD

Staff Turnover rate

Retain

Total Establishment (WTE)

Retain

Vacancy Rate (All Staff)

Retain

%age of staff who have completed MAST training in the last 12 months

Retain

Data Security Awareness Training

Add

% Trust wide policies in date

Add

Well Led - Annual Plan - Staff Health, well being and working lives Meeting to discuss

4. â&#x20AC;˘

Recommendation The board is asked to agree the proposed changes to content and layout for introduction over Q1 of 2017/18

Angela Stevenson Chief Operating Officer April 2017

6 An Associated University Hospital of Brighton and Sussex Medical School

Date: 25th May 2017

TRUST BOARD IN PUBLIC

Agenda Item: 6.1

REPORT TITLE:

Workforce Retention Strategy - Update

EXECUTIVE SPONSOR:

Mark Preston Director of OD & People

REPORT AUTHOR (s):

Janet Miller, Deputy Director of Workforce

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

Discussion

Assurance (√)

Purpose of Report: This report updates the Board on progress with implementing the Retention Strategy approved by Executive Committee in January 2017. Summary of key issues The principles of the Strategy apply to all staff groups, however the focus is primarily on improving retention rates for qualified nursing and midwifery staff. Actions completed so far: Mobilising and engaging with the divisional nursing teams  Sharing experience and input from the national Retention Programme with HRBPs and wider nursing groups  Agreed documentation to support annualised hours contracts  Fast-track process for student nurses to work on the Trust bank on joining  Practice development support for new starters and those seeking next career move Priority actions in progress: Development of ‘Stay interviews’  Use of Talent Grid during Achievement Review  Revitalise and re promote ‘leavers survey’  Refresh employer branding  Development of ‘transfer window’ process for internal moves Recommendation: The Board are asked to note the contents of this report for assurance purposes. Relationship to Trust Strategic Objectives & Assurance Framework:

The workforce and development of our organisation are crucial to the delivery of all the Trust objectives. SO1: Safe – Deliver safe, high quality care and improving services which pursue perfection and be in the top 25% of our peers SO2: Effective – As a teaching hospital, deliver effective and improving sustainable clinical services within the local health economy SO3: Caring – Work with compassion in partnership with patients, staff, families, carers and community partners

SO4: Responsive â&#x20AC;&#x201C; To continue to be the secondary care provider of choice for the people of our community SO5: Well led - To be a high quality employer of choice and deliver financial and clinical sustainability around a patient centred, clinically led leadership model Corporate Impact Assessment: Legal and regulatory impact

NHS Outcomes Framework, NHS contract, Public Sector Equality Duties

Financial impact

Improvements in retention will reduce the Trustâ&#x20AC;&#x2122;s vacancy gap and reduce spend on temporary staff cover There is a direct link between staff satisfaction and improved patient experience

Patient Experience/Engagement

Retention of staff and reduction on agency will improve both patient experience and engagement

Risk & Performance Management

Improved retention reduces productivity losses

NHS Constitution/Equality & Diversity/Communication

NHS Constitution, NHS Values, Public Sector Equality Duty

Attachments: (1) Retention Strategy - Update Report

Page 2 of 8

TRUST BOARD REPORT – 25TH MAY 2017 RETENTION STRATEGY – UPDATE REPORT 1.0 Introduction The themes and suggested actions in the Trust’s retention strategy were informed by analysis of the data in our NHS Staff Survey Results and Staff Friends and Family Tests and through conversations between multi-professional networks including the Nursing & Midwifery Professional Committee, Workforce Committee, HR Business Partners and both the Workforce Development and Practice Development teams. These are now also being informed by our involvement in a national Retention Programme run by NHS Employers. This has given us access to retention initiatives from over 86 NHS organisations together with improvement methodologies for implementation. 2.0 Updates Our strategy, approved in January 2017, acknowledges that by providing a staff experience that is responsive to the needs of our workforce and positively supports our people, the Trust will be able to retain our talent, staff will be more motivated and engaged which in turn enhances the delivery of high quality care to our patients and service users. Our actions to deliver the strategy are focused under six themes.

Putting People First: our 6 themes

It is important to acknowledge that there is no ‘magic bullet’ that will solve an organisation’s retention problems however, the Trust’s actions over the past 6 years to improve staff engagement as demonstrated by our national staff survey results does give us a solid platform to work from. The Executive Committee approved 4 key priorities for retention in January 2017. These are:   

Development of ‘Stay interviews’ Use of Talent Grid during Achievement Review Annualised hours contracts for appropriate roles (commencing with student nurses)

Page 3 of 8



Revitalise and re-promote ‘leavers survey’

Action plans and metrics are being developed for each action and are linked to the Agency CIP and monitored through Divisional PMO’s. Progress with these priorities is as follows:2.1 Stay Interviews Documentation is in development to support one-to-one discussions between line managers and staff members that will be part of the Achievement Review Process. Using a small number of focused questions this facilitates the conversation with staff about their aspirations and gives line managers vital information on how to support the member of staff within the team or signpost developments in the Division or Trust. This will be linked to support available to individuals from the practice development team to progress within the organisation and the development of additional skills in the development of their roles and career aspirations going forward. 2.2 New Joiners Survey A short survey has been developed which is being sent to all new starters who have joined the Trust in the previous six months. Responses to the survey will give us valuable information about what attracted them to the organisation and gain their opinion following appointment. By understanding how it feels to work for SASH, and their thoughts on our organisational culture, we can review the interventions that have been put in place to support retention, and design appropriate new initiatives. The feedback will also be used to help us further develop the Trust’s employer brand as part of a coordinated recruitment marketing campaign to support candidate attraction. 2.3 Fast Track University Recruitment The Trust is developing a way to fast track the recruitment of undergraduate nursing students and allow them to register with the bank for casual work. This should help reduce any reliance on agency Nursing Assistants and retain nursing students within the organisation. This work should allow us to form positive relationships with pre-registered nurses with the aim of them being employed post qualification at SASH on a permanent basis. 2.4 Transfer Windows Transfer Windows are a way of facilitating the movement of existing staff to work in alternative wards, clinical areas or divisions to support their short or long term personal development. The concept is separate to the recruitment process and is designed for a specific grade of staff, (eg staff nurses wishing to move from one part of the organisation to another). The process is designed to be used for staff

Page 4 of 8

transferring position whilst maintaining their current pay band and terms; this may be for a fixed period or on a permanent basis. A transfer process is used to retain staff who may be considering leaving the Trust to broaden their experience of work in a different area. The arrangements are kept informal and controlled locally at divisional level giving Matrons and Ward Managers the opportunity to accept or decline requests based on current establishment and operational need. The proposal to introduce a transfer process is currently being discussed with Ward Managers, Matrons and Divisional Chief Nurse’s and a final decision will be made at a forthcoming Nursing Executive Group (NEG), meeting. 3.0 Achievement Review – Talent Grid Our AR process already includes assessment of those who are ‘ready now’ and part of our talent management approach is to develop processes which allow the identification of these individuals and where appropriate, provide opportunities for their ongoing development within the organisation.

Work has commenced this year on bringing these processes together and the Head of Resourcing & Talent will be focusing on developing succession plans for key posts within the Trust. This will help support the retention of top performers and help ensure that career development plans are put in place to allow those identified to maximise their potential. These plans will also link in with the Practice Development Nurse for Career Progression. 3.1 Career Development Service In addition to the succession planning work arising from the achievement reviews, the career development service offers guidance, support, interview skills and Page 5 of 8

career development advice for all staff. Those involved also have access to the Head of Resourcing & Talent who can provide interview coaching and advice to individuals applying for promotion. The sessions have already proved very popular and successful with a range of staff from Nursing Assistants to medical Consultants. Over 50 Trust staff have accessed this service to date and a good proportion have achieved the next step in their career aspirations. The service has developed a useful infogram which is being used to illustrate the career progression that is possible in the Trust.

3.3 Nurse in Charge Course This course prepares frontline nurses for taking charge of the clinical space in which they work. The aim of the programme is to equip them with the skills and knowledge to manage the ward in the absence of senior support. The programme commenced in July 2016 and to date, 84 registered have completed the course. 3.4 Band 6 Ready The objective of this programme is to provide Registered Nurses and Allied Health professionals at the Trust with the opportunity to develop the â&#x20AC;&#x153;inner leaderâ&#x20AC;? who can model and empower change, contribute knowledge and understanding to individual practice and team collaboration, and promote personal and professional growth that will contribute to future clinical leadership abilities. The programme focuses on developing leadership knowledge and skills through investigation and critical enquiry as part of a taught programme, and applying this knowledge by leading an improvement in the workplace. A variety of acquired experiences and insight also underpin the understanding of the working of the Trust and assist personal career development. The first cohort commenced in April 2017 with the second due to start in August. So far 13 people have commenced on the 5 month long programme. Page 6 of 8

Feedback from these programmes has been very positive and has highlighted the need for further development in other areas and in some cases has led to promotion into new roles. â&#x20AC;&#x153;After all our work I finally had the interview for Band 6 position today and I am so glad to tell you that they gave it to me!! So, so, so thankful for all your help and support! It could have been completely different without you! Thanks again! Exciting times now!â&#x20AC;? Band 5 Staff Nurse who has accessed the Career Development Service, the Nurse in charge programme and is a current participant in the Band 6 ready programme

3.5 Time to Talk and Make a Difference Conversations Adapted from the Kitchen table approach developed in the Sign up to Safety work and based on the power of conversations the Trust will shortly launch this event. Over a cup of tea or coffee and a cake our Deputy Chief Nurse will provide our nursing staff with a genuinely safe space to talk openly and honestly without judgement. Issues raised which relate to retention will be directed into the Trustâ&#x20AC;&#x2122;s strategy 3.6 Annualised Hours Contracts Documentation in now in place to support the use of annualised hours. Originally envisaged as a mechanism for our student nurses to undertake guaranteed minimum hours as Nursing Assistants during their training, the principles can also be used for other workers where this type of flexible contract would support retention. We will be promoting this opportunity Trust wide. 3.7 Divisional Level Retention Plans HR Business Partners have developed divisional level retention plans with key leaders within the operational divisions. The plans focus on hot spot areas and support the overall corporate initiatives with local action to target specific areas where retention has been identified as an issue. Issues currently being addressed in the Divisions include: Cancer & Diagnostic Services -

Radiology will be one of four in the Trust to receive support under the Health and Wellbeing strategy for mental health in the workplace.

Surgery -

particularly retention issues in ICU, Endoscopy and Theatres, current work includes:-

Enlarging the practice development nurse portfolio and recruiting an additional PDN to support Endoscopy and Theatres to enhance succession planning and grow and maintain our own. Train and support them to ensure the education and training is relevant to the specialist area.

Page 7 of 8

Liaising with external organisation to ensure we continue to support ICU training for our band 5’s through. Rotational post been advertised, so that we can better retain band 5s and DCN is reviewing internal rotation with the corporate PDN.

Medicine -

Focused exit interviews in high turnover areas, Holmwood and Emergency Department. Re-drafted the exit questionnaire and currently discussing a possible pilot in the Division of this.

Continue to roll out the rotation programmes in Acute Medicine/ ED and Medicine / Care of the Elderly. Consider a further Cardiology rotation.

Annual ‘thank you’ letter to all staff.

Talent map of band 6s to identify opportunities – examples of support being offered - coaching to Band 6 who is acting up to band 7; targeted training for a number of band 6s who will be ready soon for band 7 roles.

Review violence and aggression policy and develop bite size teaching sessions linked to “It’s Not OK” work.

WACH -

Clinical Supervision for EPU staff commenced and to expand to all Nursing Staff. Team Days for all staff on Brockham. Review of structure within the ward/EPU/GAU area following recent resignations.

Include with Achievement Review a discussion on personal career aspirations and if there is anything we can offer to support those aims e.g. rotations/taster session.

Reintroduce Team Meetings and Newsletter.

Estates and Facilities -

Use of apprenticeship programmes to enhance skills and help in the retention of staff identified through the achievement review process as ‘ready now’. Currently there are 25 employees on these courses with the aim that there will be more in the future.

Mark Preston Director of Organisational Development & People May 2017

Page 8 of 8

Janet Miller Deputy Director of Workforce

TRUST BOARD IN PUBLIC

Date: 25TH May 2017

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

Agenda Item: Board Self-Certification for NHS Trusts – Provider Licence Gillian Francis-Musanu Director of Corporate Affairs Gillian Francis-Musanu Director of Corporate Affairs Executive Committee 17.05.17

Action Required: Approval (√)

Discussion (√)

Assurance (√)

Purpose of Report: To seek board approval to confirm compliance with the requirements of the NHS SelfCertification for the Provider Licence. Summary of key issues For the first time NHS trusts are required to self-certify that they can meet the obligations set out in the NHS provider licence (which itself includes requirements to comply with the National Health Service Act 2006, the Health and Social Care Act 2008, the Health Act 2009 and the Health and Social Care Act 2012, and to have regard to the NHS Constitution) and that they have complied with governance requirements. The aim of self-certification is for providers to carry out assurance that they are in compliance with the conditions. From July, NHSI will contact a select number of NHS trusts to ask for evidence that they have self-certified. Although not an NHS Foundation Trust, all NHS Trusts are required to self-certify against the NHS Provider Licence. The attached assessment (Appendix A) confirms our compliance with the relevant requirements of the NHS Provider Licence. Recommendation: The Board is review and confirm compliance with the NHS Self Certification for the NHS Provider Licence. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe – Deliver safe, high quality care and improving services which pursue perfection and be in the top 25% of our peers SO2: Effective – As a teaching hospital, deliver effective and improving sustainable clinical services within the local health economy SO3: Caring – Work with compassion in partnership with patients, staff, families, carers

and community partners SO4: Responsive – To continue to be the secondary care provider of choice for the people of our community SO5: Well led - To be a high quality employer of choice and deliver financial and clinical sustainability around a patient centred, clinically led leadership model Corporate Impact Assessment: Legal and regulatory impact Financial impact Patient Experience/Engagement Risk & Performance Management NHS Constitution/Equality & Diversity/Communication

Completion of the self-certification is now a regulatory requirement Financial impact and due regard to the tariff is a requirement Patient choice and provision of information is a requirement Management of risks and strong performance management are also requirements Having due regard to the NHS Constitution is also a requirement

Attachments: Appendix A – SaSH Declarations for the NHS Provider License Appendix B – Self Certification documentation template Appendix C – Self Certification documentation template

REPORT TO TRUST BOARD IN PUBLIC 25TH MAY 2017 SELF CERTIFICATION STATEMENTS FOR NHS PROVIDER LICENCE 1.

Introduction

NHS trusts are required to self-certify that they can meet the obligations set out in the NHS provider licence (which itself includes requirements to comply with the National Health Service Act 2006, the Health and Social Care Act 2008, the Health Act 2009 and the Health and Social Care Act 2012, and to have regard to the NHS Constitution) and that they have complied with governance requirements. The self-certification requirement set out in CoS7(3) does not apply to NHS trusts. This is the first year NHS trusts must self-certify. Although NHS trusts are exempt from needing the provider licence, directions from the Secretary of State require the NHS Improvement to ensure that NHS trusts comply with conditions equivalent to the licence as it deems appropriate. The Single Oversight Framework (SOF) bases its oversight on the NHS provider licence. NHS trusts are therefore legally subject to the equivalent of certain provider licence conditions (including Condition G6 and Condition FT (4) and must self-certify under these licence provisions. 2. What is required?

Providers need to self-certify the following after the financial year-end: NHS provider licence condition The provider has taken all precautions necessary to comply with the licence, NHS Acts and NHS Constitution (Condition G6(3)) The provider has complied with required governance arrangements (Condition FT4(8)) The aim of self-certification is for providers to carry out assurance that they are in compliance with the conditions. From July, NHSI will contact a select number of NHS trusts to ask for evidence that they have self-certified.

3. Condition G6 Condition G6 (2) requires NHS trusts to have processes and systems that: a. identify risks to compliance b. take reasonable mitigating actions to prevent those risks and a failure to comply from occurring. Providers must annually review whether these processes and systems are effective and must publish their G6 self-certification within one month following the deadline for sign-off (as set out in Condition G6 (4)). Providers should choose ‘confirmed’ or ‘not confirmed’ as appropriate for the declaration. Providers choosing ‘not confirmed’ should explain why using in the free text box provided in the template.

4. Condition FT4 NHS trusts must self-certify under Condition FT4 (8).

Although not Foundation Trusts, NHS Provider Trusts should review whether their governance systems achieve the objectives set out in the licence condition. The standards set out in FT4 are similar to the standards of governance set out in the NHSI general objective. There is no set approach to these standards and objectives but we expect any compliant approach to involve effective board and committee structures, reporting lines and performance and risk management systems.

5. Sign off The board must sign off on self-certification.

6. Deadlines Boards must sign off on self-certification no later than: a. G6/CoS7: 31 May 2017 b. FT4: 30 June 2017.

7. Audits From July, NHS Improvement will contact a select number of NHS trusts and foundation trusts to ask for evidence that they have self-certified. This can either be through providing the templates if they have used them, or by providing relevant Board minutes and papers recording sign-off. 8. NHS Improvement - NHS Trusts Self-Certification Recommendation Following review and discussion, the Executive Committee is asked to support the proposed declaration as follows: 8.1 Condition G6

Not later than two months from the end of the Financial Year (by 31 May 2017), the CMFT Board of Directors (‘the Licensee’) is required to self-certificate to the effect that it “Confirms” or “Does not confirm” that it had well established and effective processes and systems to identify risks and guard against their occurrence in 2016/17, and, that these are still in place and their implementation and effectiveness is regularly reviewed going forward. Based on the evidence highlighted in Appendix A, it is recommended to the Board that the Self-Certification is formally signed-off as “Confirmed”.

8.2 Condition FT4 The Board of Directors is required to self-certificate “Confirmed” or “Not confirmed” (by 30th June 2017) to a number of governance-related statements and set-out any risks and mitigating actions planned for each one within the NHSI self-declaration template. Appendix A identifies evidence against each statement to support the declaration against Condition FT4. Based on the evidence highlighted in Appendix A; it is recommend to the Board that the ‘Condition FT4 is formally signed off as “Confirmed”. All Self-Certifications will be made public on the Trust’s website within one month of the highlighted self-certification deadlines. Gillian Francis-Musanu Director of Corporate Affairs & Company Secretary May 2017

APPENDIX A - PROVIDER LICENCE COMPLIANCE The Provider has taken all precautions necessary to comply with the licence, NHS Acts and the NHS Constitution (Condition G6 (3))

Licence Condition

Level of Compliance

Evidence/Board Assurance

This condition requires licensees to provide Monitor/NHSI with any information they may require for licencing functions.

Compliant

SASH has robust data collection and validation processes and has a good track record of producing and submitting large amounts of accurate, complete and timely information to regulators and other third parties to meet specific requirements.

Compliant This condition contains an obligation for all licensees to publish such information as Monitor/NHSI may require, in a manner that is made accessible to the public.

SASH is committed to operating in an open and transparent manner and has robust governance arrangements to ensure that required information is made accessible to the public.

Comment where noncompliant or at risk of non-compliance and required action N/A

Completion Date

N/A

The Board meets in public and will continue to undertake the majority of Trust business in public meetings; agendas, minutes and associated papers are published on our website. Our website contains a variety of information and referral point details providing advice to the public and referrers who may require further information 1

about services. Copies of the Trust’s Annual Report and Accounts and Quality Account are published on the website and the Trust operates a publication scheme for Freedom of Information requests. G3

Payment of fees to Monitor/NHSI

N/A

The Health & Social Care Act 2012 (“The Act”) gives Monitor/NHSI the ability to charge fees and this condition obliges licence holders to pay fees to NHSI if requested.

N/A

No decision has yet been made by NHSI to charge fees. However, the obligation to pay fees is a condition and will be accounted for within the Trust’s financial planning. SASH pays fees to other parties such as the Care Quality Commission and the NHS Litigation Authority. G4

Fit and proper persons as Governors and Directors (also applicable to those performing equivalent or similar functions)

Compliant

All employment contracts contain a clause concerning possible termination in the event of gross misconduct. The Trust disciplinary policy defines misconduct.

N/A

The Trust operates a rolling programme of Disclosure & Barring Service (DBS) checks for front line staff and for staff with access to sensitive information. The Board of Directors are subject to DBS checks on appointment and every 3 years thereafter. 2

The Board of Directors sign a Code of Conduct that identifies expected standards of behaviour which includes clear references to the new FPP regulation. The constitution contains relevant clauses for governors and directors about eligibility, disqualification and removal. Governors sign a code of conduct on appointment and are subject to DBS checks on election/appointment and every 3 years thereafter. This requirement is formalised in the Draft Trust constitution. Non-Executive (via NHSi) and Executive Directors are required to sign an annual declaration that they remain a FPP. G5

Having regard to Monitor/NHSI Guidance

Compliant

This condition requires licensees to have regard to any guidance that NHSI issues.

N/A

The Trust has had regard to NHSI guidance through submission of required annual and quarterly declarations, self-certifications and exception reporting as set out in the Single Oversight Framework and previous Compliance Frameworks. The Board has had regard to the Code of 3

Governance and has complied with all other guidance documents and requirements. G6

Systems for compliance with licence conditions and related obligations

Compliant

This requires providers to take all reasonable precautions against the risk of failure to comply with the licence and other important requirements.

N/A

SASH has an approved Risk Management Policy and a clear approach to identifying, managing, escalating and mitigating risk. The Executive Committee for Quality & Risk monitors risks across the organisation. The Trust has a robust Board Assurance Framework which is reviewed on a monthly basis by the Board. Internal and External Audit reports on regulatory compliance.

Registration with the Care Quality Commission

Compliant

This licence condition requires providers to be registered with the Care Quality Commission and to notify NHSI if registration is cancelled.

N/A

The Trust has full registration of all services with the CQC. G8

Patient eligibility and selection criteria

Compliant

This condition requires licence holders to set transparent eligibility and selection criteria for patients and to apply these in a transparent manner.

N/A

The Trust publishes descriptions of the services it provides and who the services are for on the Trust website.

Application of Section 5 (Continuity of Services)

Compliant

Eligibility is defined through commissioners’ contracts. Assurance is gained through the assessment stages to ensure that the appropriate services are provided. This condition applies to all licensees. It sets out the conditions under which a service will be designated as a Commissioner Requested Service.

N/A

Licensees are required to notify NHSI at least 28 days prior to the expiry of a contractual obligation if no renewal or extension has been agreed. Licensees are required to continue to provide the service on expiry of the contract until NHSI issues a direction to continue service provision for a specified period or is advised otherwise. Services shall cease to be Commissioner Requested Services (CRS) if:  commissioners agree in writing that there is no longer a service need and the regulator has issued a determination in writing that the service is no longer a CRS;  three years have elapsed since the 1 April 2013 or one year has elapsed since the commencement of the license, whichever is the latter; or  the contract to provide a service has expired and the direction notice issued by 5

NHSI specifying a further period of provision has expired. Licencees are required under this Condition, to notify NHSI of any changes in the description and quantity of services which they are under contractual or legal obligation to provide. Similar to the previous Mandatory Services, Commissioner Requested Services continue to be set within the contracts agreed with commissioners. The Trust has strong working relationships with its commissioning partners within the local health economy. The Board has a director responsible for leading on contract negotiations. The Trust has a strong track record of delivering service transformation, efficiency, productivity and quality improvement to meet the needs of the local population. SECTION 2 - PRICING P1

Recording of information

Compliant

Under this condition, NHSI may oblige licensees to record information, particularly information about their costs, in line with guidance to be published by Monitor/NHSI.

N/A

The Trust records all of its information about costs in line with current guidance and will comply fully 6

Provision of information

Assurance report on submissions to Monitor /NHSI

Compliance with the National Tariff

Compliant

with any new guidance. Having recorded the information in line with Pricing condition 1 above, licensees can then be required to submit this information to NHSI. The Trust will comply fully with any new requirements to submit information to NHSI. When collecting information for price setting, it will be important that the submitted information is accurate. This condition allows NHSI to oblige licensees to submit an assurance report confirming that the information that they have provided is accurate. The price of Trust services is described in our Acute Care Contracts with commissioners, set according to Contract rules and agreed with them. Local arrangements (provider to provider contracts/agreements) are similarly set and agreed in formal documents. The Audit & Assurance Committee receives and monitors all Internal Audit reports including specific reports on pricing. The Health and Social Care Act 2012 requires commissioners to pay providers a price which complies with, or is determined in accordance with, the National Tariff for NHS health care services. This licence condition imposes a similar obligation on licensees, i.e. the obligation to charge for NHS health care services in line with the National Tariff.

N/A

The Trust will follow national guidance which is consistent with the NHS payment system, with a value based commissioning contract where variable payments are related to outcomes or activities. Such contracts are in place with all commissioners and operated according to the process laid down in those contracts. The Finance & Workforce Committee receives reporting on Contracts and the Audit and Assurance Committee receives internal and external audit reports in relation to these Contracts. P5

Constructive engagement concerning local tariff modifications

Compliant

The Act allows for local modifications to prices. This licence condition requires licence holders to engage constructively with commissioners, and to try to reach agreement locally, before applying to NHSI for a modification.

N/A

The Trust will follow national guidance which is consistent with the NHS payment system, with a value based commissioning contract where variable payments are related to outcomes or activities. Any such arrangements are included within the Acute care Contract as specified â&#x20AC;&#x201C; no application to NHSi was made in 2016/17 or in setting eth 2017/18 Contracts.

CHOICE & COMPETITION CI

The Right of patients to make choices

Compliant

This condition protects patients’ rights to choose between providers by obliging providers to make information available and act in a fair way where patients have a choice of provider. This condition applies wherever patients have a choice under the NHS Constitution, or where a choice has been conferred locally by commissioners.

N/A

The Trust complies fully with all guidance in relation to patient choice.

Competition oversight Compliant

This condition prevents providers from entering into or maintaining agreements that have the object or effect of preventing, restricting or distorting competition to the extent that it is against the interests of health care users. It also prohibits licensees from engaging in other conduct that has the effect of preventing, restricting or distorting competition to the extent that it is against the interests of health care users.

N/A

All licensed provider organisations will be treated as ‘undertakings’ under the terms of the Competition Act 1998. This means that all licensed providers will be deemed to be organisations engaging in an ‘economic activity’ 9

for which the provisions of the Competition Act will apply. Licensed providers therefore need to comply with the Competition Act. The Trust Board and Executive Committee has access to expert advice to ensure compliance with this condition. INTEGRATED CARE IC1

Provision of integrated care

Compliant

The licensee shall not do anything that could reasonably be regarded as detrimental to enabling integrated care.

N/A

SASH is an active participant and leader in the local health and social care economy across the STP and is working in partnership with commissioners to take forward models of integrated care. The Trust has a strong track record of working on integrated care pathways with other health and social care providers. CONTINUITY OF SERVICES CoS1 Continuing provision of Commissioner Requested Services

Compliant

This condition prevents licensees from ceasing to provide Commissioner Requested Services, or from changing the way in which they provides Commissioner Requested Services, without the agreement of relevant commissioners.

N/A

The Trust has strong working relationships with its commissioning partners within the local health 10

economy. The Board has a director responsible for leading on contract negotiations. The Trust has a strong track record of delivering service transformation, efficiency, productivity and quality improvement to meet the needs of the local population. CoS2 Restriction on the disposal of assets

Compliant

This licence condition ensures that licensees keep an up to date register of relevant assets used in the provision of Commissioner Requested Services. It also creates a requirement for licensees to obtain NHSI’s consent before disposing of these assets when Monitor is concerned about the ability of the licensee to carry on as a going concern.

N/A

The Finance Department maintains a capital asset register for all depreciable assets valued at over £5,000 on purchase, or group assets valued individually over £1,000, and when grouped together functionally, valued at more than £5,000.

CoS3 Standards of Corporate Governance and Financial

Compliant

The Finance Department maintains an asset register and the Contracts Department a register of contracts. This condition requires licensees to have due regard to adequate standards of corporate governance and financial management. The single Oversight Framework will be utilised by

N/A

Management

CoS4 Undertaking from the ultimate controller

NHSI to determine compliance The Trust has a corporate Governance manual containing a suite of governance documents including:  An overarching corporate governance framework;  Standing Orders  Standing Financial Instructions; and  Reservation of Powers to the Board and Delegation of Powers.

N/A

Governance and Financial reports to Board meetings and Board sub-committees confirming details of the Trust’s governance and financial management and information which supports the Governance and Continuity of Services declarations. This condition requires licensees to put in place a legally enforceable agreement with their ‘ultimate controller’ to stop ultimate controllers from taking any action that would cause licensees to breach the license conditions. This is best described as a ‘parent/subsidiary company’ arrangement. If no such controlling arrangements exist then this condition would not apply.

N/A

Should a controlling arrangement come into being, the ultimate controller will be required to put in place arrangements to protect the assets and services within 7 days. Directors and Trustees of Charities are not regarded by NHSI as ‘Ultimate Controllers’. 12

This licence condition would not apply as the Trust is not an authorised NHS Foundation Trust. CoS5 Risk Pool Levy

N/A

This licence condition obliges licensees to contribute, if required, towards the funding of the ‘risk pool’ – this is like an assurance mechanism to pay for vital services if a provider fails.

N/A

The regulatory Risk Pool Levy has not come into effect to date. The Trust currently contributes to the NHS Litigation Authority risk pool for clinical negligence, property expenses and public liability schemes. CoS6 Cooperation in the event of financial stress

Compliant

This licence condition applies when a licensee fails a test of sound finances, and obliges the licensee to cooperate with NHSI and any of its appointed persons in these circumstances in order to protect services for patients.

N/A

In 2016/17 the Trust did not fail any such tests – should it do so it will cooperate with NHSi. The Trust reports its financial position according to regular reporting and is held to account by NHSi through monthly integrated delivery meetings. The Trust has a track record of co-operating with external bodies and regulators. 13

CoS7 Availability of Resources

Compliant

This licence condition requires licensees to act in a way that secures access to the resources needed to operate Commissioner Requested Services.

N/A

As with the provision of Mandatory Services, the Trust has well established services in place and currently provides all of the Commissioner Requested Services to a high standard. The Trust has forward plans and agreements in place with commissioners that meet this condition, including a 2 year Contract for 2017 -2019. NHS FOUNDATION TRUST CONDITIONS FT1

Information to update the register of NHS Foundation Trusts.

N/A

This licence condition ensures that NHS Foundation trusts provide required documentation to Monitor/NHSI

N/A

FT2

Payment to NHSI in respect of registration and related costs.

N/A

FT3

Provision of information to advisory panel.

N/A

If Monitor/NHSI moves to funding by collecting fees, we may need this licence condition to charge additional fees to NHS Foundation Trusts to recover the costs of registration. Monitor/NHSI would consult stakeholders before introducing such a fee. The Act gives Monitor/NHSI the ability to establish an advisory panel that will consider questions brought be governors. It is Monitorâ&#x20AC;&#x2122;s/NHSI current intention to establish this panel. This licence condition requires NHS Foundation Trusts to provide the information requested by an advisory panel.

N/A

FT4

NHS Foundation Trust Governance arrangements.

Though not an NHS Foundation Trust SASH is Compliant

This condition will enable NHSI to continue oversight of governance of NHS Foundation Trusts and NHS Trusts. In summary, licensees are required to:  have systems and processes and standards of good corporate governance;  have regard for the guidance published by NHSI;  have effective Board Committee Structures  have clear accountabilities and reporting lines throughout the organisation and maintain appropriate capacity and capability of the Board;  comply with healthcare standards;  have effective financial management, control and decision making; and  maintain accurate information

N/A

The Board undertakes regular reviews of:  Board effectiveness;  Strategic objectives and risks to delivery through the Board Assurance Framework, Strategic Risk Register and Annual Plan  Board committee and assurance framework; their terms of reference and performance against these; and  Standing Financial Instructions and Reservation of Powers to the Board and Delegation of Powers.  Rules of Procedure 15

Other forms of assurance include;  Good CQC review of Well Led Domain in 2014  Internal Well-led framework review  Managerial and professional lines of accountability and clinical leadership;  Annual Governance Statement;  Audit and Assurance Committee scrutiny;  Internal Controls Framework  Internal and External Audit reports;  Integrated Performance reports received by the Board each month  Annual appraisals and development plans;  Performance Management Framework;  Annual Report and Quality Account;  Monthly reports to the Board from NED sub-committee Chairs  Divisional quality scorecards & dashboards  Specialty “Deep Dives”  Strategies and policies kept under regular review.

Worksheet "FT4 declaration" Corporate Governance Statement (FTs and NHS trusts) The Board are required to respond "Confirmed" or "Not confirmed" to the following statements, setting out any risks and mitigating actions planned for each one

Corporate Governance Statement

Confirmed The Board is satisfied that the Licensee applies those principles, systems and standards of good corporate governance which reasonably would be regarded as appropriate for a supplier of health care services to the NHS.

[including where the Board is able to respond 'Confirmed']

The Board has regard to such guidance on good corporate governance as may be issued by NHS Improvement from time to time

Confirmed

[including where the Board is able to respond 'Confirmed']

The Board is satisfied that the Licensee has established and implements: (a) Effective board and committee structures; (b) Clear responsibilities for its Board, for committees reporting to the Board and for staff reporting to the Board and those committees; and (c) Clear reporting lines and accountabilities throughout its organisation.

Confirmed

[including where the Board is able to respond 'Confirmed']

The Board is satisfied that the Licensee has established and effectively implements systems and/or processes:

Confirmed

Response

Risks and Mitigating actions

Please complete Risks and Mitigating actions

Please complete both Risks and Migitating actions Please complete Risks and Mitigating actions & Explanatory Please complete both Risks and Migitating actions Please complete Risks and Mitigating actions Please complete both Risks and Migitating actions & Explanatory Please complete Risks and Mitigating actions Information

[including where the Board is able to respond 'Confirmed']

(a) To ensure compliance with the Licensee’s duty to operate efficiently, economically and effectively; (b) For timely and effective scrutiny and oversight by the Board of the Licensee’s operations; (c) To ensure compliance with health care standards binding on the Licensee including but not restricted to standards specified by the Secretary of State, the Care Quality Commission, the NHS Commissioning Board and statutory regulators of health care professions; (d) For effective financial decision-making, management and control (including but not restricted to appropriate systems and/or processes to ensure the Licensee’s ability to continue as a going concern); (e) To obtain and disseminate accurate, comprehensive, timely and up to date information for Board and Committee decision-making; (f) To identify and manage (including but not restricted to manage through forward plans) material risks to compliance with the Conditions of its Licence; (g) To generate and monitor delivery of business plans (including any changes to such plans) and to receive internal and where appropriate external assurance on such plans and their delivery; and (h) To ensure compliance with all applicable legal requirements.

Please complete Risks and Mitigating actions

Please complete both Risks and Migitating actions & Explanatory Please complete Risks and Mitigating actions Information Please complete both Risks and Migitating actions & Explanatory Please complete Risks and Mitigating actions Information

The Board is satisfied that the systems and/or processes referred to in paragraph 4 (above) should include but not be restricted to systems and/or processes to ensure:

Confirmed

[including where the Board is able to respond 'Confirmed']

(a) That there is sufficient capability at Board level to provide effective organisational leadership on the quality of care provided; (b) That the Board’s planning and decision-making processes take timely and appropriate account of quality of care considerations; (c) The collection of accurate, comprehensive, timely and up to date information on quality of care; (d) That the Board receives and takes into account accurate, comprehensive, timely and up to date information on quality of care; (e) That the Licensee, including its Board, actively engages on quality of care with patients, staff and other relevant stakeholders and takes into account as appropriate views and information from these sources; and (f) That there is clear accountability for quality of care throughout the Licensee including but not restricted to systems and/or processes for escalating and resolving quality issues including escalating them to the Board where appropriate.

The Board is satisfied that there are systems to ensure that the Licensee has in place personnel on the Board, reporting to the Board and within the rest of the organisation who are sufficient in number and appropriately qualified to ensure compliance with the conditions of its NHS provider licence.

Please complete Risks and Mitigating actions

Please complete both Risks and Migitating actions & Explanatory Information Please complete Risks and Mitigating actions

Confirmed

[including where the Board is able to respond 'Confirmed']

Please complete Risks and Mitigating actions

Signed on behalf of the Board of directors, and, in the case of Foundation Trusts, having regard to the views of the governors

Signature

Name Alan McCarthy

Signature

Name Michael Wilson CBE

Further explanatory information should be provided below where the Board has been unable to confirm declarations under FT4. A

Please Respond

Please complete both Risks and Migitating actions & Explanatory Information Please complete Risks and Mitigating actions Please complete both Risks and Migitating actions & Explanatory Please complete Risks and Mitigating actions

Worksheet "G6 & CoS7" Declarations required by General condition 6 and Continuity of Service condition 7 of the NHS provider licence The board are required to respond "Confirmed" or "Not confirmed" to the following statements (please select 'not confirmed' if confirming another option). Explanatory information should be provided where required.

General condition 6 - Systems for compliance with license conditions (FTs and NHS trusts)

1&2 1

Following a review for the purpose of paragraph 2(b) of licence condition G6, the Directors of the Licensee are Confirmed satisfied that, in the Financial Year most recently ended, the Licensee took all such precautions as were necessary in order to comply with the conditions of the licence, any requirements imposed on it under the NHS Acts and have had regard to the NHS Constitution.

Signed on behalf of the board of directors, and, in the case of Foundation Trusts, having regard to the views of the governors

Signature

Name Alan McCarthy Capacity Chairman Date

Signature

Name Michael Wilson CBE Capacity Chief Executive Officer Date

Further explanatory information should be provided below where the Board has been unable to confirm declarations under G6. A

TRUST BOARD IN PUBLIC

Date: 25TH May 2017 Agenda Item: 6.3

Updated Standard of Business Conduct Policy Gillian Francis-Musanu Director of Corporate Affairs

REPORT TITLE:

EXECUTIVE SPONSOR (s):

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

Mark Preston Director of Organisational Development & People Gillian Francis-Musanu Director of Corporate Affairs Executive Committee JNCC in May

Action Required: Approval (√)

Discussion (√)

Assurance ( )

Purpose of Report:

Following the recent national review by NHS England on Conflicts of Interest, new national guidance has been issued to all NHS organisations which take effect from 1st June 2017. This has mean that Trust was required to review the new guidance and update the current Standards of Business Conduct Policy. Summary of key issues

The Standards of Business Conduct Policy has been updated policy following the publication of a new national policy “Managing Conflicts of Interest in the NHS” – publications gateway reference: 06419 – Feb 2017 Changes are as follows (noted in red text throughout the policy):  NHS definition of conflict of interests  Managing conflicts of interest  Changes to the total value of gifts a staff member can receive  More detail included on hospitality, outside employment, procurement, clinical private practice intellectual property  failure to make a declaration including breaches New sections on:  Shareholding & other ownership interests  Loyalty interests  Strategic decision making groups  Donations  Sponsored events  Sponsored research  Sponsored posts  Maintenance & publication of registers

Reference to Managing Conflicts of Interests in the NHS A requirement to make registers publicly available. A communication plan will be rolled out Trust-wide to raise awareness of the changes to the policy and the new requirements for staff. Recommendation:

The Trust Board is asked to ratify the updated policy. Relationship to Trust Strategic Objectives & Assurance Framework:

Now a national requirement for all NHS organisations

Financial impact

Included in the report

Patient Experience/Engagement

N/A

Risk & Performance Management

Included in the report

NHS Constitution/Equality & Diversity/Communication

Once ratified the updates to the policy will be communicated to all staff and the details made available on the intranet.

Attachment: Updated Standards of Business Conduct Policy â&#x20AC;&#x201C; May 2017

2 An Associated University Hospital of Brighton and Sussex Medical School

Surrey & Sussex Healthcare NHS Trust AN ORGANISATION WIDE POLICY ON STANDARDS OF BUSINESS CONDUCT Final Draft Key words: Openness, integrity, public funds, gifts, sponsorship, declaration, interests, business, conduct, transparent, hospitality, commercial, accountability

Version:

2.1

Status:

Final Revised Version for Ratification

Date ratified:

12/12/2012, 25/02/2016 & 25/05/2017

Name of Owner

Director of Corporate Affairs & Director of OD & People

Name of Sponsor Group

Audit & Assurance Committee

Name of Ratifying Group

Trust Board

Type of Procedural document

Policy

Policy Reference:

To be completed by Policy Coordinator

Date issued:

12/12/2012

Review date:

December 2015

Updated:

February 2016

Additional Update due to new NHS Conflicts of Interest Policy

May 2017

Next Review date:

May 2020

Target audience:

All Trust Staff, Volunteers and Agency/Contract workers.

Human Rights Statement

The Trust incorporates and supports the human rights of the individual, as set out by the European Convention on Human Rights and the Human Rights Act 1988

EIA Status Completed (Appendix 7) This policy will be made available in different languages and formats upon request. Requests of this nature should be made to the Patient Advice Liaison Service (PALS) at East Surrey Hospital, whose contact details are provided below: Telephone: E-Mail:

01737 768511 extensions 6922 or 6831 pals@sash.nhs.uk

Correspondence: PALS at East Surrey Hospital, Canada Avenue, REDHILL, Surrey, RH1 5RH The latest approved version of this document supersedes all other versions. Upon receipt of the latest approved versions all other version should be destroyed, unless specifically stated that the previous version(s) are to remain extant. If in any doubt please contact the document owner or Policy Coordinator.

Version Control 2.0

Date//Lead

January 2016 G Francis-Musanu

Comment Updating to include new regulations (FPPT) Revising requirement to submit annual declarations forms Including the Shadow Council of Governors Inclusion of Fraud Act 2006 Reference to the NHS Fraud and Corruption Reporting Line

2.1

May 2017 G Francis-Musanu

Overall strengthening of the policy Updated policy following the publication of a new national policy “Managing Conflicts of Interest in the NHS” – publications gateway reference: 06419 – Feb 2017 NHS definition of conflict of interests Detailed updates on the following: Managing conflicts of interest Changes to the total value of gifts a staff member can receive    

More detail included on: hospitality outside employment procurement clinical private practice intellectual property 2



failure to make a declaration including breaches

New sections on:  Shareholding & other ownership interests  Loyalty interests  Strategic decision making groups  Donations  Sponsored events  Sponsored research  Sponsored posts  Maintenance & publication of registers Reference to Managing Conflicts of Interests in the NHS Requirement to make registers publicly available

Contents

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.

Page No.

Summary

Introduction Purpose Public Service Values Scope of Policy Organisational Responsibilities Fit & Proper Persons Test Conflict of Interests Employment external to the Trust Contracts & Procurement Donations Clinical Private Practice Intellectual Property Confidentiality – Sensitive Information Consultation and Communication with Stakeholders Approval and Ratification Review and Revision Dissemination and Implementation Failure to make a declaration & breaches Archiving Monitoring and Compliance References Associated Documents

8 8 9 9 9 10 12 18 20 21 24 25 26 26 26 26 26 27 28 28 28 29

Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Appendix 7

Brief Overview of Bribery Act 2010 Short Guide to Standards of Business Conduct for NHS Staff HSG (93)5 Form – Declaration of Interests Form – Declaration of Gifts/Hospitality/sponsorship Form – Declaration of Relationship with Candidate Nolan Principles Equality Impact Assessment

30 31 33 34 35 36 37

Equality statement

This document demonstrates commitment to create a positive culture of respect for all individuals, including staff, patients, their families and carers as well as community partners. The intention is, as required by the Equality Act 2010, to identify, remove or minimise discriminatory practice in the nine named protected characteristics of age, disability, sex, gender reassignment, pregnancy and maternity, race, sexual orientation, religion or belief, and marriage and civil partnership. It is also intended to use the Human Rights Act 1998 to promote positive practice and value the diversity of all individuals and communities. This document is available in different languages and formats upon request to the Trust Procedural Documents Coordinator and the Equality and Diversity Lead.

Summary - of the Standards of Business Conduct Policy To assist NHS employers and staff in maintaining strict ethical standards in the conduct of NHS Business in 1993 the NHS Executive published HSG (93) 5 – Standards of Business Conduct for NHS Staff. (Please refer to the statement in the ‘Introduction’ of this document relating to HSG (93) 5. In brief, the guidelines cover the declaration of interests and acceptance of gifts and hospitality. It is the responsibility of all NHS staff to ensure that they are not placed in a position which risks, or appears to risk, conflict between their private interests and their NHS duties. The Trust’s Director of Corporate Affairs holds the Register of Interests, Gifts and Hospitality, which is checked periodically by the Audit Committee, internal and external auditors and the Trust Board. If you have anything to declare, please complete the declaration form and forward to the Director of Corporate Affairs, Trust Headquarters, East Surrey Hospital. Short Guide for staff Do: 

Make sure you understand the guidelines on Standards of Business Conduct (HSG (93) (5) referred to in your terms and conditions of employment and consult your line manager if you are not sure



Make sure you are not in a position where your private interests and NHS duties conflict.



Declare any relevant interests. If in doubt, ask yourself:

1. Am I, or might I be, in a position where I (or my family/friends) could gain from the connection between my private interests and my employment, or where it could be perceived by others that a gain could be made? 2. Do I have access to information which could influence the Trust’s purchasing or contracting decisions, or could it be perceived by others that I have such access? 3. Could my outside interests be in any way detrimental to the NHS or to patients’ interests, or could others perceive them to be detrimental? 4. Do I have any other reason to think I may be risking a conflict of interest? IF IN DOUBT – DECLARE IT

Always : 

Adhere to the ethical code of the Institute of Purchasing and Supply if you are involved in any way with the acquisition of goods and services. https://www.cips.org/en-gb/aboutcips/cips-code-of-conduct/



Seek your line manager’s permission before taking on outside work if there is any question of it adversely affecting your NHS duties.



Obtain the Trust’s permission (through your line manager) before accepting any commercial sponsorship.

Do Not 

Abuse your past or present official position to obtain preferential rates for private deals.



Unfairly advantage one competitor over another or show favoritism in awarding contracts.



Misuse or make available ‘commercial in confidence’ information.



Accept gifts, inducements or inappropriate hospitality.

Casual gifts offered by Contractors or others e.g. at Christmas time, may not be in any way connected with the performance of duties so as to be committing an offence under the Bribery Act. Such gifts should nevertheless, be politely but firmly declined. Articles of intrinsic value up to the value of £50 such as diaries or calendars, or small tokens of gratitude from patients or relatives, i.e. chocolates etc. need not be refused. Cash gifts including gift vouchers must not be accepted. In cases of doubt staff should either consult their line manager or politely decline acceptance. Modest hospitality provided it is normal and reasonable in the circumstances i.e. lunches in the course of working visits may be acceptable, though it should be similar to the scale of hospitality which the NHS as an employer would be likely to offer. Receipt of such hospitality should be declared. Staff should decline all other offers of gifts, hospitality or entertainment. If in doubt they must seek advice from their line manager and/or declare it.

1. Introduction Public service values must be at the heart of the National Health Service (NHS). 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 (NHS code of conduct: code of accountability in the NHS: Appointments Commission/DOH - 2nd Rev: 2004). The Trust is committed to the highest standards of openness, probity and accountability so that its employees remain beyond suspicion. In addition, under the Bribery Act 2010, it is an offence for any employee to corruptly accept any gifts or consideration as an inducement or reward for: • doing, or refraining from doing anything, in his or her official capacity, or • corruptly showing favor or disfavour, to any person in their official capacity. A brief description of the Bribery Act can be found at Appendix 1. All staff should be aware of the NHS Management Executive Health Service Guidelines on ’Standards of Business Conduct for NHS HSG (93)5 see Appendix 2. Guidance contained within this document referring to the ‘Prevention of Corruption Acts 1906 and 1916’ has been superseded by the Bribery Act 2010. However, much of the information contained within HSG (93) 5 is still relevant and until the document is either updated or replaced by the Department of Health it should still be available and used by employers, alongside a ‘Code of Conduct for NHS Managers’ 2002 as it still contains useful guidance. This policy has been written to take account of latest legislation as well as guidance and recommendations received from the Trust’s Local Counter Fraud Specialist, with particular reference to the new provisions under the Bribery Act 2010, which received Royal Assent and is now part of UK Law. www.legislation.gov.uk/ukpga/2010/23/introduction 2. Purpose The purpose of this policy is to provide employees with an awareness of their own personal responsibilities in their conduct at work as a public service employee in the NHS. It is also to make them aware that any breach of the provisions legislated in the Bribery Act 2010 is a criminal offence for which they could be prosecuted. The Fraud Act 2006 came into force in 2007 and created three ways of committing an offence of fraud, by false representation, by failing to disclose information and abuse of position. This policy offers guidelines intended to assist employees in being aware they have a duty to demonstrate high ethical standards of both business and personal conduct. Specifically it deals with gifts and hospitality and conflicts of interest to minimise placing themselves in a position which risks, or appears to risk, conflict between their private interests and their NHS duties. All suspected breaches of this policy will be reported to the Local Counter Fraud Specialist for investigation and may result in criminal proceedings being commenced and/or disciplinary 8

action being taken. 3. Public Service Values The NHS code of conduct: code of accountability in the NHS (Appointments Commission/DOH - 2nd Rev: 2004) defines three crucial public service values which must underpin the work of the health service. i) Accountability – everything done by those who work in the Surrey and Sussex Healthcare NHS Trust must be able to stand the test of parliamentary scrutiny, public judgments on propriety and professional codes of conduct; ii) Probity – staff should have an absolute standard of honesty in dealing with the assets of the NHS: integrity should be the hallmark of all personal and professional conduct in decisions affecting patients, colleagues and suppliers and in the use of information acquired in the course of NHS duties; iii) Openness – there should be sufficient transparency about Surrey and Sussex Healthcare NHS Trust’s activities to promote confidence between staff, patients and the public. These Public Service values are in accordance with the Seven Nolan Principles of Public Life. See Appendix 6 4. Scope of Policy This policy applies equitably to all employees of the Trust and includes all those who work for the Trust, whether full-time, part-time, self-employed, or employed through an agency, a contractor or as a volunteer. 5. Organisational Responsibilities 5.1. Trust Board – Executive and Non Executive Directors The Trust Board must ensure compliance with the NHS Code of Conduct: Code of Accountability (Appointments Commission/DOH – 2nd Rev: 2004), the principles of which are contained in this policy and the reference documents. The Trust Board are responsible for ensuring all Executives, Non Executives and Senior managers complete declaration of interest forms on appointment and these are reviewed on an annual basis. The Register of Interests is presented to the Trust Board on an annual basis for monitoring purposes and corrective action if appropriate. Any changes to declaration of interests should be made immediately and the CEO must be informed if these changes relate to an Executive Director. The Chairman must be in informed if this relates to a Non-Executive Director. 5.2. Managers Managers must ensure compliance with the NHS Code of Conduct for Managers 2002, the principles of which are contained in this policy and the reference documents. They must ensure all staff under their direction are aware of this policy and the referenced documents. 9

5.3. Employees All employees of, and those who work for, Surrey and Sussex Healthcare NHS Trust have a duty to ensure they are aware of and comply with this policy and referenced documents. In so doing employees and those working for the Trust must: a) ensure the interest of patients remain paramount at all times, b) be impartial and honest in the conduct of their official business and c) use the public funds entrusted to them to the best advantage of the service, always ensuring value for money Employees and those working for the Trust must also ensure that they do not: a) seek to advantage a private interest which is of such value that it could improperly influence performance of their official duties - for example to benefit their family and friends, religious belief, professional affiliation or political alignment, personal assets, investments or debts or b) seek to advantage a private interest which is of such value that it could improperly influence performance of their official duties for personal gain - for example a business interest, or an opportunity to make a financial profit or avoid a loss. 5.4. Human Resources HR will provide advice and guidance on the interpretation of this policy to managers and staff. 5.5. Trade Unions and Professional Organisations Trade Unions and Professional Organisations are required to be aware of this policy and the referenced documents and to advise staff accordingly. 6. Fit & Proper Person’s Test The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) places a duty on NHS providers not to appoint a person or allow a person to continue to be an executive director or equivalent or a non-executive director (NED) under given circumstances. Providers must not appoint a person to an executive director level post (including associate directors) or to a non-executive director post unless they are: • Of good character; • Have the necessary qualifications, skills and experience; • Are able to perform the work that they are employed for after reasonable adjustments are made; • Can supply information as set out in Schedule 3 of the Regulations (see the Role of the CQC below). Paragraph 5 (4) of regulations states that in assessing whether a person is of good character, the matters considered must include those listed in Part 2 of Schedule 4.’ Part 2 of Schedule 10

4 refers to: • Whether the person has been convicted in the United Kingdom of any offence or been convicted elsewhere of any offence which, if committed in any part of the United Kingdom, would constitute an offence, and • Whether the person has been erased, removed or struck off a register of professionals maintained by a regulator of health care or social work professionals. The Care Quality Commission’s (CQC) definition of good character is not the objective test of having no criminal convictions but instead rests upon a judgement as to whether the person’s character is such that they can be relied upon to do the right thing under all circumstances. This implies discretion for boards and councils in reaching a decision and allows for the fact that people can and do change over time. The regulations list categories of persons who are prevented from holding the office and for whom there is no discretion: • The person is an undischarged bankrupt or a person whose estate has had a sequestration awarded in respect of it and who has not been discharged; • The person is the subject of a bankruptcy restrictions order or an interim bankruptcy restrictions order or an order to like effect made in Scotland or Northern Ireland; • The person is a person to whom a moratorium period under a debt relief order applies under Part VIIA (debt relief orders) of the Insolvency Act 1986(40); • The person has made a composition or arrangement with, or granted a trust deed for, creditors and not been discharged in respect of it; • The person is included in the children’s barred list or the adults’ barred list maintained under section 2 of the Safeguarding Vulnerable Groups Act 2006, or in any corresponding list maintained under an equivalent enactment in force in Scotland or Northern Ireland; • The person is prohibited from holding the relevant office or position, or in the case of an individual from carrying on the regulated activity, by or under any enactment; • The person has been responsible for, been privy to, contributed to or facilitated any serious misconduct or mismanagement (whether unlawful or not) in the course of carrying on a regulated activity, or discharging any functions relating to any office or employment with a service provider. It will be the responsibility of the Chief Executive of the provider to discharge the requirement placed on the provider, to ensure that all directors meet the fitness test and do not meet any of the ‘unfit’ criteria. The CQC expects senior leaders to set a tone and culture of the organisation that leads to staff adopting a caring and compassionate attitude. It is important therefore that in making appointments boards and councils take account of the values of the organisation and the extent to which candidates provide a good fit with those values. The regulations give the CQC powers to assess whether both executive and non-executive directors (but not foundation trust governors) are fit to carry out their role and whether providers have put in place adequate and appropriate processes to ensure that directors are fit and proper persons. The CQC has the right to require the provision of information set out in Schedule 3 of the Regulations and such other information as is kept by the organisation that is relevant to the individual as follows: 

Proof of identity including a recent photograph.



Where required for the purposes of an exempted question in accordance with section 11

113A(2)(b) of the Police Act 1997(38), a copy of a criminal record certificate issued under section 113A of that Act together with, after the appointed day and where applicable, the information mentioned in section 30A(3) of the Safeguarding Vulnerable Groups Act 2006 (provision of barring information on request)(39) 

Where required for the purposes of an exempted question asked for a prescribed purpose under section 113B(2)(b) of the Police Act 1997, a copy of an enhanced criminal record certificate issued under section 113B of that Act together with, where applicable, suitability information relating to children or vulnerable adults.

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Satisfactory evidence of conduct in previous employment concerned with the provision of services relating to: (a) health or social care, or, (b) children or vulnerable adults

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Where a person (P) has been previously employed in a position whose duties involved work with children or vulnerable adults, satisfactory verification, so far as reasonably practicable, of the reason why P’s employment in that position ended.

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In so far as it is reasonably practicable to obtain, satisfactory documentary evidence of any qualification relevant to the duties for which the person is employed or appointed to perform.

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A full employment history, together with a satisfactory written explanation of any gaps in employment.

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Satisfactory information about any physical or mental health conditions which are relevant to the person’s capability, after reasonable adjustments are made, to properly perform tasks which are intrinsic to their employment or appointment for the purposes of the regulated activity.

The guidance states the following: (a) ’the appointed day’ means the day on which section 30A of the Safeguarding Vulnerable Groups Act 2006 comes into force; (b) ’satisfactory’ means satisfactory in the opinion of the Commission; (c) ’suitability information relating to children or vulnerable adults’ means the information specified in sections 113BA and 113BB respectively of the Police Act 1997 The Trust has procedures in place to ensure that Directors and Non-Executive Directors are fit and proper persons. 7. Conflict of Interest A ‘conflict of interest’ involves a conflict between the public duty and the private interest of a public service individual, in which a public official’s private interest could improperly influence the performance of their official duties or responsibilities. 12

NHS Definition: A set of circumstances by which a reasonable person would consider that an individual’s ability to apply judgement or act, in the context of delivering, commissioning, or assuring taxpayer funded health and care services in, or could be, impaired or influenced by another interest they hold”. Situations can arise in which there appears to be a conflict of interest but this is not in fact the case, or may not be the case. This situation is regarded as an “apparent conflict of interest”. Having an “apparent conflict of interest” as a public official, however, can be as serious as having an actual conflict because of the potential for suspicion of the official’s integrity and that of the organisation. An employee may have private interests which may be such as to cause a conflict of interests to arise in the future this is called a “potential conflict of interest”. Staff may hold interests for which they cannot see potential conflict. However, caution is always advisable because others may see it differently. It will be important to exercise judgement and to declare such interests where there is otherwise a risk of imputation of improper conduct. ‘Interests’ can arise in a number of different contexts. A material interest is one which a reasonable person would take into account when making a decision regarding the use of taxpayers’ money because the interest has relevance to that decision. Interests fall into the following categories:

7.1 Managing a Conflict of Interest Employees must notify any conflicts, apparent conflicts or potential conflicts, to their Line Manager as soon as they become aware of such conflict (and in any event within 28 days) via a positive declaration to their organisation and complete a declaration of interest form at Appendix 3. This form will be retained on the Trust’s Register of Interests and a copy retained in the employee’s personal file. Declarations should be made:  On appointment with an organisation  When a person moves to a new role or their responsibilities change significantly  At the beginning of a new project/piece of work  As soon as circumstances change and new interests arise 13

The following non-exhaustive list describes who these individuals are likely to be:     

Executive and non-executive directors* who have decision making roles which involve the spending of taxpayers’ money Members of advisory groups which contribute to direct or delegated decision making on the commissioning or provision of taxpayer funded services Those at Agenda for Change band 8d** and above Administrative and clinical staff who have the power to enter into contracts on behalf of their organisation Administrative, management and clinical and medical staff involved in decision making concerning the commissioning of services, purchasing of goods, medicines, medical devices or equipment, and formulary decisions.

* equivalent roles in different organisations carry different titles – this should be considered on a case by case basis ** reflecting guidance issued by the Information Commissioner’s Office with regard to Freedom of Information Legislation: https://ico.org.uk/media/1220/definition-document-health-bodies-in-england.pdf

Managers should consider how a conflict of interest be managed. In the first instance advice should be sought from the Chief Financial Officer or Director of Corporate Affairs, where one or more of the following options may be considered: 

deciding that no action is warranted



removal of the interest



removal of the employee from involvement in an affected decision-making process



restriction of access by the employee to particular information



transfer of the employee to duties in a non-conflicting function

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re-arrangement of the employee’s duties and responsibilities

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assignment of the conflicting interest in a genuinely ‘blind trust’ arrangement



keeping an audit trail of the actions taken

Each case will be different. The general management actions, along with relevant industry/professional guidance, should complement the exercise of good judgement. It will always be appropriate to clarify circumstances with individuals involved to assess issues and risks. However, there are a number of common situations which can give rise to risk of conflicts of interest, being:  Gifts  Hospitality  Outside employment  Shareholdings and other ownership interests  Patents  Loyalty interests  Donations 14

Sponsored events Sponsored research Sponsored posts Clinical private practice

   

7.2 Benefits – Gifts, Hospitality and Sponsorship A gift means any item of cash or goods, or any service, which is provided for personal benefit, free of charge, or at less than its commercial value. Overarching principle applying in all circumstances: Staff should not accept gifts that may affect, or be seen to affect, their professional judgement. Gifts from suppliers or contractors:  

Gifts from suppliers or contractors doing business (or likely to do business) with an organisation should be declined, whatever their value. Subject to this, low cost branded promotional aids may be accepted where they are under the value of a common industry standard of £6* in total, and need not be declared.

*The £6 value has been selected with reference to existing industry guidance issued by the ABPI: http://www.pmcpa.org.uk/thecode/Pages/default.aspx The Trust is required to keep a record of all gifts or hospitality offered and/or received, even when refused. All employees must complete the Declaration of Gifts and Hospitality Form (see Appendix 4) when offered any gift or hospitality, however small. This will be recorded on the Trust’s Gifts and Hospitality Register held by the Director of Corporate Affairs. Sight of the Trust’s Gifts and Hospitality Register is a frequent feature under the Freedom of Information Act and the Trust is obliged to produce this on request. The following guidelines should be followed when offered any gift or hospitality: Gifts from others sources (e.g. patients, families, service users):  Gifts of cash and vouchers to individuals should always be declined.  Staff should not ask for any gifts.  Gifts valued at over £50 should be treated with caution and only be accepted on behalf of an organisation (i.e. to an organisation’s charitable funds), not in a personal capacity. These should be declared by staff.  Modest gifts accepted under a value of £50 do not need to be declared. A common sense approach should be applied to the valuing of gifts (using an actual amount, if known, or an estimate that a reasonable person would make as to its value).



Multiple gifts from the same source over a 12 month period should be treated in the same way as single gifts over £50 where the cumulative value exceeds £50.

Hospitality Delivery of services across the NHS relies on working with a wide range of partners (including industry and academia) in different places and, sometimes, outside of ‘traditional’ working hours. As a result, staff will sometimes appropriately receive hospitality. Staff receiving hospitality should always be prepared to justify why it has been accepted, and be mindful that even hospitality of a small value may give rise to perceptions of impropriety and might influence behaviour. Hospitality means offers of meals, refreshments, travel, accommodation, and other expenses in relation to attendance at meetings, conferences, education and training events, etc. Overarching principles applying in all circumstances:  Staff should not ask for or accept hospitality that may affect, or be seen to affect, their professional judgement.  Hospitality must only be accepted when there is a legitimate business reason and it is proportionate to the nature and purpose of the event.  Particular caution should be exercised when hospitality is offered by actual or potential suppliers or contractors – these can be accepted if modest and reasonable but individuals should always obtain senior approval and declare these. Meals and refreshments:  Under a value of £25 - may be accepted and need not be declared.  Of a value between £25 and £75* - may be accepted and must be declared.  Over a value of £75* - should be refused unless (in exceptional circumstances) senior approval is given. A clear reason should be recorded in the Trusts Gifts & Hospitality declaration register(s) as to why it was permissible to accept.  A common sense approach should be applied to the valuing of meals and refreshments (using an actual amount, if known, or an estimate that a reasonable person would make as to its value). *The £75 value has been selected with reference to existing industry guidance issued by the ABPI http://www.pmcpa.org.uk/thecode/Pages/default.aspx All other offers of hospitality or entertainment should be declined. In cases of doubt employees should either consult their line manager, the Director of Corporate Affairs or Chief Financial Officer or else politely decline acceptance. Employees should only accept commercial sponsorship to attend relevant conferences or courses after they have received advance permission from the Trust by referring the matter to their Line Manager and on completion of the gifts and hospitality form at Appendix 4 for inclusion on the Register. Travel and accommodation: Modest offers to pay some or all of the travel and accommodation costs related to attendance at events may be accepted and must be declared.  Offers which go beyond modest, or are of a type that the organisation itself might not usually offer, need approval by senior staff, should only be accepted in exceptional circumstances, and must be declared. A clear reason should be recorded on the Gifts and Hospitality declaration register(s) of interest as to why it was permissible to accept travel and accommodation of this type. 16

A non exhaustive list of examples includes:  offers of business class or first class travel and accommodation (including domestic travel).  offers of foreign travel and accommodation. Employees should refer offers of drugs and/or clinical equipment/devices to their Line Manager or Chief Financial Officer and acceptance of the offer can only be made after they have received advance permission from the Trust and on completion of the gifts and hospitality form at Appendix 4 for inclusion on the Register. There are strict guidelines contained in the Policy for Commercial Representatives which should be followed. Employees should also refer to their Line Manager in the first instance and also the Chief Finance Officer when seeking, or being offered, sponsorship funding from an external source towards costs, or for the cost, of a specific event or work programme. 7.3 Declaration of relationship to candidates The Trust Board, Senior Officers, Medical Staff and any other staff involved in the recruitment and selection of candidates must declare the relationship (see Appendix 5). Candidates for any staff appointments must declare if they are related to any employee of the Trust. This includes partners and anyone whose affairs are so closely connected with the affairs of the candidate that a benefit derived by the other person, or a substantial part of it, could pass to the candidate, or could constitute a conflict of interest. A copy of such declaration must be retained on the Personal File (see Appendix 5). 7.4 Declaration of Interests If an employee has interests in any outside business they should declare this to the Trust as their employer. The following are examples of situations where a declaration must be made: 

The individual (or their family or friends) has a financial interest in a business which may compete for a contract to supply goods or services to the Trust



The individual has access to information that may influence where the Trust is to place a contract for goods or services

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The individual has outside interests that may be in any way detrimental to the NHS or to patients’ interest.

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A role or interest undertaken in a capacity which is paid or unpaid which a member of staff wishes to place on record but does not fall into the categories above.

A full list of examples is listed in the declaration of interest forms at Appendix 3. 7.5 Council of Governors As part of our journey to become an NHS Foundation Trust we have elected a shadow council of governors. The shadow council consists of elected and appointed governors. All governors are required to declaration any interest. Declarations are held in the Governors Declaration of Interests Register. 17

7.6 Pharmacy Staff who present applications for additions to the formulary are required to make a declaration of interest as part of that process. All members of the Drugs and Therapeutic Committee and Formulary committee are asked to make a declaration of interest each time an application is considered by the committee. All declarations are recorded in the minutes of the meeting even if no relevant interest is declared. 7.7 Medical Devices Staff who present applications to the medical devices group are required to make a declaration of interest as part of that process. All members of the Medical Devices Group should make a declaration of interest each time an application is considered. All declarations should be recorded in the minutes of the meeting even if no relevant interest is declared. 8. Employment external to the Trust 8.1 Working Time Regulations To comply with the Working Time Regulations (1998), it is a requirement that employees notify the Trust of any outside employment, including private work or work for outside agencies, particularly where their total time worked is in excess of 48 hours a week and they will be required to sign an “opt-out” agreement. An opt-out form can be accessed from the Trust Intranet. 8.2 Conflict of Interest with outside employment The NHS relies on staff with good skills, broad knowledge and diverse experience. Many staff bring expertise from sectors outside the NHS, such as industry, business, education, government and beyond. The involvement of staff in these outside roles alongside their NHS role can therefore be of benefit, but the existence of these should be well known so that conflicts can be either managed or avoided. Outside employment means employment and other engagements, outside of formal employment arrangements. This can include directorships, non-executive roles, selfemployment, consultancy work, charitable trustee roles, political roles and roles within notfor-profit organisations, paid advisory positions and paid honorariums which relate to bodies likely to do business with an organisation. (Clinical private practice is considered in a separate section).    

Staff should declare any existing outside employment on appointment and any new outside employment when it arises. Where a risk of conflict of interest is identified, the general management actions outlined in this guidance should be considered and applied to mitigate risks. Where contracts of employment or terms and conditions of engagement permit, staff may be required to seek prior approval from an organisation to engage in outside employment. Organisations may also have legitimate reasons within employment law for knowing about outside employment of staff; even this does not give rise to risk of a conflict. 18

Nothing in this guidance prevents such enquiries being made. Employees should not engage in any activities outside the Trust which may impact on their ability to fulfill their duties and responsibilities without first obtaining consent, which will not be unreasonably withheld. The Trust retains the right to review this position, should it become aware of issues affecting the employee’s employment with the Trust. Employees are advised not to take on outside employment or become involved in another company that may conflict with their Trust employment or be detrimental to it. This includes any work in or on behalf of a business owned by the employee, a member of his/her family or friends, as well as work for outside agencies. 8.3 Shareholding and other ownership interests Holding shares or other ownership interests can be a common way for staff to invest their personal time and money to seek a return on investment. However, conflicts of interest can arise when staff personally benefit from this investment because of their role with an organisation. For instance, if they are involved in their organisation’s procurement of products or services which are offered by a company they have shares in then this could give rise to a conflict of interest. In these cases, the existence of such interests should be well known so that they can be effectively managed. 

 

Staff should declare, as a minimum, any shareholdings and other ownership interests in any publicly listed, private or not-for-profit company, business, partnership or consultancy which is doing, or might be reasonably expected to do, business with their organisation. There is no need to declare shares or securities held in collective investment or pension funds or units of authorised unit trusts. Where shareholdings or other ownership interests are declared and give rise to risk of conflicts of interest then the general management actions outlined in this guidance should be considered and applied to mitigate risks.

8.4 Loyalty Interests As part of their jobs staff need to build strong relationships with colleagues across the NHS and in other sectors. These relationships can be hard to define as they may often fall in the category of indirect interests. They are unlikely to be directed by any formal process or managed via any contractual means - it can be as simple as having informal access to people in senior positions. However, loyalty interests can influence decision making. Conflicts of interest can arise when decision making is influenced subjectively through association with colleagues or organisations out of loyalty to the relationship they have, rather than through an objective process. The scope of loyalty interests is potentially huge, so judgement is required for making declarations. Loyalty interests should be declared by staff involved in decision making where they:  

Hold a position of authority in another NHS organisation or commercial, charity, voluntary, professional, statutory or other body which could be seen to influence decisions they take in their NHS role. Sit on advisory groups or other paid or unpaid decision making forums that can influence how their organisation spends taxpayers’ money. 19

 

Are, or could be, involved in the recruitment or management of close family members and relatives, close friends and associates, and business partners. Are aware that their organisation does business with an organisation with whom close family members and relatives, close friends and associates, and business partners have decision making responsibilities.

Where holding loyalty interests gives rise to a conflict of interest then the general management actions outlined in this guidance should be considered and applied to mitigate risks. 9. Contracts & Procurement All Trust employees who are in contact with suppliers and contractors, in particular those who are authorised to sign purchase orders, or place contracts for goods or services, must ensure that they are familiar with the Trust’s Standing Orders and Standing Financial Instructions. Procurement should be managed in an open and transparent manner, compliant with procurement and other relevant law, to ensure there is no discrimination against or in favour of any provider. Procurement processes should be conducted in a manner that does not constitute anti-competitive behaviour which is against the interest of patients. The Trust is required to keep records that show a clear audit trail of how conflicts of interest have been identified and managed as part of procurement processes. At every stage of procurement steps should be taken to identify and manage conflicts of interests to ensure and to protect the integrity of the process which is in line with the procurement guidance published by NHS Improvement and NHS England. Nothing in this section of the policy waives or modifies any existing legal requirements relating to conflicts of interests and procurement decisions. 9.1 Favoritism in Awarding Contracts Fair and open competition between prospective contractors or suppliers for Trust contracts is a requirement of the Trust’s Standing Financial Instructions, NHS Standing Orders and the EU Directives on Purchasing. Employees involved in placing or awarding contracts must not unfairly advantage one contractor or competitor over another, or show any favoritism in awarding contracts. This means that: no private, public or voluntary organisation which may bid for NHS business should be given an advantage over its competitors. each new contract should be awarded solely on merit, taking into account the requirements of the NHS and the ability of the contractors to fulfil them. All invitations to potential contractors to tender for NHS business should include a notice warning with regard to the consequences of engaging in any corrupt activity involving employees of the Trust. All contractors should be made aware of the Trust’s Whistle Blowing policy (Public Interest Disclosure Act). 20

NHS Fraud and Corruption Reporting Line is available on Freephone 0800 028 4060 or by completing an online form at www.reportnhsfraud.nhs.uk 9.2

Strategic Decision Making Groups/Committees

The Trust uses a number of meetings (Trust Board, Committees, sub-committees and working groups, including procurement panels) to make key strategic decisions about:  Entering into (or renewing) large scale contracts  Awarding grants  Making procurement decisions  Selection of medicines, equipment and devices These decision making groups are referred to in this policy as “strategic decision making groups/committees”. It is important that the interests of those who are involved in these groups are well known to the members of these groups. The Trust must therefore have a clear process to identify relevant strategic decision making groups and ensure they operate in a manner consistent with the following principles, which reflect wider standards of good governance.    

Chairs should consider any known interest of members in advance, and begin each meeting by asking for declaration of relevant interests Members should take personal responsibility for declaring material interests at the beginning of each meeting and as they arise Any new interest should be added to the Trusts Register of Interests The vice chair (or non-conflicted member) should chair all or part of the meeting if the chair has an interest that may prejudice their judgement

If a member has an actual or potential interest the chair should consider the following approaches and ensure that the reason for the chosen action is documented in minutes or records:  Requiring the member to not attend the meeting  Ensuring that the member does not receive meeting papers relating to the nature of their interest  Requiring the member to not attend all or part of the discussion and decision on the related matter  Noting the nature and extent of the interest, but judging it appropriate to allow the member to remain and participate  Removing the member from the group or process altogether The default response should not always be to exclude members with interests, as this may have a detrimental effect on the quality of the decision being made. An example is the need for clinical involvement, when clinicians may hold and represent a diversity of interests. Good judgement is required to ensure proportionate management of risk. The composition of groups should be kept under review to ensure effective participation. 10.

Donations

A donation is a charitable financial payment, which can be in the form of direct cash payment 21

or through the application of a will or similar directive. Charitable giving and other donations are often used to support the provision of health and care services. As a major public sector employer the NHS holds formal and informal partnerships with national and local charities. Staff will, in their private lives; undertake voluntary work or fundraising activities for charity. A supportive environment across the NHS and charitable sector should be promoted. However, conflicts of interest can arise. Acceptance of donations made by suppliers or bodies seeking to do business with an organisation should be treated with caution and not routinely accepted. In exceptional circumstances a donation from a supplier may be accepted but should always be declared. A clear reason should be recorded as to why it was deemed acceptable, alongside the actual or estimated value. 

  

Staff should not actively solicit charitable donations unless this is a prescribed or expected part of their duties for an organisation, or is being pursued on behalf of that organisation’s registered charity (if it has one) or other charitable body and is not for their own personal gain. Staff must obtain permission from their organisation if in their professional role they intend to undertake fundraising activities on behalf of a pre-approved charitable campaign. Donations, when received, should be made to a specific charitable fund (never to an individual) and a receipt should be issued. Staff wishing to make a donation to a charitable fund in lieu of a professional fee they receive may do so, subject to ensuring that they take personal responsibility for ensuring that any tax liabilities related to such donations are properly discharged and accounted for.

The Trust will maintain records in line with wider obligations under charity law, in line with the above principles and rules. 10.1 Sponsored Events Sponsorship of NHS events by external parties is valued. Offers to meet some or part of the costs of running an event secures their ability to take place, benefiting NHS staff and patients. Without this funding there may be fewer opportunities for learning, development and partnership working. However, there is potential for conflicts of interest between the organiser and the sponsor, particularly regarding the ability to market commercial products or services. As a result there should be proper safeguards in place to prevent conflicts occurring.    

Sponsorship of events by appropriate external bodies should only be approved if a reasonable person would conclude that the event will result in clear benefit for the organisation and the NHS. During dealings with sponsors there must be no breach of patient or individual confidentiality or data protection rules and legislation. No information should be supplied to the sponsor from which they could gain a commercial advantage, and information which is not in the public domain should not normally be supplied. At an organisation’s discretion, sponsors or their representatives may attend or take part in the event but they should not have a dominant influence over the content or the main purpose of the event. 22

  

The involvement of a sponsor in an event should always be clearly identified in the interest of transparency. Organisations should make it clear that sponsorship does not equate to endorsement of a company or its products and this should be made visibly clear on any promotional or other materials relating to the event. Staff should declare involvement with arranging sponsored events to their organisation.

The Trust is required to maintain records regarding sponsored events in line with the above principles and rules. 10.2 Sponsored Research Research is vital in helping the NHS to transform services and improve outcomes. Without sponsorship of research some beneficial projects might not happen. More broadly, partnerships between the NHS and external bodies on research are important for driving innovation and sharing best practice. However, there is potential for conflicts of interest to occur, particularly when research funding by external bodies does or could lead to a real or perceived commercial advantage. There needs to be transparency and any conflicts of interest should be well managed.   

 

Funding sources for research purposes must be transparent. Any proposed research must go through the relevant health research authority or other approvals process. There must be a written protocol and written contract between staff, the organisation, and/or institutes at which the study will take place and the sponsoring organisation, which specifies the nature of the services to be provided and the payment for those services. The study must not constitute an inducement to prescribe, supply, administer, recommend, buy or sell any medicine, medical device, equipment or service. Staff should declare involvement with sponsored research to their organisation.

10.3 Sponsored Posts Sponsored posts are positions with an organisation that are funded, in whole or in part, by organisations external to the NHS. Sponsored posts can offer benefits to the delivery of care, providing expertise, extra capacity and capability that might not otherwise exist if funding was required to be used from the NHS budget. However, safeguards are required to ensure that the deployment of sponsored posts does not cause a conflict of interest between the aims of the sponsor and the aims of the organisation, particularly in relation to procurement and competition.   

Staff who are establishing the external sponsorship of a post should seek formal prior approval from their organisation. Rolling sponsorship of posts should be avoided unless appropriate checkpoints are put in place to review and confirm the appropriateness of arrangements continuing. Sponsorship of a post should only happen where there is written confirmation that the arrangements will have no effect on purchasing decisions or prescribing and dispensing habits. For the duration of the sponsorship, auditing arrangements should be established to ensure this is the case. Written agreements should detail the circumstances under which organisations have the ability to exit sponsorship 23

 

arrangements if conflicts of interest which cannot be managed arise. Sponsored post holders must not promote or favour the sponsor’s specific products, and information about alternative products and suppliers should be provided. Sponsors should not have any undue influence over the duties of the post or have any preferential access to services, materials or intellectual property relating to or developed in connection with the sponsored posts.

Organisations should retain written records of sponsorship of posts, in line with the above principles and rules. Staff should declare any other interests arising as a result of their association with the sponsor, in line with the content in the rest of this guidance. 11. Clinical Private Practice Service delivery in the NHS is done by a mix of public, private and not-for-profit organisations. The expertise of clinicians in the NHS is in high demand across all sectors and the NHS relies on the flexibility that the public, private and not-for-profit sectors can provide. It is therefore not uncommon for clinical staff to provide NHS funded care and undertake private practice work either for an external company, or through a corporate vehicle established by themselves. Existing provisions in contractual arrangements make allowances for this to happen and professional conduct rules apply. However, these arrangements do create the possibility for conflicts of interest arising. Therefore, these provisions are designed to ensure the existence of private practice is known so that potential conflicts of interest can be managed. These provisions around declarations of activities are equivalent to what is asked of all staff in the section on Outside Employment. Consultants and Associate Specialists are permitted to carry out private practice subject to the provisions of their Trust contract of employment and clearly identified in their job plan. Other grades of staff may undertake private work or work for outside agencies provided this work does not conflict with their Trust employment or take place during their contracted hours with the Trust and complies with the requirements in their Contract of Employment and clearly identified in their job plan. Any work should also be subject to the conditions outlined in the NHS Code of Conduct for Private Practice and the Trust’s Policy on Private Patients and should be declared to the Trust using the declaration of interests form Appendix 3. Clinical staff should declare all private practice on appointment, and/or any new private practice when it arises* including:  where they practise (name of private facility)  what they practise (specialty, major procedures).  when they practise (identified sessions/time commitment) *Hospital Consultants are already required to provide their employer with this information by virtue of Para.3 Sch. 9 of the Terms and Conditions – Consultants (England) 2003: https://www.bma.org.uk/-/media/files/pdfs/practical advice at work/contracts/consultanttermsandconditions.pdf 24

Clinical staff should (unless existing contractual provisions require otherwise or unless emergency treatment for private patients is needed):  Seek prior approval of their organisation before taking up private practice.  Ensure that, where there would otherwise be a conflict or potential conflict of interest, NHS commitments take precedence over private work.**  Not accept direct or indirect financial incentives from private providers other than those allowed by Competition and Markets Authority guidelines: https://assets.publishing.service.gov.uk/media/542c1543e5274a1314000c56/NonDivestment_Order_amended.pdf Hospital Consultants should not initiate discussions about providing their Private Professional Services for NHS patients, nor should they ask other staff to initiate such discussions on his or her behalf.** ** These provisions already apply to Hospital Consultants by virtue of Paras.5 and 20, Sch. 9 of the Terms and Conditions – Consultants (England) 2003: https://www.bma.org.uk//media/files/pdfs/practical advice at work/contracts/consultanttermsandconditions.pdf) Where clinical private practice gives rise to a conflict of interest then the general management actions outlined in this guidance should be considered and applied to mitigate risks. 12. Intellectual Property The development and holding of patents and other intellectual property rights allows staff to protect something that they create, preventing unauthorised use of products or the copying of protected ideas. Staff are encouraged to be innovative in their practice and therefore this activity is welcomed. However, conflicts of interest can arise when staff who hold patents and other intellectual property rights are involved in decision making and procurement. In addition, where product development involves use of time, equipment or resources from their organisation, then this too could create risks of conflicts of interest, and it is important that the organisation is aware of this and it can be managed appropriately. Managers should ensure that they are in a position to identify intellectual property rights (IPR) as and when they arise so that they can exploit them properly. This will ensure that the Trust receives any reward or benefit (such as royalties), both in respect of work carried out by third parties, or work carried out by employees of the Trust. To ensure this is achieved managers should build appropriate specifications and provisions into the contractual arrangements before work is commissioned or begins, and seek legal advice in relation to specific cases. This complex area relates to copyright, patents, new inventions and collaborative research projects. Before any work is undertaken in this area, legal advice, in liaison with the Chief Finance Officer on intellectual property should be sought and contractual arrangements drawn up with the Trust, as to how rewards or benefits in respect of this work may be allocated. 

Staff should declare patents and other intellectual property rights they hold (either individually, or by virtue of their association with a commercial or other organisation), including where applications to protect have started or are ongoing, which are, or 25



might be reasonably expected to be, related to items to be procured or used by their organisation. Staff should seek prior permission from their organisation before entering into any agreement with bodies regarding product development, research, work on pathways, etc, where this impacts on the organisation’s own time, or uses its equipment, resources or intellectual property. Where holding of patents and other intellectual property rights give rise to a conflict of interest then the general management actions outlined in this guidance should be considered and applied to mitigate risks.

13. Confidentiality – Sensitive Information Staff should ensure they are aware of information relating to business conducted by the Trust which is “commercial in confidence”. All such information should be restricted with regard to disclosure particularly if its disclosure would prejudice the principle of a purchasing system based on fair competition. This refers to both private and public providers of services. The term “commercial in confidence” should not be taken to include information about service delivery and activity levels, which should be publicly available, under the Freedom of Information Act. The exchange of data for medical audit purposes is subject to the rules governing patient confidentiality and data protection. 14. Consultation and Communication with Stakeholders The policy has been drawn up in consultation with the trade unions, counter fraud, the Executive Committee and the Audit and Assurance Committee. 15. Approval and Ratification The following groups were responsible for the discussion, approval and ratification of this policy: Joint Consultative Committee The Executive Committee The Audit & Assurance Committee The Trust Board 16. Review and Revision All policies will be monitored and data presented to the relevant committee on a quarterly basis to analyse trends, and act on any areas of concern. 17. Dissemination and implementation The Trust process for dissemination of policies will be followed as described in the Organisation-wide Policy for the Management and Development of Procedural Documents. 26

It will be posted on the dedicated Policies and Procedures page of the intranet and a notification to all staff of the new policy placed on the next available E Bulletin. All forms which are attached (Appendices 2 – 5) are available as individual forms on the Form section of the intranet. Standards of Business Conduct are also referred to in all Employee Statement of Main Terms and Conditions of Employment. 17.1 Maintenance of Registers The Director of Corporate Affairs is responsible for maintaining up to date organisational registers. An interest will remain on the register for a minimum of 6 months after the interest has expired and details will be kept for a minimum of 6 years after the date of expiry. 17.2 Publication The Trust is required to publish the interests of decision making staff on an annual basis in a prominent place on the Trust’s website. The information should be accessible and available for inspection on request. The Trust will ensure that where an individual’s name and or other information will be redacted from any publicly available registers where the public disclosure of information could give rise to a real risk of harm or is prohibited by law. 18. Failure to Make a Declaration & Breaches There will be situations when interests will not be identified, declared or managed appropriately and effectively. This may happen innocently, accidentally or because of the deliberate actions of staff organisations. For the purposes of this policy these situations are referred to as breaches. Should it be suspected that a member of staff has failed to appropriately declare an interest, or failed to demonstrate compliance with the conduct outlined in this policy, it may be deemed appropriate to take action in line with the Trust’s Disciplinary Policy and/or make a referral to the Trust’s Local Counter Fraud specialist (LCFS). Staff can obtain details via the intranet should they have any concerns It is the responsibility of ALL staff to ensure that declarations must be updated on an annual basis and sent to the Director of Corporate Affairs. Each breach will be investigated and judged on its own merits and this should start with those involved having the opportunity to explain and clarify any relevant circumstances. Following an investigation the Trust will:  Decide if there has been or is potential for an actual breach and the severity  Assess whether further action is required in response – this is likely to involve any staff member involved and their line manager as a minimum  Consider who else inside and outside the organisation should be made aware of the breach  Take appropriate action, such as clarifying existing policy, taken against the staff member(s) responsible for the breach, or escalating to external parties such as auditors, NHS Protect, the Police, statutory health bodies and/or regulatory bodies. 27

When dealing with instances of breaches organisations may consider taking legal or other appropriate advice prior to imposing sanctions which could have serious consequences for those involved. A range of responses should be considered in terms of proportionate sanctions for breaches including:  Employment law action  Reporting incidents to external bodies  Contractual or legal consequences 19. Archiving This policy will be held in the Trust database and archived in line with the arrangements in the Organisation-wide Policy for the Management and Development of Procedural Documents. 20. Monitoring and Compliance The Department of Corporate Affairs will monitor the daily operation of this policy. Breaches of the policy will be monitored and reported on an annual basis. Registers will be maintained by the Department of Corporate Affairs to record declarations of gifts/hospitality/sponsorship received or refused and disclosures of interest. Registers will be presented for review at the Audit & Assurance Committee and the Trust Board on a bi-annual basis. Annual reports will be made to the Trust Consultative Committee. Periodic communications to maintain a level of awareness of responsibilities of staff will be undertaken through the SASH news, e Bulletin, counter fraud initiatives, any other appropriate medium as identified. Executive and Non Executive Directors and Senior Managers will be written to on an annual basis to ensure compliance with the policy.

21. References Trust’s Standing Orders Trust’s Standing Financial Instructions Trust Policy for Commercial Representatives Standards of Business Conduct HSG (93)5 Code of Conduct for NHS Managers 2002 Professional Codes of Conduct Contracts of Employment Bribery Act 2010 Nolan Principles Standards for Members of NHS Boards 2011 (Professional Standards Authority for Health & Social Care) Private Patients Policy Fit & Proper Persons Regulations Working Time Directive Policy 28

Fraud Act 2006 Managing Conflicts of Interest in the NHS (2017) 22. Associated Documents Disciplinary Policy Code of Conduct for Confidentiality Counter Fraud Response and Bribery Plan Policy for Raising Serious Concerns (Whistleblowing) Intellectual Property Policy Private Patients Policy Working Time Directive Policy Contracts of Employment Professional Codes Conduct Medical Devices Policy Trust Policy for Commercial Representatives

APPENDIX 1 Bribery and Corruption The new Bribery Act 2010 replaces the fragmented and complex offences at common law and in the Prevention of Corruption Acts1889 â&#x20AC;&#x201C; 1916. The Act sets out four offences: 1. Offering, promising or giving a bribe to another person to perform improperly a relevant function or activity, or to reward a person for the improper performance of such a function or activity (the active offence). It does not matter whether the person to whom the bribe is offered or given is the same person who is to perform the function or activity concerned. This applies to both public and private functions. 2. Requesting, agreeing to receive or accepting a bribe to perform a function or activity improperly (the passive offence). It does not matter whether the recipient of the bribe requests or receives it directly or through a third party, or whether it is for the recipient's benefit or not. In some cases, it is not necessary for the recipient to know or believe that the performance of the function or activity is improper. This applies to both public and private functions. 3. Bribing a foreign public official â&#x20AC;&#x201C; where a person directly, or through a third party, offers, promises or gives any financial or other advantage to a foreign public official ("FPO") (or to a third party at the request or acquiescence of the FPO) in an attempt to influence them in their capacity as a FPO in order to obtain or retain business, or to obtain an advantage in the conduct of business. To constitute bribery under the Act the FPO must be neither permitted nor required by applicable law to be influenced by the offer, promise or gift. 4. Failure of a commercial organisation to prevent bribery (the "Corporate Offence"). A commercial organisation will commit an offence if a person associated with it bribes another (in the UK or overseas) intending to obtain or retain business or a business advantage for that commercial organisation. An associated person includes any person who performs services for the commercial organisation. So, for example, an associated person may include not only employees, agents and subsidiaries, but also entities over which the organisation has no ownership or control.

APPENDIX 2 Short Guide to Standards of Business Conduct for NHS Staff To assist NHS employers and staff in maintaining strict ethical standards in the conduct of NHS Business in 1993 the NHS Executive published HSG (93) 5 – Standards of Business Conduct for NHS Staff. (Please refer to the statement in the ‘Introduction’ of this document relating to HSG (93) 5. In brief, the guidelines cover the declaration of interests and acceptance of gifts and hospitality. It is the responsibility of all NHS staff to ensure that they are not placed in a position which risks, or appears to risk, conflict between their private interests and their NHS duties. The Trust’s Director of Corporate Affairs holds the Register of Interests, Gifts and Hospitality, which is checked periodically by the Audit Committee, internal and external auditors and the Trust Board. If you have anything to declare, please complete the declaration form and forward to the Chief Financial Officer, THQ. Short Guide for staff Do: 

Make sure you understand the guidelines on Standards of Business Conduct (HSG (93) (5) referred to in your terms and conditions of employment and consult your line manager if you are not sure



Make sure you are not in a position where your private interests and NHS duties conflict.



Declare any relevant interests. If in doubt, ask yourself:

5. Am I, or might I be, in a position where I (or my family/friends) could gain from the connection between my private interests and my employment, or where it could be perceived by others that a gain could be made? 6. Do I have access to information which could influence the Trust’s purchasing or contracting decisions, or could it be perceived that I have such access? 7. Could my outside interests be in any way detrimental to the NHS or to patients’ interests, or could others perceive them to be detrimental? 8. Do I have any other reason to think I may be risking a conflict of interest? IF IN DOUBT – DECLARE IT

Always : 

Adhere to the ethical code of the Institute of Purchasing and Supply if you are involved in any way with the acquisition of goods and services.



Seek your employer’s permission before taking on outside work, if there is any question of it adversely affecting your NHS duties.



Obtain the Trust’s permission before accepting any commercial sponsorship.

Do Not 

Abuse your past or present official position to obtain preferential rates for private deals.



Unfairly advantage one competitor over another or show favoritism in awarding contracts.



Misuse or make available ‘commercial in confidence’ information.



Accept gifts, inducements or inappropriate hospitality.

APPENDIX 3 DECLARATION OF INTERESTS Name …………………………………………………………………………………. Title ………………………………………………………………………………….. Under the Codes of Conduct and Accountability, the Trust’s Standing Orders and Standing Financial Instructions and the content of the Standards of Business Conduct Policy I declare my interests as follows: Category Category A Directorships, including non-executive directorships held in Private companies or PLCs (with the exception of those of Dormant companies ) i.e. being a Board Member of a Statutory Organisation Category B Undertaking of private practice at any facility.

Details (include start date of interest & all locations)

Category C Ownership or private companies, business or consultancies likely or possible to do business with the NHS or any other organisation. Category D Majority, controlling or large shareholdings in organisations likely to possibly seek to do business with the NHS Category F A position of authority in a charity or voluntary organization in the field of health and social care Category F Any connection with a voluntary or other organisation contracting for NHS services Category G Any additional role or other interest undertaken in a capacity is paid or unpaid which a member wishes to place on record but does not fall into categories A-E above If this situation changes during the next 12 months I will advise you accordingly Signed …………………………………………………………………………………………………………………………. Date ……………………………………………………………………………………………………………………………. Countersigned Director /Chief of Service/Assistant Director………………………………………………………………………………… Date……………………………………………………………………………………………………………………………… Copy to be placed on employee’s file and original to be retained by the Corporate Affairs Team on the Register of Interests File.

APPENDIX 4 Declaration of Gifts, Entertainment, Hospitality/ Sponsorship/Sample Medical Equipment or Drugs Please complete this form if you receive or have offered any of the above that is beyond that set out in the Policy Please complete this form if you receive or have offered any of the above that is beyond that set out in the Policy Nature of Hospitality /gift given: ………………………………………………………………………………………….. Hospitality/gift offered to: ……………….………………………………………………………………………………… Name of organisation: ……………………………………………………………………………………………………. Date ………………………………………………………………………………………………………………………… Value (Approx.)……………………………………………………………………………………………………………… Description of hospitality/sponsorship/gift/entertainment/sample medical equipment or drugs: ……………………………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………………………….. Do you have any personal relationship with, or personal business connection with the person/organization from whom you received, or to whom you offered hospitality/gift/sponsorship/sample medical equipment /drugs declared above Yes

If yes, please describe

Declaration I declare that the above record represents a complete and accurate statement of the hospitality/gift/sponsorship/ sample medical equipment/drugs I have given/received Signed……………………………………………………. Date ………………………….. Name …………………………………………………………. Countersigned…………………………………………………………………. Director/Chief of Service/Assistant Director/ …………………………………………………Date………. …………. Copy to be placed on employee’s file and original to be retained by the Corporate Affairs Team on the Register of Interests File.

APPENDIX 5 Declaration of relationships with Candidates Guidance: 

Candidates will be required to disclose in writing whether to their knowledge they are related to the Chairman, Director, Consultant Medical staff or other staff with responsibilities for the recruitment process. Failure to do so shall disqualify from the recruitment and selection process. If an appointment is made, it shall render the appointee liable to dismissal.



Relationships to which these rules apply are those of husband, wife, where two persons live together as partners, sons, daughter, grandson, granddaughter, brother, sister, nephew, nieces of either partner.



Direct or indirect canvassing of the Chairman or Directors or of any committee of the Trust by or on behalf of any candidates shall disqualify the candidate from the appointment.



Employees of the Trust shall not solicit for any person or any appointment with the Trust or recommend any person for such an appointment. However, this does not preclude the member of staff from giving a written or verbal reference on request concerning a candidate’s ability or experience for submission to the Trust.



A panel member or recruiting manager/director must also complete this form and withdraw from the appointment process where they have an existing relationship with a candidate. Please refer to section 10 of the Recruitment & Talent Acquisition Policy for further guidance and/or seek advice from the Head of Resourcing & Talent.

Name …………………………………………………………………………………… Job Title ……………………………………………………………………………….. Declaration of Relationship Name of Candidate ………………………………………………………………….. Post applied for ……………………………………………………………………… Nature of relationship………………………………………………………………… Signed…………………………………………………Date…………………………. Countersigned

Director of OD & People………………………………………………………………

Copy to be placed on employee’s file and original to be retained by the Human Resources Team.

APPENDIX 6 The Seven Principles of Public Life (Nolan) 1.

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. 2.

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. 3.

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. 4.

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. 5.

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. 6.

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. 7.

Leadership

Holders of public office should promote and support these principles by leadership and example. The Committee on Standards in Public Life has set out â&#x20AC;&#x153;Seven Principles of Public Lifeâ&#x20AC;? which it believes should apply to all in the public service. www.public-standards.gov.uk

APPENDIX 7

Equality Impact Assessment Names of assessors carrying out the screening procedure (min of 2- author / manager and staff member / patient representative)  Gillian Francis-Musanu  1. Name of the strategy / policy / proposal / service function POLICY ON STANDARDS OF BUSINESS CONDUCT

Name of lead author /manager & contact number Gillian FrancisMusanu Date last reviewed or created & version number.

2. Who is the strategy / policy / proposal / service function aimed at? All staff, whether full-time, part-time, self-employed, or employed through an agency, a contractor or as a volunteer 3. What are the main aims and objectives? The purpose of this policy is to provide employees with an awareness of their own personal responsibilities in their conduct at work as a public service employee in the NHS. It is also to make them aware that any breach of the provisions legislated in the Bribery Act 2010 is a criminal offence for which they could be prosecuted 4. Consider & list what data / information you have regarding the use of the strategy / policy / proposal / service function by diverse groups? Workforce data, Employee relations data. 5. Is the strategy / policy / proposal / service function relevant to any of the protected characteristics or human rights below? If YES please indicate if the relevance is LOW, MEDIUM or HIGH Protected Characteristics    

Age Disability Gender Reassignment Race/ Ethnic Communities / groups

 Religion or belief  Sex (male female)  Sexual Orientation(Bisexual, Gay, heterosexual, Lesbian)  Marriage & Civil Partnership  Pregnancy & Maternity  Human Rights

Patient, their carer or family NO NO NO NO

Staff

NO NO NO

NO NO NO Yes. Low negative NO NO NO

NO NO NO

NO NO NO 37

What aspects of the strategy / policy / proposal / service function are of particular relevance to the protected characteristics? Race and potential for disciplinary action

Does the strategy / policy / proposal / service function relate to an area where there are known inequalities? If so which and how? Allegations of fraud may result in disciplinary action. In the past the number of BME staff in disciplinary cases has been disproportionate to the overall number in the Trust.

Please identify what evidence you have used / referred to in carrying out this assessment. See q 4 and authors knowledge

If you identify LOW relevance only can you introduce any minor changes to the strategy / policy / proposal / service function which will reduce potential adverse impacts at this stage? If so please identify here. Annual monitoring of breaches of the policy by protected characteristics of the staff involved will help identify any potential discrimination. This can be reported on as a subset of the employee relations report.

10.

Please indicate if a Full Equality Impact NO Assessment is recommended. (required for all where there is MEDIUM & HIGH relevance) If you are not recommending a Full Equality Impact assessment please explain why. The policy follows national guidance, good practice and UK legislation. The policy is identified in all employment contracts. Monitoring and reporting of the breeches by protected characteristics annually will provide additional assurance.

11.

12.

Signature of author / manager

Date of completion and submission

Definitions of relevance Low   

The policy may not be relevant to the Equality General Duty* as stated by law Little or no evidence is available that different groups may be affected differently Little or no concern raised by the communities or the public about the policy etc when they are consulted – (recorded opinions, not lack of interest) Medium    High

The policy may be relevant to parts of the Equality General Duty* in the policy etc regarding differential impact There may be some evidence suggesting different groups are affected differently There may be some concern by communities and the public about the policy

There will be relevance to all or a major part of the Equality General Duty* in the policy regarding differential impact.  There will be substantial evidence, data and information that there will be a significant impact on different groups There will be significant concern by the communities and relevant partners on the potential impact on implementation of the policy etc. 

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

 Human Rights the right to life the right not to be tortured or treated in an inhuman or degrading way the right to be free from slavery or forced labour the right to liberty the right to a fair trial the right to no punishment without law the right to respect for private and family life home and correspondence the right to freedom of thought, conscience and religion the right to freedom of expression the right to freedom of assembly and association the right to marry and found a family the right not to be discriminated against the right to peaceful enjoyment of possessions the right to an education the right to free elections

Safety & Quality Committee Thursday 6th April, 12.00-14.00 AD77, East Surrey Hospital Minutes of Meeting Present: Richard Shaw Alan McCarthy Des Holden Paul Simpson Zara Nadim Sarah Rafferty Victoria Daley Paula Tucker Ben Emly Katharine Horner

RS AMcC DH PS ZN SR VD PT BE KH

Non-Executive Director (Chair) Non-Executive Director Medical Director Finance Director Chief, WaCH Chief, Education Deputy Chief Nurse Deputy Chief Nurse Head of Performance Patient Safety & Risk Lead

Apologies: Pauline Lambert, Caroline Warner, Fiona Allsop, Ed Cetti, Jonathon Parr, Colin Pink, Karen Devanny, Julia Layzell, Angela Stevenson, Ben Mearns, Barbara Bray

Action 1 COMMITTEE BUSINESS 1.1. Chair welcomed everyone to the meeting. Apologies noted. 1.2. Minutes of the previous meeting The public minutes of the last meeting were agreed as an accurate record of the meeting. The private minutes were not available on board pad and will be approved via e-mail. 1.3. Actions Log and matters arising

C/F 7th July 2016 Data Quality Audit (date of death) update Ben presented the latest audit data. This is a standard audit completed which compares the data from the bereavement office with the date of death recorded on Cerner. BE circulated the data to the committee and noted that following the last audit there was slight improvement in August and September 2016. The error rate returned to historic rates - 26.1% consistently over the week. The error is that patients who have died are discharged the following day; adding a day to their length of stay and misrepresenting the day of the week on which they died. All corrections will be made and the data resubmitted to SUS to ensure that the data is accurate. Then a new approach to staff training will be taken to embed good practice. BE explained that this function is typically undertaken by ward clerks. The audit has raised the issue of accuracy of length of stay. Currently AMU has the highest volume of errors. A more focused audit will look at all discharges, including the non-deaths to ascertain whether an additional day is being added to all episodes of care. th

SQC Minutes 6 April 2017 Page 1 of 7

RS asked what problems this recording delay causes. DH explained that it is a data quality/reputational issue. C/F 2nd February 2017 On the agenda. C/F 2nd March 2017 It was noted that this update is not due until June. DH asked that Mark Salmon be invited to the meeting. 1.4. Highlights from Executive Committee for Quality & Risk DH presented the report and explained that each of the services have been providing updates on their preparation for the impending CQC inspection. This report presents the deep dives into maternity & paediatrics, medicine, surgery and end of life care. In general the reports have been useful; the team presentations have been good and well supported.

Overall the majority of self-assessments would suggest that we are “good” in some cases pushing into outstanding. This would correlate with the assessment by PWC who have done extensive work with CQC. DH noted that we code fewer of our deaths as EoL than most comparable Trusts (a third compared to half in other providers). This implies that a smaller proportion of SASH patients are receiving clinical input from the palliative care team. This could suggest that there is room for improvement. PS commented that the presentations have been positive and informative. The structure of the sessions allows objective challenge which has been constructive and involves the clinicians. AM asked how this information is being communicated to the Board and what level of understanding will be expected by CQC of the NEDs. BE explained that each Exec is the lead for a domain and/or a service. Their task is to understand what the challenges are what needs to happen to get to outstanding. The plan is that each Exec will have a NED buddy. Following the PWC workshop on the 28th April the non-execs will be given a paper including a summary of the matrix with: • where we are now • where we think we are going to get to • what we are doing about it RS asked ZN how she felt about the process. ZN summarised the main points of the maternity and paediatric presentations and concluded that the Division was happy with their position. In summary the committee agreed that this was an evolution of the four year deep dive process which has been refreshed and deepened to involve nonexec directors. The key lines of enquiry are to understand our services and what are we doing to improve.

SQC Minutes 6 April 2017 Page 2 of 7

1.5. Highlights from Clinical Quality Review Meeting PS presented the report although he had not been at the meeting.

RS asked whether the committee should be investigating the performance notices issued by the CCG. PS explained that the performance notice had been received from Sussex, with regard to ED, RTT and diagnostic performance targets. Following further discussion this was withdrawn. The Trust then received a performance notice from East Surrey CCG for the same performance areas and the addition of ED discharge summaries with a view to the Trust formulating an action plan. PS explained to the committee that the ED discharge summaries had been variable in quality, the issues have been identified and the Trust has now put in place an action plan. It was agreed that a presentation would be brought to SQC in June 2017 to talk through the work undertaken and the outcome. BM would be asked to present along with a representative from ED.

1.6. CQUIN update BE explained that the Trust is currently concluding the year. The Trust’s Q3 counter proposal is still under discussion, so the year end position is unknown. The main challenges have been around sepsis, anti-microbial resistance (there was a peak in Q3 antibiotic usage thought to relate to admissions).

The scope for 17/18 will be different; there are no local CQUINS, only National CQUINs. The following areas will be included: • Health & Wellbeing continues • e-referral and advice and guidance is coming in and will be a challenge to current working practices • discharge • length of stay (improvement required in the 2-7 day length of stay of the 65+ age range) • sepsis and anti-microbial resistance continues (the implementation of EPR should support this) PS updated the committee on the financial position and the impact on the final accounts. The biggest financial portion of CQUIN money is assessed and agreed at the end of Q4. The Trust has not had the CCG response in terms of Q3. Q4 reporting is being collated ahead of the freeze date at the end of April. A two month contractual process then follows. The CQUIN final settlement will not happen until June or July therefore cannot be reflected precisely within the Trust accounts. Financially PS will assume a positive outcome in respect of the CQUIN, therefore there will be a risk in terms of the financial position reported by PS. DH drew the committee’s attention to a CQUIN regarding patient activation and motivational interviewing. It was originally meant to be a 2 year CQUIN, but now not. • Patient activation – where do they fall on a spectrum from a level 1 (denial of their disease) to level 4 (self-management of condition th

SQC Minutes 6 April 2017 Page 3 of 7

through apps). Motivational interviewing is concentrating on aspects of the condition that most affect and impact the patient. DH noted that the work had been interesting and inspiring. He suggested that there could be opportunities to use this with staff health and wellbeing. By understanding how many of the Trust’s 3,800 staff are “1s” or “4s” will enable the health and wellbeing strategies to be appropriately targeted. DH will be working with the research design service to work out the best approach. •

2 QUALITY PERFORMANCE 2.1 Quality Report BE summarised the key issues highlighted by page 3 of the report.

RS asked that UTI’s in patients with a catheter be added to the Quality report, BE agreed that the Safety Thermometer sub-categories could be added to page 18 of the Quality Report. DH noted that this will support the work which is about to start on reducing gram negative septicemia most of which is related to UTI and gut sepsis. AM asked whether there would be any value is determining whether certain safety events should be declared internal never events. DH agreed that experience shows that high profile interventions are useful in making operational staff aware of safety issues. However, the Virginia Mason “stop the line” process not as easy to apply in an organisation that provides obstetrics and emergency care. In an intense operational environment there may be unintended consequences of rapid response team being diverted from their normal ward activity. RS noted the work being undertaken by PT on falls where a zero tolerance approach is being taken. PT explained that the after action reviews are done as soon as possible to ensure that staff are debriefed in the moment. It is an evolving process which might have applications elsewhere. DH noted that the recording of data related to safety is a challenge within the Trust for example VTE assessments, day of discharge etc. and made the point that these are process issues, not outcomes for patients. DH noted that absolute safety should not judged on the number of VTE assessments done on admission, but on the number of patients who develop and die of venous thromboembolism. Last year SASH did not report any patients who died as a consequence of inadequate screening or treatment. DH concluded that work will continue to review how the Trust reports performance and the self-allocated KPIs, especially where Trust performance may not compare favourably to other organisations. Further analysis will demonstrate where safety improvements are required or where the variance is a function of process issues around data. RS requested that a paper be brought back to SQC to summarise the output of this work.

AM requested further information about the urology and Gynae 62 day targets. BE explained that urology have put together a detailed plan around the resolving difficulties in meeting the target. These include clinic reconfiguration and how they co-ordinate with MDTs, on the day preassessments. The performance will also improve with changes to the rules th

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around shared breaches. Gynae have seen significant growth and capacity is not right. PS noted that a business case has been agreed to provide additional resources to meet the demand. BE noted that the Urology pathway is complex due to the number of investigations required and this is a national problem. 3 PATIENT EXPERIENCE 3.1 NHS “Stop the pressure campaign – action plan”

RS noted that there have been three grade 3 pressure cases recently and that grade 1 incidents have been showing as red on the quality report, so the committee would like assurance that the issue is being addressed. PT explained that the Tissue Viability Nurse will be meeting with BE to review the way in which pressure damage data is collected and that it will be measured in the same way as falls per 1,000 bed days. PT noted that two of the grade 3 incidents occurred on Tandridge in December 2016. It has been established that there were challenges relating to staffing and training on Tandridge at this time. The vacant posts have been filled; support and development has been given to the staff and they have grown as a team. No further incidents have been reported. The wards come together at the pressure damage panel to review incidents and discuss management strategies for example helping staff to manage conversations with patients about repositioning. Where patients have capacity and are non-compliant with advice, that the potential consequences are appropriately explained, documented and that the relevant matron is informed. Other measures include a new preventative dressing is being trialed that can stay on for two weeks, moisture damage will be reviewed in more detail. PT has unable to identify any change which may have led to the recent incidents of pressure damage. The action plan has been submitted to NHSI and runs for 12 months. RS noted that the success of the action plan will be monitored by the committee through the Quality Report. 4 SAFETY 4.1 Children’s safeguarding – lessons learnt RS informed the committee that this paper had been requested to provide assurance to the committee on the lessons for the Trust and the wider system from serious case reviews. VD summarised her report.

VD acknowledged that serious case reviews can be disturbing because they concern vulnerable children who have come to significant harm because there has been a systemic issue in the relationship between the agencies tasked with protecting them. VD noted that such cases are relatively rare and that only a couple of the current cases involve SASH. VD explained that the Trust is monitored by the Safeguarding Boards on any actions assigned to the Trust as part of the review. Furthermore the Trust th

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will apply learning identified by other organisations. This is reported to and monitored by the Trust Safeguarding committee. The process is that each individual agency provides a report about the care provided to the child and this is consolidated into a single report. The Boards bring together the staff involved in each case for further questioning, analysis and learning. Cases are rare and it is difficult to identify interlinking themes. The cases are presented to the Safeguarding Boards in draft prior to the publication of the report. This can be a lengthy process. Learning is identified as the process is being followed; issues that require immediate attention are dealt with by the relevant agency. RS asked, in the case of AA, whether the Trust were sufficiently alert, and confident enough to flag up the issues of the parenting of the child. VD confirmed that information sharing between agencies is good but acknowledged that the home environment of child AA was challenging and recognised that it is important that staff seek full assurance prior to discharge. This is addressed through formal and informal training. Bespoke training is provided by the safeguarding staff in addition to the Level 2 and 3 mandatory training. AM asked in the case of child AA how we assure ourselves that, once the Trust has flagged a concern to another agency, appropriate action has been taken. ZN undertook to follow this issue up with her team and report back to the committee. RS thanked VD for an interesting and useful report. He concluded that the committee could take good assurance that these issues are being handled very carefully. 5 QUALITY

DH explained that there was in event in London aimed at Execs and NEDs organised by NHS Improvement regarding the national expectation for mortality. There were two take home messages: â&#x20AC;˘ Trusts have to understand the learning that comes from deaths within the organisation. The Trust needs to devise a method of systematically reviewing as many deaths as possible to understand what that death said about the pathway of care and how the organisation works. â&#x20AC;˘ Must ask families how they felt about the death, it is not enough for the Trust to satisfy itself that the death was a good one. SASH has an established system of categorising deaths into expected and unexpected. There are some specialties that review all deaths; ITU, paediatrics and maternity. ED is not sufficiently knowledgeable of the patient to know whether the death was avoidable and often refer to the Coroner. Care for the Elderly will often judge a death to be expected with limited interrogation of the pathway, for example was the admission appropriate. A pilot is underway regarding the accuracy of the certification of death. th

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Established practice is that the death certificate is signed by a junior doctor who has been involved in the patient’s care. As part of the pilot the junior doctor will review the patient’s notes with a consultant and speak to the family. It is anticipated that this will improve the accuracy of referrals to the Coroner. DH will write to the Coroners to explain the pilot.

DH will give a more formal update to the committee at the June meeting.

6.1 Any other business No other items for business raised. 6.2 Proposed Agenda for next meeting The proposed agenda for the next meeting was approved. DATE OF NEXT MEETING Thursday 4th May 2017 12.00 – 14.00 AD77

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