SASH Board papers April 2017 by Surrey and Sussex Healthcare NHS Trust

Surrey and Sussex Healthcare NHS Trust Board papers

April 2017

Trust Board Meeting – IN PUBLIC Thursday 27th April 2017 – 11:00 to 13:00 AD77, Trust Headquarters, East Surrey Hospital, Canada Avenue, Redhill, RH1 5RH

AGENDA 1. 11.00

2. 11.30

3. 12.15

GENERAL BUSINESS 1.1 Welcome and apologies for absence

A McCarthy

Verbal

1.2 Declarations of Interests

A McCarthy

Verbal

1.3 Minutes of the last meeting held on 30th March 2017 For approval

A McCarthy

Paper

1.4 Action tracker & Matters arising For assurance

A McCarthy

Paper

1.5 Chairman’s Report For assurance

A McCarthy

Verbal

1.6 Chief Executive’s Report For assurance

M Wilson

Paper

2.1 Clinical Presentation/Patient Story For assurance

D Holden/ F Allsop

Presentation

2.2 Safety & Quality Committee Chair Update For assurance

R Shaw

Paper

2.3 Safety & Quality Indicators For assurance

F Allsop/ D Holden

Paper

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

F Allsop

Paper

2.5 Safer Working Guardian Quarterly Report For assurance

M Preston

Paper

2.6 Serious Incident Report For assurance

F Allsop

Paper

A Stevenson

Paper

QUALITY OF CARE

OPERATIONAL PERFORMANCE 3.1 Integrated Performance Report (M12) 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 Annual Plan Q4 Update For assurance 6. 13:15

13.25

S Jenkins

Paper

6.1 Updated Rules of Procedure 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 25th May 2017 at 11.00am

A McCarthy

Verbal

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

Chairman Chief Executive Non-Executive Director/Deputy Chairman Deputy Chief Executive & Chief Finance Officer Chief Nurse Chief Operating Officer Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director (Designate)

In Attendance (MP) Mark Preston (IM) Ian Mackenzie (CP) Colin Pink (DH) David Heller (SJ) Sue Jenkins 1.

Director of Organisational Development and People Director of Information & Facilities Acting Director of Corporate Affairs Chief Pharmacist (agenda item 2.1) Director of Strategy & Kaizen Promotion Office (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 David Sadler to the Trust as a NED. DS brings a wealth of experience to the Trust and we look forward to working with him. Apologies for absence were noted from Des Holden, Gillian Francis-Musanu and Pauline Lambert.

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 26th January 2017 were reviewed. These were agreed as an accurate record.

1.4

Action Tracker The Board reviewed the action tracker and CP confirmed : TBPU -17 relating to the inclusion of impact of gastroenteritis in the IPR was closed as a full refresh of the IPR is planned to take place at the start of the financial year. TBPU - 21 is due at the end of April 2017. Page 1 of 11

TBPU - 22 is due at the end of June 2017. There were no other matters arising. 1.5

Chairmanâ&#x20AC;&#x2122;s Report for Assurance AM provided feedback from a recent NHSI event focussing on early implementers of STP plans, in areas where there is a history of partnership working and limited numbers of primary and secondary providers. The geography and number of partner organisations makes the local STP complex, but there are examples of good practice of efficiencies and governance that can be adopted. The Trust will continue to explore and work with its partners across the STP. The Board noted the report and there were no questions raised.

1.6

Chief Executives report for Assurance The Board noted the report in advance of the meeting. MW presented the report highlighting the CQCâ&#x20AC;&#x2122;s state of hospitals report which provides a summary of the first review of all acute providers in the country. This is a particularly useful document for identifying areas of best practice and the challenges being faced by the NHS. MW went on to highlight the DOH NHS mandate which strengthens the commitments and expectations of what the NHS needs to deliver by 2021. MW went on to highlight the fantastic results of the 2016 national staff survey, thanking all staff who took part in the survey and the assurance it provides the Trust. The detail of the survey is covered later in the agenda. The Trust has launched its BAME network with support from an external charity, this is a good step forward for ensuring inclusion of all staff groups. MW reported that there will be a new national infection control reduction target for 2017/18 which specifically focusses on infections such as E-coli. This will be a very challenging goal as E-coli infections are not necessarily healthcare related. Finally MW congratulated PS on his appointment as the chair of the local STPs finance committee. RS noted that although many hospitals have identified safety as their highest priority none have achieved outstanding in this domain. MW concurred highlighting the need for an outstanding culture and environmental issues that impact on inspection. Investigations are now becoming intelligence driven and the CQC will take a great deal of information from national data sets such as the staff survey. FA concurred highlighting that those Trustâ&#x20AC;&#x2122;s with an overall outstanding assessment have a positive culture that you can feel. DS asked if the NHS mandate and the objectives had changed materially. MW commented that the mandate covers the areas that you would expect it to cover highlighting increased focus on home based integrated care, innovation and reduction of health inequalities. The Board duly noted and took assurance from the report. Page 2 of 11

1.7

Board Assurance Framework (BAF) and Significant Risk Register (SRR) for Approval and Assurance The Board received the paper in advance of the meeting. CP presented the report, noting that the BAF details the 13 risks to the trusts strategic objectives. The Executive Team are proposing a reduction in risk 4.1, from 15 to a 12, relating to the increased likelihood of meeting the objective of becoming the secondary provider of choice for our catchment area and delivery of national standards. Supporting evidence indicates that the likelihood of this risk materializing is reducing. PB noted that the AAC had reviewed the BAF and there are plans to refresh the document going into 2017/18. There are 10 significant risks recorded on the Trust risk register. AS highlighted the supporting evidence which is linked to the proposed reduction in strategic risk relating to becoming the provider of choice, increasing referrals and increased elective care choice for specific services. This reduction of likelihood in risk will move this to a 12, amber risk. The Board agreed with the proposal to reduce the risk score for risk 4.1. The Board noted and took assurance and approved the report.

Quality of Care 2.1 Clinical Presentation Hospital Pharmacy Transformation Plan for Assurance and approval DH introduced the report highlighting that modernisation of pharmacies is one of the key deliverables of the early Carter work and that the Trust is expected to develop an action plan to deliver efficiencies. DH highlighted the Trust governance that supported the initiative and the work that had been carried out to date. This is all detailed in the report. The focus is on clinical services which put the patient at the centre of the care provided. DH highlighted the Trustâ&#x20AC;&#x2122;s cost per weighted activity unit which is one of the lowest in the country and reflects the work that has already been undertaken to implement efficiencies, such as outsourcing outpatient prescriptions and preparation of chemotherapy drugs. It is not an indicator of Trust drug usage, in which the Trust is not cutting corners on its use of medications. DH and CW discussed how the drugs and therapeutics committee sets the Trustâ&#x20AC;&#x2122;s formulary based on evidence and NICE appraisal. The Board discussed potential impacts on length of stay relating to the efficient management of discharge and work to support junior doctors through the process. The Board went on to discuss national proposals to reduce spend on 10 key drugs which had recently been reported. DH reported that this was mainly a commissioning drive and that work was been driven to reduce overall usage. The Trust has a robust formulary from which drugs can be prescribed, any of formulary medications must be agreed with pharmacy. RD asked if SASH Plus methodology was being used in the pharmacy. DH Page 3 of 11

confirmed that it was. FA and DH discussed how 7 day working and the Trust’s cost per weighted unit could impact on staff choice and the delivery of the 7 day working. Acknowledging that lean work and outsourcing should be that the service is effective rather than just stretched. RS asked what 7 day services would mean for the pharmacy, DH reported that the service is currently 7 day but there is a difference between services provided at the weekend which should impact on patient experience and flow. IM and DH discussed the potential electronic prescribing project which is included in the electronic patient record project. This has previously been positively piloted by the Trust. The Board asked to receive two updates a year on the implementation of the plan. Action: DH AM thanked DH for the presentation.

2.2

The Board duly noted the report, took assurance and approved the report and action plan. Safety & Quality Committee Chair Update for assurance The Board received and noted the report in advance of the meeting. RS presented the report highlighting the recent improvement in patient falls, compliance with the Trust’s Duty of Candor systems for low harm incidents, the Chief of Cancer and Diagnostics report to the committee on peer reviews and the initial governance to support the Trust’s assessment of CQC compliance. It had been a good meeting and the committee had taken assurance throughout. RS noted the challenges that the WACH division is facing specifically relating to demand, capacity and staffing. AM asked that the Board receive an update on the Trusts analysis of alignment with CQC guidance and actions plans. Action: FA 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 elements of the Integrated Performance Report highlighting the two serious incidents (SI) reported in month and improvements in the Trust’s safety thermometer data. RS asked for the detail relating to the two SIs reported. FA highlighted that the investigations for both are underway, the incidents fall 6 months apart and at first review have no common contributory factors. FA will include narrative in SI reports to Board once the investigation is completed. FA noted the Trust’s patient experience data, highlighting that during March and April the Trust’s systems are changing which might impact on response rates. The Board duly noted and took assurance from the report. Page 4 of 11

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 introduced the report highlighting day to day numbers and activity to access and maintain safe working levels. Further national guidance will be published in May. The Board discussed staffing ratios in maternity particularly ratio of midwives. The Trust is at a ratio of 1 to 32 and is considering what can be done and the need to meet best practice ratios. Other organisations have included maternity assistants or maternity support workers in this ratio, which is a possible option that is being explored. The management of risk and leadership is key to ensure safe staffing levels are maintained. The Board duly noted and took assurance from the report.

Operational Performance Report 3.1

Integrated Performance Report (M10) 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 Trust did not achieve the ED standard in February but remains a high performer rating 11th out of 139 organisations. Ambulance handover is improving with focused attention and delivery of improvement actions. The Trust and sector is considering focusing on response times as a key metric to supplement handover times. Cancer access standards have been achieved for 8 months, there is continuing growth in demand. Diagnostic standards are now being achieved. RTT remains challenging as referral rates continue to grow. As part of the review of RTT 15 patients have been identified who have been waiting for longer than 52 weeks. Each case has been reviewed using root cause analysis methodology and no clinical issues have been identified, patient choice and capacity are the main issues identified in these cases. The Board discussed the achievement of the ED standard, the interface between GP and ambulance services and how challenging the winter period had been for the Trust. AM expressed the Boardâ&#x20AC;&#x2122;s thanks for to all staff for their hard work supporting the delivery of safe care during the winter.

The Board duly noted and took assurance from the report. 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 the agreement of the ambulatory care business case, which had been noted at the FWC having been signed off by the Committee before the meeting. Page 5 of 11

The Trust has developed a useful schedule for tracking planned and implemented business cases, which will help maintain an overall picture. The Committee had received a detailed report on the results of the excellent staff survey. RD went on to highlight discussions relating to recruitment and retention of overseas nurses and the decision to review the growth in front line staffing that had occurred in recent years. RD finished his report by highlighting that other matters discussed by the FWC would be discussed throughout the next three agenda items. The FWC reviewed the draft 2017/18 budget and are recommending that it is adopted by the Board. 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 the reduction in turnover, vacancy rates and staff sickness recorded in February. Attendance at training has dropped and this is being reviewed and appears to be linked to refresher periods varying for different training courses. The Trust has developed its occupational health team and is focusing on staff wellbeing, with the provision of extra clinics, alternative therapies and implementation of a smoke free site being the first phase. MP reported the national agreement of pay awards which will see a 1% increase for staff on agenda for change contracts. The Board reflected on the potential challenge of becoming a truly smoke free site, the need to improve smoking cessation opportunities and provide staff with the support they need to challenge smokers.

4.3

The Board duly noted and took assurance from the report. Finance and Use of Resources Performances Indicators for Assurance The Board received the paper in advance of the meeting. PS reported that the Trust is reporting a £2 million surplus at the end of month 11. This is adverse to the original plan, but in line with the forecast position that was changed in month 9 and reported to NHS Improvement (NHSI). PS reported that the RAG rating in the report was incorrect, as the month 11 position should be green rather than red. The underlying surplus should also read £(2.8) million, negative rather than positive. The end of year forecast outturn agreed at month 9 was a £5 million surplus, the Trust is expecting to deliver £3.9 million, noting the £1.1 million readmissions credit belatedly included within the additional £3.0 million NHS England payment This has been discussed with NHSI. There is a £2.5 million risk to this position linked to negotiations with the CCGs. PS reported that the Trust’s cash position at month 11 is good and that capital spend is on plan with £1.1 million deferred to the next financial year. Page 6 of 11

RD confirmed that this had been discussed in detail at the FWC. The Board duly noted and took assurance from the report. 4.4

2017/18 Revenue and Capital Budget for Discussion and Approval The Board received the paper in advance of the meeting. PS introduced the budget for 2017/18 for approval. This has been discussed at FWC who are recommending that it is adopted. The budget is based on contractual agreements and plans made earlier in the financial year. The budget includes a £21.3 million income and expenditure surplus control total which has been agreed by the Trust subject to a list of caveats to this position. The budget includes; receipt of £8.8 million strategic transformation funding, a cost improvement and productivity programme of £11.2 million, £3 million contingency and £12.4 million benefit from the new tariff HRG 4+. The budget takes into account the national pay award and the national apprentice levy. The proposed capital budget is £17.7 million. Capital funding assumes £7 million of additional loan receipts with the £10.7 million being funded internally through depreciation and working capital management. RD confirmed that the draft budget, associated risk and mitigations had been discussed at FWC. FWC have recommended that the Board adopts the proposed budget. The Board discussed the risk associated with the budget, divisional spending, use of contingency and how the surplus will be returned to support other organisations deficit position. PB and PS discussed the development of plans to use contingency throughout the year. AM noted the potential frustration at the front line linked to delivery of a surplus which is then not reinvested in Trust services. The Board approved the 2017/18 revenue and capital budget.

4.5

Charitable Funds Committee Chair Update for Assurance

The Board received the paper in advance of the meeting. CW reported that the Trust’s fundraising manger had left the Trust and that efforts are underway to recruit a suitable staff member using all available metrics. The Committee is looking to agree a focus for the charity for 2018. The team continues to focus on dementia for 2017. The Committee agreed that all unspent non-restricted funds will now be managed by Finance under the General Funds budget. All departments will continue to have access to these monies. PS reported that this matter is sensitive and been managed appropriately. The Board discussed the vacancy noting that candidates with essential experience and skills are not easy to appoint. The Board duly noted and took assurance from the report. Page 7 of 11

Page 8 of 11

Strategic Change 5.1 SASH Plus Quarterly Update for assurance The Board received the paper in advance of the meeting. SJ presented the report, focusing on the 3 main value streams and the delivery of lean for leaders training. The Trust is now 18 months into the journey with VMI. The cardiology work stream is refreshing focusing on the availability of beds within the angio department. The out patients value streams has produced real improvements which are being implemented across the department and medical records. The management of diarrhea value stream continues to deliver sustained improvements and innovation. The first two cohorts of lean for leaders are now finishing their assessments and these are now impacting on the way we work. PS asked why the overarching indicators were not yet moving towards green. SJ highlighted that these indicators are as much to do about culture as they are to do about performance and that RPIWs had yet to be carried out that would impact on all Trust wide indicators yet. CW asked for examples of the actions that are being taken at a local level. MW and SJ reflected on the projects that been carried out highlighting the AMU patient care packs and use of a linen cupboard and linen stock on one ward that was saving both time and money. The Board went on to discuss the quarterly report format and the need to bring through the information relating to front line benefits as well as maintaining oversight of the Trustâ&#x20AC;&#x2122;s value streams. Noting that having the NED seeing the improvements in action is in the spirit of â&#x20AC;&#x2DC;walking the gembaâ&#x20AC;&#x2122;, which is a key function of leadership. The Board duly noted and took assurance from the report. 6

Leadership and improvement capability 6.1 Review of Staff Survey for assurance The Board received the paper in advance of the meeting. MP introduced the report. The National Staff Survey results were published nationally in March, overall the Trust results were very positive with 22 of the key findings in the Top 20% nationally and only one key finding being in the lowest 20% nationally. The Trust has scored particularly well for staff motivation and recommendation as a place to work. This is a very positive message and should have an impact on recruitment. There has been a thank you message to all staff and the divisions and HR business partners are developing actions to continue to improve the position. Staff experience of abuse from patients and family members remain in the lowest 20%. AM commented on the excellent results of the survey and thanked all staff involved for their contribution. Page 9 of 11

AM asked what was being doing to understand the abuse issues highlighted in the survey. MP commented that the Trust was working hard to really understand the issue, the staff survey does not triangulate with incident reporting for abuse which is very low. The Board noted this and asked for a quarterly update on what was being done to resolve the issue. Action:MP The Board duly noted and took assurance from the report. 6.2

Audit and Assurance Committees Chair Update for assurance The Board received the paper in advance of the meeting. PB introduced the report, focusing on the committees review of corporate governance controls, work to do to record the governance of partnership working and the management of the Trustâ&#x20AC;&#x2122;s â&#x20AC;&#x2DC;going concernâ&#x20AC;&#x2122; status as part of the review of the annual accounts. The Committee had received a benchmarking paper from internal audit which detailed potential CIPs, specifically improving did not attend rates, length of stay and delayed transfers of care. The report however had focused on performance numbers rather than narrative or supporting detail that could impact on the results. 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.

7.1.3

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

7.1.4

Charitable Funds Committee The minutes of the Committee were noted with no questions raised.

7.2

Any Other Business 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 No comments were recorded.

7.5

Date of the next meeting Page 10 of 11

27th April Thursday 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 Trustâ&#x20AC;&#x2122;s website in the interests of openness and transparency under Freedom of Information Act 2000 legislation. These minutes were approved as a true and accurate record. Alan McCarthy Chairman:

Date:

Page 11 of 11

TRUST BOARD ACTION TRACKER - PUBLIC BOARD MEETING - April 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

TB Public

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

Open

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

31/05/2017

Open

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

Status

Date: 27th April 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:  Next Steps on the NHS Five Year Forward View  NHS England - Workforce Race Equality Standard 2016 report Local:  KSS Workforce Heroes Awards  Professor Abhay Rane OBE, Appointed as Adjunct Professor  Next Hot Topic Event – Focus on Diabetes 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 –27th April 2017 CHIEF EXECUTIVE’S REPORT 1.

National/Regional Issues

1.1

Next Steps on the NHS Five Year Forward View

Published on 31st March 2017, NHS England has reviewed the progress made since the launch of the NHS Five Year Forward View in October 2014 and sets out a series of practical and realistic steps for the NHS to deliver a better, more joined-up and more responsive NHS in England. Next year the NHS turns 70. New treatments for a growing and aging population mean that pressures on the service are greater than they have ever been. Treatment outcomes are far better – and public satisfaction higher – than ten or twenty years ago. However, the NHS needs to adapt to take advantage of the opportunities that science and technology offer patients, carers and those who serve them. But it also needs to evolve to meet new challenges: we live longer, with complex health issues, sometimes of our own making. This plan is not a comprehensive description of everything the NHS will be doing. Instead, it sets out the NHS’ main national service improvement priorities over the next two years, within the constraints of what is necessary to achieve financial balance across the health service. The measures set out in this plan will deliver a more responsive NHS in England, focussed on the issues which matter most to the public. And that is on a more sustainable footing, so that it can continue to deliver health and high quality care – now and for future generations. The report identifies the following 9 priorities:  Provision of urgent and emergency care 24 hours a day, 7 days a week Staff are working with great skill and dedication looking after more patients than ever; but some urgent care services are struggling to cope with rising demand. Over the next two years the NHS will take practical action to take the strain off A&E. Working closely with community services and councils, hospitals there is a need to be able to free up 2,0003,000 hospital beds. In addition, patients with less severe conditions will be offered more convenient alternatives, including a network of newly designated Urgent Treatment Centres, GP appointments, and more nurses, doctors and paramedics handling calls to NHS 111.  General Practice Most NHS care is provided by general practice. One of the public’s top priorities is to know that they can get a convenient and timely appointment with a GP when they need one. That means having enough GPs, backed up by the resources, support and other professionals required to enable them to deliver the quality of care they want to provide. Over the next two years the NHS is on track to deliver 3,250 GP recruits, with an extra 1,300 clinical pharmacists and 1,500 more mental health therapists working alongside them. As well as improved access during the working week, bookable appointments at evenings and weekends will be available covering half the country by next March, and everywhere in two years’ time.  Cancer Cancer remains one of the public’s most feared illnesses, affecting more than one in three of us in our lifetimes, meaning most of us will face the anxiety of ourselves or a loved one

receiving this diagnosis at some point. Fortunately cancer survival rates are at record highs, and an estimated 7,000 more people are surviving cancer after NHS treatment than would have three years before. Identifying cancer earlier is critical to saving more lives. The NHS will speed up and improve diagnosis, increase current capacity and open new Rapid Diagnostic and Assessment Centres. Patients will have access to state of the art new and upgraded linear accelerators (LINACs) across the country. By taking these actions we expect at least an extra 5,000 people to survive their cancer over the next two years.  Mental Health Increasingly, the public also understand that many of our lives will at some point be touched by mental health problems. Historically, treatment options for mental health compare unfavourably with those for physical conditions, particularly for children and young people. The public now rightly expect us to urgently address these service gaps. The NHS will also address physical health needs by providing an extra 280,000 health checks in 2018/19 for people with severe mental illness. New mothers will get better care. Four new Mother and Baby Units across the country, more specialist beds and 20 new specialist perinatal mental health teams will provide help to 9000 more women by 2018/19.  Helping frail and older people stay healthy and independent As people live longer lives the NHS needs to adapt to their needs, helping frail and older people stay healthy and independent, avoiding hospital stays where possible. To improve prevention and care for patients, as well as to place the NHS on a more sustainable footing, the NHS Five Year Forward View called for better integration of GP, community health, mental health and hospital services, as well as more joined up working with home care and care homes.  Sustainability and Transformation Partnerships Some areas are now ready to go further and more fully integrate their services and funding. NHS England will back them in doing so through Accountable Care Systems. Working together with patients and the public, NHS commissioners and providers, as well as local authorities and other providers of health and care services, will gain new powers and freedoms to plan how best to provide care, while taking on new responsibilities for improving the health and wellbeing of the population they cover.  NHS’ 10 Point Efficiency Plan NHS England will also be taking further action nationally to ensure that the NHS can deliver more benefit for patients from every pound of its budget. While the NHS is already one of the leanest publicly-funded health services in the industrialised world, there are still opportunities to do better, as set out in the NHS’ 10 Point Efficiency Plan.  Staff None of these plans are possible without the outstanding staff of the NHS. Although we have 3,000 more doctors and 5,000 more nurses than 3 years ago, and productivity continues to improve, frontline staff face great personal and organisational pressures from rising demand. As a crucial part of delivering the next steps of the Five Year Forward View, NHS England will continue to support the NHS frontline over the next two years, with Health Education England expanding current routes to the frontline, and opening innovative new ones to attract the best people into the health service, whatever stage of their career they are at.  Technology and innovation The NHS is on a journey to becoming one of the safest and most transparent health systems in the world. As well as harnessing people power, the NHS also needs to leverage the potential of technology and innovation, enabling patients to take a more active role in their own health and care while also enabling NHS staff and their care

colleagues to do their jobs - whether that is giving them instant access to patient records from wherever they are, or to remote advice from specialists. There are considerable risks to delivery of this stretching but realistic agenda, but taken together the measures set out in the plan will deliver a better, more joined-up and more responsive NHS in England. The full document is available: https://www.england.nhs.uk/wpcontent/uploads/2017/03/NEXT-STEPS-ON-THE-NHS-FIVE-YEAR-FORWARD-VIEW.pdf

1.2

NHS England - Workforce Race Equality Standard 2016 report

Published on 19th April, the 2016 report is the second publication since the Workforce Race Equality Standard (WRES) was mandated and covers all nine indicators across the NHS. The report has three key roles: 

 

To enable organisations to compare their performance with others in their region and those providing similar services, with the aim of encouraging improvement by learning and sharing good practice To provide a national picture of WRES in practice, to colleagues, organisations and the public on the developments in the workforce race equality agenda To share summaries of what works, good examples and recognising organisations which, at this early stage of WRES implementation, are making progress against the indicators

This year’s report includes for the first time data covering nine WRES indicators including four relating to the workplace covering recruitment, promotion, career progression and staff development alongside BME board representation. The remaining four indicators are based on data from the NHS staff survey 2016, covering harassment, bullying or abuse from patients, relatives or the public. Key findings include: 

White shortlisted job applicants are 1.57 times more likely to be appointed from shortlisting than BME shortlisted applicants, who remain noticeably absent from senior grades within Agenda for Change (AfC) pay bands.



BME staff remain significantly more likely to experience discrimination at work from colleagues and their managers, although the percentage of BME staff reporting that in the last 12 months they have personally experienced discrimination at work from staff fell slightly.



An increase in numbers of BME nurses and midwives at AfC Bands 6 to 9 is observed for the period between 2014 and 2016.



White and BME staff are equally likely to experience harassment, bullying or abuse from patients, relatives and members of the public in the last 12 months.



BME staff in the NHS are significantly more likely to be disciplined than white staff members.



BME staff remain more likely than white staff to experience harassment, bullying or abuse from other staff though this fell very slightly last year.



The proportion of very senior managers (VSMs) from BME backgrounds increased by 4.4% from 2015 to 2016 – an additional 9 headcounts. However, BME representation at board and VSM level remains significantly lower than BME representation in the overall NHS workforce and in the local communities served.



BME staff remain less likely than white staff to believe that their trust provides equal opportunities for career progression. However, the gap between white and BME staff on this indicator fell from 14.5 percentage points in 2014 to 12.6 percentage point in 2015.

On Indictor 3 (Relative likelihood of BME staff entering the formal disciplinary process compared to white staff), SASH is recognised as one of the Trusts ‘where data suggests practice may be better’. This is a positive for SASH. As a Trust we welcome this report and will review the data and consider what this means for SASH in taking forward work as part of our local Inclusion Strategy. The full report is available: https://www.england.nhs.uk/wp-content/uploads/2017/03/workforce-race-equalitystandard-data-report-2016.pdf

Local Issues

2.1

Staff Win KSS Workforce Heroes Awards

I was delighted to learn that this value has been recognised in awards won by two members of the SASH team in in the Kent, Surrey and Sussex Support Workforce Heroes Awards. Congratulations go to Mary Clare Salmon, therapy rehabilitation assistant who won the Working to Improve the Patient Experience category and Kerry Duval, therapy rehabilitation assistant, who won the Apprenticeship Ambassador category. This is brilliant recognition for their contribution to patient care and experience and further endorsement of the great people who make SASH the place it is and put it in the top 20 per cent of hospitals in the country; well done.

2.2

Professor Abhay Rane OBE, Appointed as Adjunct Professor

Congratulations to Professor Abhay Rane OBE, consultant urologist at SASH who has been appointed as adjunct professor at the Icahn School of Medicine at Mount Sinai, New York. This is the first ever such appointment for an overseas clinician, which is certainly a real credit to Abhay and a great endorsement of the specialist knowledge and skills here at SASH. 2.3

Next Hot Topic Event – Focus on Diabetes

Our next Hot Topic event, hosted by the children’s and adults diabetes teams takes place at 6.00pm on 27 April in the Post Graduate Education Centre.

Recommendation

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

Michael Wilson CBE Chief Executive April 2017

TRUST BOARD IN PUBLIC

Date: 27th April 2017

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

Agenda Item: 2.1 Patient Story: Missed appendicitis and loss of parental confidence Dr Des Holden Medical Director Des Holden Medical Director Discussed at Serious Incident Review Group (S.I.R.G) and with CCG quality group

Action Required: Discussion (√) Purpose of Report: To inform the Board of one patient’s (and her parents’) experience of unscheduled care in our hospital Summary of key issues Appendicitis can be a difficult diagnosis to make especially if the history is atypical. It is therefore necessary to ensure all abnormal physiological observations are noted, all investigations provide results, that where a wait and see management plan is being made it has hard stops, and that re-presentation affords the opportunity for a fresh and senior review of the differential diagnosis. In the context of failure to improve clinically, and repeated unscheduled presentation, lack of confidence in staff can quickly develop where perceived poor communication with the patient and parents, or between team members is observed. Recommendation: To discuss what learning and assurance we can take from this patient story (paediatric surgery at sash, the role of the surgical board in providing assurance that care and onward pathways are robust and of high quality) 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

Relevant to regulation

Financial impact

minor

Patient Experience/Engagement

Poor experience for patient and family

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

Joint care of children by paediatricians and surgeons adds a safety net and to the quality of the patient and carer experience.

Attachment:

2 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT â&#x20AC;&#x201C; 27TH April 2017 PATIENT STORY - : Missed appendicitis and loss of parental confidence Background: A 10 year old girl was brought to ED by her mother with lower abdominal pain and possible appendicitis. She was admitted to the paediatric ward under the surgeons but her EWS remained 0 and when reviewed by a consultant the next day her symptoms were improved though not settled. She was discharged with working diagnosis of ileitis. The patient was brought back two weeks later with continued pain, bowel upset, and weight loss. Urine dip was clear and some blood tests were not done for technical reasons, but a middle grade doctor diagnosed a urine infection and again discharged the patient after USS of the lower abdomen commented appendix was seen and at upper limit of normal. Four days later the patient was re-referred by the GP and was seen by the paediatricians. She had a high temperature; blood tests indicated significant inflammatory morbidity and imaging showed a large mass in the lower abdomen. A malignant diagnosis was initially considered though MRI quickly suggested this was a ruptured appendix. Referral was made to SGHFT, but they had no capacity. The patient was taken to BSUH and had radiological drainage of the abscess with a plan for interval review. She developed bowel obstruction and was re-admitted there for laparotomy. She subsequently made a good recovery. Given the additional morbidity suffered by this patient the case was declared an SI. 80 of 300 appendicectomies performed each year at SaSH are in children aged over 5 (under 5s are referred to tertiary care). It is well known that the diagnosis can be difficult to make. Nationally about 10% of cases are found to be normal at operation, reflecting a desire not to leave suspected appendix to complicate, particularly in female patients. For this patient it is possible that insufficient weight was given to a raised temperature that settled while on the paediatric ward. On the second admission a raised temperature was recorded but not timed and dated, some blood tests were sent but for technical reasons not processed and then not repeated (incomplete clinical information) and in hindsight the USS of the lower abdomen, with recurrent admission, was too readily reported as within normal limits. The diagnosis of urinary tract infection was not supported by the clinical information and probably represents a care pathway in line with the earlier diagnosis rather than a fresh look at the clinical picture. Learning: Appendicitis can be difficult to diagnose, especially with a changing clinical picture and in this the case the time course was unusually long. The SI investigation concluded that where a firm diagnosis canâ&#x20AC;&#x2122;t be reached a more proactive follow up than wait and see should be instituted. The now established Paediatric surgical board has reviewed the case and worked with all departments to review pathways and investigations.

3 An Associated University Hospital of Brighton and Sussex Medical School

The parents in their being open meetings reported feelings of lack of confidence in the service they received. This came from difficulty in being heard, late review compared to other children on the ward, perceived negativity they and their GP received when talking to the SaSH surgical team and senior clinicians making contradictory statements about the care pathway and the staff involved in decision making. This has been discussed at the surgical governance board by the Chief of surgery, and within the department by the clinical lead for surgery, and with several individuals named by the parents. Dr Des Holden Medical Director April 2017

4 An Associated University Hospital of Brighton and Sussex Medical School

Date: 27th April 2017

TRUST BOARD IN PUBLIC

Agenda Item: 2.2 REPORT TITLE:

Safety & Quality Committee Chair Update

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 April 2017. Apart from standing items, the main focus of the meeting was on gaining assurance about pressure damage and children’s safeguarding. 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

Included within the report

Risk & Performance Management

Reporting, investigation and learning from serious incidents informs risk management

NHS Constitution/Equality & Diversity/Communication Attachment:

As per the report

Trust Board Report – 27th April 2017 Safety and Quality Committee Chair’s Report The Safety and Quality Committee met on 2nd March 2017. ECQR and CQRM The Committee received a summary report on the meetings of ECQR and its sub-committees in February. The report focused on deep-dive self-assessments of how services measure up against CQC domains. The report considered Maternity, Paediatrics, Emergency Department, Acute Medicine, Medical Care, Surgical Care and End of Life Care. The Committee took good assurance from the rigour of the review, the constructive challenge involving clinicians, and the attention being given by the Executive Committee. The outcomes of the assessment also gave confidence, with services judged to be either Good or Outstanding, which correlates with recent work by PWC. The aim of the deep dives is to understand what needs to happen to get to outstanding in each service. This phase will conclude with a PWC workshop on 28th April, leading to an overview of the current position, and actions needed to get to outstanding. The intention is that each Executive lead will have a NED buddy to aid the process. The Committee took good assurance from this evolution of the four year deep dive process. We will continue to monitor progress and use it to increase awareness of the Trust’s strengths and opportunities for further improvements. We noted that no items were escalated by the CQRM in respect of clinical quality performance to Single Performance Conversation. We discussed a performance notice raised by East Surrey CCG in relation to a number of areas of performance and were assured that the issues were already known and the subject of action plans. However, a presentation will be brought to SQC in June to explain the actions taken and the outcomes. Quality Report The Committee explored a number of questions arising from the monthly Quality Report, including:  It was agreed that all of the Safety Thermometer sub-categories would be added to the Quality Report to help performance monitoring and to support the work about to start on reducing gram negative septicemia, most of which is related to UTI and gut sepsis.  There was a wider discussion about approaches to avoidance of patient harm, with suggestions that there could be some form of internal “never events” or “stop the line” approach, and that the zero tolerance approach to falls might have lessons for other areas. The Committee did not recommend a specific course of action, and recognized the risk of unintended consequences from focusing on a particular area, but it was agreed that the potential to improve our approach should be kept under review.  We discussed the distinction between the recording of data related to safety, which is a challenge for the Trust in some areas such as VTE assessments or day of discharge, and the safety outcomes for patients where performance is strong. There will be further work to ensure clarity about the nature of any improvements needed, with a report to SQC.  We discussed performance in Urology and Gynaecology in meeting 62 day targets, and were assured that plans are in place to improve performance. These include clinic reconfiguration and strengthening of capacity in Gynaecology, which has seen significant growth in demand. We noted the complexity of the Urology pathway due to high numbers of investigations required.

NHS Stop the Pressure Campaign The Committee had asked for a report on the four cases of major (i.e. Grade 3 or above) hospital acquired pressure ulcers since September 2016 â&#x20AC;&#x201C; after a period of three years in which there were no such cases. Grade 1 incidents have also been showing red on the Quality Report. Overall the incidence of pressure damage has reduced in the past four years from over 200 to less than 60, which represents good progress. Other positive achievements have also been made. Nevertheless it is agreed that more work needs to be done. The Committee explored further the reasons for the recent incidents, noting that two occurred on a ward which was experiencing challenges in staffing and training. These have since been addressed. An action plan has been drawn up for 2017/18 that sets clear objectives for reducing the overall incidence of pressure damage and for zero incidence of pressure damage at Grade 3 or above. There will be a strong emphasis on accurate and timely risk assessments, accurate reporting and grading, and on relevant training. The collection of data is being reviewed and measurement will in future be on the basis of incidents per 1,000 bed days, as for falls. The action plan has been submitted to NHSI and runs for 12 months. The success of the action plan will be monitored by the Committee through the Quality Report. Childrenâ&#x20AC;&#x2122;s Safeguarding The Committee took a different approach to assurance by requesting a report on the learning from recent Serious Case Reviews considered by the Surrey and Sussex Local Safeguarding Childrenâ&#x20AC;&#x2122;s Boards. A Serious Case Review is undertaken where a child has died, or has come to serious harm, and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. We found that there is a robust process for carrying out these reviews, which engages front line staff and managers in reviewing cases and the reasons why those involved acted as they did. This includes involvement of a wide range of practitioners, managers and agency safeguarding leads in debating the draft overview report and drawing learning from the review. The Committee took good assurance from the process, and also from the fact that there had been very limited involvement of this Trust in the care of children who were the subject of Serious Case Reviews. The most important learning point for the Trust was a need for staff to be constantly vigilant for signs, not only that children may already have come to harm in the community, but that they may be at risk of coming to harm in the future; and that staff should be ready and willing to raise a concern. Next Meeting The next SQC meeting is at 12.00 noon on Thursday 4th May.

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

TRUST BOARD IN PUBLIC

Date: 27th April 2017

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

Agenda Item: 2.4 Safer Staffing & Care Hours Per Patient Day Report 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 (March 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 March

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 – 27th April 2017 Safer Staffing and Care Hours Per Patient Day (CHPPD) 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 – March 2017

Ward

Ward Specialty

Entries

RN Day

RN Night

NA Day

NA Night

Total Day

Total Night

Abinger Ward

430 - GERIATRIC MEDICINE

95.66%

100%

95.16%

100%

95.4%

100%

Acute Medical Unit

300 - GENERAL MEDICINE

98.08%

100%

93.79%

92.74%

96.82%

97.36%

Birthing Centre

501 - OBSTETRICS

82.75%

86.67%

100%

N/A

83.29%

86.67%

Bletchingley Ward

430 - GERIATRIC MEDICINE

100%

93.55%

96.77%

97.24%

98.39%

Brockham Ward

502 - GYNAECOLOGY

97.09%

98.92%

83.82%

100%

92.55%

99.19%

Brook Ward

100 - GENERAL SURGERY

97.32%

98.39%

97.89%

N/A

97.51%

98.39%

Buckland Ward

101 - UROLOGY

97.59%

96.77%

95.42%

95.16%

96.65%

95.97%

Burstow Ward

501 - OBSTETRICS

81.94%

62.37%

77.77%

85.48%

80.55%

71.61%

Capel Annex l Ward

300 - GENERAL MEDICINE

98.39%

100%

95.79%

100%

97.27%

100%

Capel Ward

300 - GENERAL MEDICINE

90.76%

98.92%

92.6%

93.55%

91.34%

96.77%

Chaldon Ward

328 - STROKE MEDICINE

93.1%

98.39%

94.26%

97.83%

93.59%

98.05%

Charlwood Ward

301 GASTROENTEROLOGY

94.41%

100%

96.95%

98.33%

95.29%

99.17%

Copthorne Ward

100 - GENERAL SURGERY

94.88%

100%

96.79%

98.33%

95.52%

99.17%

Coronary Care Unit

320 - CARDIOLOGY

95.7%

100%

N/A

90.32%

96.77%

Delivery Suite

501 - OBSTETRICS

95.14%

94.09%

92.99%

95.16%

94.6%

94.35%

Discharge Lounge

300 - GENERAL MEDICINE

100%

Godstone Ward (Haem)

303 - CLINICAL HAEMATOLOGY

100%

92.46%

N/A

98.03%

100%

Godstone Ward (Med)

300 - GENERAL MEDICINE

98.06%

101.08%

89.25%

96.77%

94.76%

98.92%

Hazelwood

430 - GERIATRIC MEDICINE

98.92%

100%

95.79%

100%

97.34%

100%

Holmwood Ward

320 - CARDIOLOGY

96.77%

98.39%

93.33%

95.16%

95.81%

96.77%

ITU/HDU

192 - CRITICAL CARE MEDICINE

98.21%

98.16%

87.7%

96.67%

96.77%

98.05%

Leigh Ward

110 - TRAUMA & ORTHOPAEDICS

97.17%

101.61%

96.23%

95.65%

96.8%

98.05%

Meadvale Ward

430 - GERIATRIC MEDICINE

90.09%

100%

95.9%

88.71%

93.11%

94.35%

Neonatal Unit

420 - PAEDIATRICS

95.67%

94.78%

100%

86.44%

96.99%

92.23%

Page 1

Newdigate Ward

110 - TRAUMA & ORTHOPAEDICS

94.28%

100%

92.96%

95.7%

93.71%

97.42%

Nutfield Ward

430 - GERIATRIC MEDICINE

97.19%

98.39%

91.79%

101.61%

95.17%

100%

Outwood Ward

420 - PAEDIATRICS

92.18%

98.95%

71.57%

58.62%

90.07%

93.64%

Rusper Ward

501 - OBSTETRICS

95.41%

100%

N/A

95.44%

100%

Surgical Assessment Unit

100 - GENERAL SURGERY

96.77%

98.39%

96.77%

87.1%

96.77%

92.74%

Tandridge Ward

430 - GERIATRIC MEDICINE

93.42%

100%

91.28%

100%

92.19%

100%

Tilgate Annex

300 - GENERAL MEDICINE

96.98%

100%

95.35%

95.16%

96.37%

97.58%

Tilgate Ward

340 - RESPIRATORY MEDICINE

97.42%

100%

89.25%

100%

94.35%

100%

Woodland Ward

110 - TRAUMA & ORTHOPAEDICS

100%

93.43%

101.59%

97.55%

100.79%

95.7%

97.4%

93.13%

95.08%

94.83%

96.53%

Total

Planned versus actual commentary The Trust has delivered planned versus actual staffing profile for March at organizational level. The red shifts showing compliance below 80% were managed by the relevant clinical team with no concerns regarding patient safety. Nursing assistant recruitment continues to the bank and to vacant posts.

Page 2

Care hours per patient day (CHPPD) Only complete sites your organisation is accountable for

Ward name

Feb-17

Day

Main 2 Specialties on each ward

Specialty 1

Specialty 2

Registered midwives/nurses

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

Abinger Ward

430 - GERIATRIC MEDICINE

1176

1146

1288

1219

644

655.5

632.5

97.4%

94.6%

100.0%

96.5%

Acute Medical Unit

300 - GENERAL MEDICINE

3151

3116

1265

1123

2254

2288.5

1288

1150

98.9%

88.8%

101.5%

89.3%

501 - OBSTETRICS

644

563

644

552

87.4%

0.0%

85.7%

0.0%

Birthing Centre Bletchingley Ward

1288

1276.5

977.5

931.5

644

632.5

99.1%

95.3%

100.0%

98.2%

502 - GYNAECOLOGY

1295

1222.5

644

586.5

966

931.5

322

94.4%

91.1%

96.4%

100.0%

100 - GENERAL SURGERY

644

314

306.5

644

100.0%

97.6%

100.0%

0.0%

Buckland Ward

101 - UROLOGY

1288

1276.5

961

892.5

621

586.5

99.1%

92.9%

100.0%

94.4%

Burstow Ward

501 - OBSTETRICS

1288

1088.5

644

575

966

598

644

563.5

84.5%

89.3%

61.9%

87.5%

Brockham Ward Brook Ward

Capel Annex l Ward

430 - GERIATRIC MEDICINE

1288

644

632.5

100.0%

96.4%

100.0%

98.2%

300 - GENERAL MEDICINE

1449.5

1400.5

644

581.5

966

954.5

644

96.6%

90.3%

98.8%

100.0%

328-STROKE MEDICINE

1737

1668.5

1288

1207.5

632.5

966

931.5

96.1%

93.8%

100.0%

96.4%

Charlwood Ward

301 - GASTROENTEROLOGY

1196

1173

598

552

598

506

98.1%

92.3%

100.0%

84.6%

Copthorne Ward

100 - GENERAL SURGERY

1265

1242

644

617

621

632.5

621

598

98.2%

95.8%

101.9%

96.3%

Coronary Care Unit

320 - CARDIOLOGY

954.5

11.5

644

333.5

100.0%

Delivery Suite

501 - OBSTETRICS

1932

1866.5

644

567

1932

1897.5

644

540.5

96.6%

88.0%

98.2%

83.9%

300 - GENERAL MEDICINE

574

562.5

552

529

322

98.0%

95.8%

100.0%

Capel Ward Chaldon Ward

Discharge Lounge

300 - GENERAL MEDICINE

302 - ENDOCRINOLOGY

Godstone Ward (Haem)

303 - CLINICAL HAEMATOLOGY

Godstone Ward (Med)

300 - GENERAL MEDICINE

Holmwood Ward ITU/HDU Leigh Ward Meadvale Ward Neonatal Unit Newdigate Ward

966

931.5

644

226.5

219

644

100.0%

96.7%

100.0%

0.0%

1610

1587

966

954.5

966

954.5

966

943

98.6%

98.8%

97.6%

320 - CARDIOLOGY

1610

1587

644

609.5

621

586.5

98.6%

94.6%

100.0%

94.4%

192 - CRITICAL CARE MEDICINE

4048

3979

643

570.5

4071

3990.5

322

276

98.3%

88.7%

98.0%

85.7%

110 - TRAUMA & ORTHOPAEDICS

1438

1369

944

925

644

632.5

966

954.5

95.2%

98.0%

98.2%

98.8%

410 - RHEUMATOLOGY

430 - GERIATRIC MEDICINE

1187.5

1131

1288

1180.5

598

95.2%

91.7%

100.0%

420 - PAEDIATRICS

1477

1396.5

655.5

663

1322.5

1345.5

644

586.5

94.5%

101.1%

101.7%

91.1%

110 - TRAUMA & ORTHOPAEDICS

1438

1415.5

1072

1064

655.5

954.5

874

98.4%

99.3%

100.0%

91.6%

Nutfield Ward

430 - GERIATRIC MEDICINE

1610

1575.5

931.5

897

621

97.9%

96.3%

100.0%

Outwood Ward

420 - PAEDIATRICS

2814

2538

276

210.5

1943.5

1955

299

253

90.2%

76.3%

100.6%

84.6%

Rusper Ward

501 - OBSTETRICS

1242

1123

644

632.5

90.4%

0.0%

98.2%

0.0%

Surgical Assessment Unit

100 - GENERAL SURGERY

1288

1230.5

322

644

621

644

632.5

95.5%

100.0%

96.4%

98.2%

Tandridge Ward

430 - GERIATRIC MEDICINE

1250.5

1617

2088.5

598

575

100.0%

129.2%

100.0%

96.2%

Tilgate Annex

300 - GENERAL MEDICINE

1610

1594.5

969.5

927.5

736

690

655.5

632.5

99.0%

95.7%

93.8%

96.5%

Tilgate Ward

340 - RESPIRATORY MEDICINE

1610

1633

954

820

966

977.5

310.5

322

101.4%

86.0%

101.2%

103.7%

1610

1544.5

1046.5

1042.5

644

95.9%

99.6%

100.0%

Woodland Ward

340 - RESPIRATORY MEDICINE 340 - RESPIRATORY MEDICINE

110 - TRAUMA & ORTHOPAEDICS

Mar-17

625 910 51 549 502 283 538 515 582 555 754 541 528 212 144 158 160 736 772 413 755 636 308 720 770 509 237 244 736 578 712 608

2.9

3.0

Overall

5.8

5.9

2.5

8.4

21.9

0.0

21.9

3.5

2.8

6.3

4.3

1.8

6.1

4.6

1.1

5.6

3.5

2.7

6.3

3.3

2.2

5.5

3.3

2.7

6.0

4.2

2.2

6.5

3.1

2.8

5.9

3.3

2.0

5.2

3.6

2.3

7.5

1.6

9.2

26.1

7.7

33.8

5.6

5.4

11.0

8.1

1.4

9.4

3.5

2.6

2.9

1.5

4.4

19.3

2.0

21.3

2.7

2.5

5.1

2.7

2.8

5.5

8.9

4.1

13.0

2.9

2.7

5.6

2.9

2.0

4.8

8.8

0.9

7.4

0.0

7.4

7.6

3.9

11.5

2.5

3.6

6.1

4.0

2.7

6.7

3.7

1.6

5.3

3.6

2.8

6.4

6.0

9.7

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

501 - OBSTETRICS

713

590

690

598

82.7%

100.0%

86.7%

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

1441

1399

748

627

1069.5

1058

356.5

97.1%

83.8%

98.9%

100.0%

555

4.4

1.8

6.2 5.4

Birthing Centre Bletchingley Ward Brockham Ward Brook Ward

430 - GERIATRIC MEDICINE

302 - ENDOCRINOLOGY

502 - GYNAECOLOGY

2.8

5.9

3.0

5.8

100 - GENERAL SURGERY

708.5

689.5

356

348.5

713

701.5

97.3%

97.9%

98.4%

320

4.3

1.1

Buckland Ward

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

Burstow Ward

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

681.5

Capel Annex l Ward

300 - GENERAL MEDICINE

1602.5

1454.5

736

1069.5

1058

713

667

90.8%

92.6%

98.9%

93.5%

593

4.2

2.3

6.5

328-STROKE MEDICINE

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

Capel 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

Chaldon 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

Coronary Care Unit

320 - CARDIOLOGY

1069.5

1023.5

11.5

713

356.5

322

95.7%

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

300 - GENERAL MEDICINE

688

667

356.5

100.0%

140

7.5

7.3

14.8 9.3

Discharge Lounge Godstone Ward (Haem)

303 - CLINICAL HAEMATOLOGY

Godstone Ward (Med)

300 - GENERAL MEDICINE

Holmwood Ward ITU/HDU Leigh Ward Meadvale Ward Neonatal Unit Newdigate Ward Nutfield Ward

5.7

713

252

233

713

100.0%

92.5%

100.0%

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

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

410 - RHEUMATOLOGY

6.1

5.1

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

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

Outwood Ward

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%

262

7.9

0.0

8.0

100 - GENERAL SURGERY

1426

1380

356.5

345

713

701.5

713

621

96.8%

98.4%

87.1%

278

7.5

3.5

11.0

91.3%

100.0%

778

2.4

2.9

5.4

Surgical Assessment Unit Tandridge Ward

430 - GERIATRIC MEDICINE

Tilgate Annex

300 - GENERAL MEDICINE

Tilgate Ward

340 - RESPIRATORY MEDICINE

Woodland Ward

1713.5

1564

713

340 - RESPIRATORY MEDICINE

1277

713

93.4%

1773.5

1720

1076

1026

713

678.5

97.0%

95.4%

100.0%

95.2%

637

3.8

2.7

6.5

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

Abinger Ward

430 - GERIATRIC MEDICINE

126 -

100 -

138 -

69 -

58 -

0 -

Acute Medical Unit

300 - GENERAL MEDICINE

282 -

251 -

161 -

215 -

242 -

207 -

138 -

173

0 -

Birthing Centre Bletchingley Ward Brockham Ward Brook Ward Buckland Ward Burstow Ward

501 - OBSTETRICS

3 -

60 -

0 -

1 -

69 -

58 -

502 - GYNAECOLOGY

146 -

177 -

104 -

41 -

104 -

127 -

35 -

0 -

100 - GENERAL SURGERY

65 -

46 -

42 -

69 -

0 -

101 - UROLOGY

146 -

123 -

131 -

150 -

92 -

69 -

92 -

0 -

0 0

80 -

21 -

104 -

69 -

0 -

114 -

103 -

69 -

Capel Ward

430 - GERIATRIC MEDICINE

153 -

54 -

92 -

100 -

104 -

69 -

0 -

300 - GENERAL MEDICINE

241 -

173 -

184 -

180 -

81 -

69 -

92 -

104

0 -

Charlwood Ward

301 - GASTROENTEROLOGY

245 -

188 -

157 -

180 -

92 -

173

0 -

Copthorne Ward

301 - GASTROENTEROLOGY

161 -

111 -

73 -

77 -

69 -

58 -

69 -

0 -

Coronary Care Unit

320 - CARDIOLOGY

115 -

69 -

Delivery Suite

501 - OBSTETRICS

207 -

169 -

69 -

96 -

207 -

115 -

69 -

300 - GENERAL MEDICINE

114 -

126 -

115 -

138 -

35 -

Godstone Ward (Haem)

303 - CLINICAL HAEMATOLOGY

Godstone Ward (Med)

300 - GENERAL MEDICINE

69 -

173 -

161 -

320 - CARDIOLOGY

173 -

138 -

192 - CRITICAL CARE MEDICINE

450 -

110 - TRAUMA & ORTHOPAEDICS

168 -

430 - GERIATRIC MEDICINE

420 - PAEDIATRICS

26 -

#VALUE!

0 -

53 -

0 -

52 -

0 -

21 -

0 -

49 -

0 -

38 -

0 -

46 -

0 -

1 -

18 -

2 -

#VALUE!

0 -

69 -

127 -

104 -

0 -

53 -

0 -

46 -

35 -

92 -

81 -

92 -

0 -

438 -

69 -

54 -

299 -

23 -

0 -

192 -

78 -

58 -

69 -

92 -

58 -

0 -

83 -

0 -

115 -

42 -

115 -

165 -

115 -

0 -

116 -

128 -

42 -

34 -

219 -

115 -

0 -

102

110 - TRAUMA & ORTHOPAEDICS

161 -

92 -

114 -

38 -

58 -

115 -

150

0 -

92 -

104

Nutfield Ward

430 - GERIATRIC MEDICINE

173 -

157 -

141 -

88 -

92 -

81 -

420 - PAEDIATRICS

383 -

409 -

88 -

50 -

253 -

219 -

Rusper Ward

501 - OBSTETRICS

184 -

238 -

12 -

69 -

138 -

150 -

35 -

#VALUE!

104 -

104

14 -

138

0 -

410 - RHEUMATOLOGY

Outwood Ward Surgical Assessment Unit

46 -

69 -

115 -

Newdigate Ward

23 -

92 -

138 -

Neonatal Unit

23 -

138 -

Meadvale Ward

0 -

27 -

ITU/HDU

142

150 -

Leigh Ward

0 -

69 -

501 - OBSTETRICS

Holmwood Ward

0 -

138 -

300 - GENERAL MEDICINE

Discharge Lounge

0 -

302 - ENDOCRINOLOGY

Capel Annex l Ward Chaldon Ward

300 - GENERAL MEDICINE

855

340 - RESPIRATORY MEDICINE

110 - TRAUMA & ORTHOPAEDICS

1193

91.8%

#VALUE!

0 -

58 -

0 -

51 -

0 -

1 -

25 -

1 -

0 -

72 -

100 - GENERAL SURGERY

23 -

69 -

81 -

0 -

Tandridge Ward

300 - GENERAL MEDICINE

340 - RESPIRATORY MEDICINE -

58 -

525 -

115 -

138

Tilgate Annex

300 - GENERAL MEDICINE

164 -

126 -

107 -

23 -

58 -

12 46

0 -

Tilgate Ward

300 - GENERAL MEDICINE

340 - RESPIRATORY MEDICINE -

173 -

104 -

116 -

135 -

104 -

92 -

69 -

0 -

Woodland Ward

100 - GENERAL SURGERY

173 -

238 -

54 -

81 -

92 -

#VALUE!

0 -

0 0

Page 3

The report for March is shown above. The data comparison with February 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 The Board is asked to note the report

Fiona Allsop Chief Nurse April 2017

Page 4

TRUST BOARD IN PUBLIC

Date: 27th April 2017 Agenda Item: 2.5

Quarterly Report by Guardian for Safe Working Hours – April 2017

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

Mark Preston, Director of Organisational Development and People Dr Virach Phongsathorn Safer Working Guardian LNC and Junior Doctors Forum

Action Required: Approval (√) √

Discussion (√) √

Assurance (√) √

Purpose of Report: To allow the Board to form a judgement as to how safely the junior doctors are working within the Trust. Summary of key issues 1. Updating the Board on the progress of the work of the Guardian for Safe Working Hours. 2. The rolling out of the new Junior Doctors 2016 Contract up to now. 3. Summary of the volume of the Exception Reports and actions taken. 4. Summary of rota gaps (unfilled posts). Recommendation: The Guardian would like to seek the approval of the quarterly 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

Role of Safer Working Guardian is a requirement for each NHS Trust

Financial impact

Included in the report.

Patient Experience/Engagement

N/A

Risk & Performance Management

Included in the report

NHS Constitution/Equality & Diversity/Communication

Report available on the public website

Attachment: Safer Working Guardian Quarterly Report â&#x20AC;&#x201C; April 2017

2 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT IN PUBLIC â&#x20AC;&#x201C; 27TH APRIL 2017 QUARTERLY REPORT BY GUARDIAN FOR SAFE WORKING HOURS: DOCTORS AND DENTISTS IN TRAINING Executive summary This quarterly report is to update the Trust Board with the progress of the new Junior Doctors Contract 2016, the pattern of the exception reports from the last quarterly report to the Trust on the 26th January 2017 and the management of the issues which have arisen, along with the information on current rota gaps (unfilled posts). Introduction The first Guardian for Safe Working Hours report, January 2017, provided a narrative on the role of Guardian for Safe Working Hours and the main principles of the new Junior Doctors Contract 2016, in particular in relation to the monitoring of the working hours, required breaks and educational opportunities. Since the January report, the new Junior Doctors Contract 2016 has been rolled out to core paediatric trainees and paediatric higher specialty trainees on the 6th March 2017. On the 5th April 2017 the new contract was rolled out to second year foundation trainees in surgery, trauma & orthopaedics, obstetrics & gynaecology, paediatrics and psychiatry. The contract was also rolled out to a proportion of the GP specialist trainees, core trainees in obstetrics & gynaecology and higher specialist trainees in the surgical specialties. The previous quarterly report raised a particular concern regarding the workload and working hours of the FY1 trainees in general surgery. Since then the Surgical Division has undertaken a number of actions to address the issues. They are described in the Qualitative Information section of this report. There was a particular incident which raised a major concern when some surgical FY1 trainees felt under pressure not to submit exception reports or felt that they were instructed by their supervisors not to submit exception reports. Such concerns were expressed to a non-executive director of the Trust. An urgent meeting between the surgical FY1 trainees and Guardian for Safe Working Hours took place and the junior doctors clarified that they did not receive specific instructions not to submit exception reports. However, some of the surgical F1, through conversations with the surgical clinical supervisors, felt that the message was by undertaking clinical work beyond prescribed hours is part of the accepted professional duties; or efficient junior doctors should be able to complete the clinical work in the prescribed hours. Therefore to work beyond the prescribed hours could reflect inefficiency in their work. In our meeting I clarified to the junior doctors that submitting exception reports is a very important tool for the organisation to monitor the workload of the clinical work. Junior doctors should not feel impeded in any way in submitting exception reports. To the contrary, by submitting exception reports they contribute to the safe 1

clinical practice within our organisation. I believe that in their subsequent meeting with the Trust Chief Executive at the Junior Doctors Forum, the same message was reinforced. High level data Number of doctors /dentists in training (total)

202 posts/212 trainees. (We have less than full time trainees as slot shares). Figure also includes those on maternity leave.

Number of doctors / dentists in training on 2016 TCS (total)

Amount of time available in job plan for Guardian to do the role

1PA

Doctors Working Hours/2016 Doctors Contract Coordinator

Currently .70WTE with funding for 1WTE

Amount of job planned time for educational supervisors

0.25PA per trainee

a) Exception reports (with regard to working hours) The analysis of the exception reports from 10th January 2017 to 12th April 2017 is as follows: Exception reports by department Specialty No. exceptions carried over from last report Surgical 1 General 1 Medicine Total 2

No. exceptions No. exceptions No. exceptions raised closed outstanding 15 2

15 3

1 0

Exception reports by grade Specialty No. exceptions No. exceptions No. exceptions No. exceptions carried over raised closed outstanding from last report F1 2 17 18 1 2

Total

Exception reports by rota Specialty No. exceptions carried over from last report General 1 Surgery General 1 Medicine Total 2

No. exceptions No. exceptions No. exceptions raised closed outstanding 15

These figures represent a significant reduction from the last quarter when the total exception reports raised totaled 32. At the time of the production of this report there is one overdue exception report regarding hours and rest. The clinical supervisor is being contacted to ensure the overdue exception report is reviewed as soon as possible. As shown on the tables above, the majority of the exception reports are still from general surgery at FY1 level. There was one exception report regarding missed educational opportunity which was reviewed and addressed. There were parts of exception reports indicating missed breaks but none of the missed breaks occurred repeatedly such that a penalty needed to be imposed. Up to now there have been no requests from trainees for a Level 2 (Appeal) of the outcome of the exception report reviews with clinical supervisors. b)

Work schedule reviews

Up to now no work schedule reviews have been required. This broadly means the timetables were seen as appropriate but the workload and work pattern required adjustments. c) Fines No fines imposed so far. There was one incident when an FY1 surgical trainee worked beyond the permitted 72 hours in seven consecutive days â&#x20AC;&#x201C; this is the maximum number of hours permitted. In reviewing the incident, it emerged the breach of the maximum working hours per seven days occurred because of a voluntary swop between two surgical FY1 trainees. Therefore the breach occurred, not due to the actions by the Surgical Division, but by the action taken by the particular FY1 trainee. The trainee was counseled and made aware she is not allowed to schedule herself to work beyond 72 hours in any seven consecutive days as prescribed by the new contract.

Fines by department Department General Surgery General Medicine Paediatrics Total Fines (cumulative) Balance at end of last quarter 0

Number of fines levied 0 0 0 0 Fines this quarter 0

Value of fines levied 0 0 0 0

Disbursements this Balance at end of quarter this quarter 0 0

Qualitative information 1. Issues arising Surgical FY1 trainees It is reassuring to see a reduction in the exception reports from the surgical FY1 trainees since the last report. This is likely to be due to the actions taken by the Surgical Division but also due to the fact that the trainees have become more conversant with the tasks required. The actions undertaken by the Surgical Division are as follows: (A) Completed Actions (A.1) Reinforced the information to the junior doctors that they are expected to start and finish at the times on the rotas and not expected to start earlier or finish later than those prescribed times. (A.2) Slowed down ward rounds. (A.3) Revision of the handover process and compilation of the ward list. (A.4) Ward log introduced for non-urgent tasks to reduce the requirement for paging (A.5) Increased the number of core trainees working during the weekend. (B) Ongoing Actions (B.1) Weekly review meeting between consultants and junior doctors. (B.2) Recruitment of surgical care assistants. (B.3) Review of MET composition.

2. Orthopaedic FY2 trainees The orthopaedic FY2 trainees transitioned to the Junior Doctor Contract 2016 on the 5th April 2017. There have been concerns regarding their work pattern and educational opportunities based on previous GMC surveys. In addition four of the seven Trust grade doctors’ posts are still unfilled. These are the doctors who work alongside the FY2 trainees. Both Chief of Education and myself feel that we need to take a pro-active approach to this issue. A proposal is being worked up to provide supervision of orthopaedic FY2s by consultant physicians, possibly consultants in orthogeriatrics. This will provide clinical support and training at ward level to this group of trainees. 3. Rota Gaps The current gaps on the rotas are as follows: General Surgery ST3+

1 trainee and 1 Trust grade

Orthopaedic SHO

4 Trust grade

Obstetrics & Gynaecology ST3+ 3 Trainees (all on maternity leave) ENT SHO

1 trainee and 40% of another trainee

Paediatric ST4+

2 trainees as some doctors are less than full time

Summary In the past quarter, the rolling out of the Junior Doctors 2016 Contract has proceeded as planned. The problems with the working hours and training amongst the FY1s has been actively managed and appears to be improving. The major test will come when the new intake of FY1 trainees start in August 2017 as this will be their first clinical post and therefore they will be less experienced. The concern in orthopaedics at FY2 level is well recognised by Chief of Education and Guardian. An action plan to address the problem is being developed. A form has been designed for LNC approval reminding junior doctors of the Terms and Conditions of the Junior Doctor Contract 2016 should they decide to undertake additional work. The form highlights Schedule 3 paragraphs 4 and 43 of the Terms & Conditions - an extract from these paragraphs is given below. Paragraph 4 ‘Individual doctors have a professional responsibility for ensuring that their total hours of work, including any work undertaken for any other employer, comply with the contractual and regulatory limits set out in paragraphs 1 and 2 … ‘ 5

Paragraph 43 ‘ Where a doctor intends to undertake hours of paid work as a locum, additional to the hours set out in the work schedule, the doctor must initially offer such additional hours of work exclusively to the service of the NHS via an NHS staff bank. The requirement to offer such service is limited to work commensurate with the grade and competencies of the doctor rather than work at a lower grade than the doctor currently employed to work at. The doctor must inform their employer / host organisation of their intention to undertake additional hours of locum work… Additional Information The attendance at the Guardians Junior Doctors Forum has up to now been very poor, particularly by the junior doctors’ representatives. The last three meetings did not achieve a quorum despite a change of timing to suit the junior doctors. A new approach to the arrangements for the forum meetings is needed possibly, through attaching the Guardian’s forum meeting to one of the existing meetings where junior doctors are currently attending. Questions for consideration The report therefore is being submitted to the Board for approval and to seek opinions and recommendations from the Board in particular any suggestions the Board might have in attracting more engagement of junior doctors with the Guardians forum meeting.

Dr Virach Phongasthorn Consultant Physician & Guardian for Safer Working April 2017

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

Date: 27th April 2017 Agenda Item: 2.6 Serious Incident Report for Q4 2016/7 Fiona Allsop Katharine Horner

n/a

Action Required: Approval ( )

Discussion ( )

Assurance ( )

Purpose of Report: This paper provides the Board of Directors with a report on the serious incidents declared in Q4 and an update on the overall position with regard to the management of serious incidents within the Trust. Summary of key issues • The Trust reported eight serious incidents in Q4 2016/17. All incidents were reviewed and escalated appropriately. • There were no never events • As at 10th April 2017 the Trust has eight serious incidents open with the CCG, of which two have been submitted for closure and one downgrade has been requested. Recommendation: The Board is asked to note the contents of this 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 Financial impact Patient Experience/Engagement Risk & Performance Management

Compliance with CQC, MHRA and Audit Commission Serious incidents often become claims Reporting, investigation and learning from serious incidents informs risk management

NHS Constitution/Equality & Diversity/Communication

Serious Incident Report – Public Board

Page 1 of 5

TRUST BOARD REPORT Serious Incident Report – period: Q4 2016/17 1.

Introduction

1.1

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

1.2

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

1.3

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

1.4

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

Patient Safety Incidents in 2016/17 Q4

2.1

There were a total of 2,216 incidents reported on Datixweb in Q4 2016/17 of which 1,873 (83%) were clinical/patient safety incidents. These incidents breakdown as follows:

Over the quarter 457 of the 1,873 incidents (24%) caused harm to a patient. The last eight quarters are as follows:

2.2

The incident categories are shown for those patient safety incidents reported in Q4 2016/17 as moderate harm, severe harm or death.

Serious Incidents declared in Q4 2016/17

3.1

The Trust declared eight serious incidents in Q4 2016/17; four in January, two in February and two in March. 2017/125 - Fall The patient, a ninety-one year old female, stood up to go to the toilet without the use of her walking aid (Zimmer), and fell backwards. 2017/1799 - Fall The patient, an eighty-nine year old male, fell on the ward resulting in a fractured neck of femur. 2017/1802 – Maternity incident An intrauterine death was confirmed at 33 weeks by scan undertaken by the on call consultant after no foetal heart could be heard on the ante natal day unit. The woman had experienced a previous stillbirth at 27/40. It was noted that no serial scans were undertaken. A discrepancy in plan for antenatal care has been noted. 2017/2638 – Missed diagnosis Patient had CT scan in April 2016 right liver lesion seen, following further imaging it was reported as haemangioma (a benign condition). The patient represented in October when a review of the April CT identified a colon splenic flexure mass which had not been identified for investigation in April. The extent of harm has not yet been confirmed. 2017/4211 – Surgical Incident (ophthalmology) The patient is an 81 year old female under the care of the Ophthalmology team. The investigation will examine a treatment complication which resulted in an extra ocular intervention and cataract formation. The investigation will consider whether the original procedure may have been unnecessary. 2017/4221 - Surgical Incident (ophthalmology) The patient was admitted via ED to Chaldon Ward in pain and unable to see in the early hours of 24/9/16. Ophthalmology review not undertaken until 26/9/16 when a diagnosis of bilateral acute glaucoma made. The delay in review resulted in a significantly worse visual outcome. 2017/8070 – Fall The patient was admitted for an elective right total hip replacement. During his postoperative recovery the patient fell and sustained a periprosthetic fracture and dislocation. Serious Incident Report – Public Board

Page 3 of 5

The patient underwent a further procedure to repair the fracture and has since been discharged home. 2017/8163 - Maternity Incident Baby was born in poor condition following emergency caesarean section. The baby was transferred to a tertiary unit for therapeutic cooling, however treatment was withdrawn after four days and the baby passed away. 3.2

SI themes over the last 12 months The serious incidents are shown by the month in which they occurred, not the month in which they were declared. The date of knowledge and therefore declaration may be different. 54% (19) of the serious incidents that occurred in the last twelve months relate to patient falls.

Weekly overview A weekly open SIs overview summary is sent to the Patient Safety and Risk Lead and the Chief Nurse which indicates overall Trust and Divisional performance in completing SI investigations within the National timeframe. The Serious Incident Review Group closely monitors the investigation and submission process. The Divisions are asked to include an update on RCA reports to the Patient Safety and Clinical Risk Sub-Committee. This is the latest reported Trust position at 6th April 2017.

Serious Incident Report â&#x20AC;&#x201C; Public Board

Page 4 of 5

Recommendation The Trust Board are asked to discuss the report and take assurance regarding the management of SIs and the on-going work to improve performance on completing SI investigations within the National timeframe.

Name of Director Fiona Allsop Title of Director Chief Nurse April 2017

Serious Incident Report â&#x20AC;&#x201C; Public Board

Page 5 of 5

Integrated Performance Report M12 â&#x20AC;&#x201C; March 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 – March 2017 Patient Safety • There were 2 SIs declared in March 2017 • Patient safety indicators continue to show expected levels of performance. • There was 1 MRSA bloodstream infection and 5 Trust acquired C-Diff case in March 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 achieved with performance of 95.1% in March 2017.

• All Cancer targets were achieved during March 2017. • 18 Weeks RTT - The Trust did not achieve the RTT Incomplete pathways standard with performance of 90.1%. Recovery actions are in place. Patient Experience • The FFT for Inpatients was 95.2% in March 2017; the ED FTT increased slightly to 96.9%. 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 – March 2017 Finance • The Trust has achieved a £3.5m [adjusted] surplus at the end of the financial year, £(11.7)m adverse to the original planned £15.2m surplus. The final year end position included £4.9m of S & T funding (Q1 & Q2) against a planned £9.2m (no payment at Q3 or Q4). The £1.5m shortfall from the NHSi required £5m forecast position was directly due to £1.2m readmissions deductions and £0.3m non reimbursement of winter resilience funding by Commissioners. 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

Mar-16

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-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)

90.2%

91.5%

94.7%

93.8%

92.3%

89.0%

90.7%

89.0%

89.9%

92.2%

89.9%

93.9%

93.1%

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

94.5%

95.0%

96.5%

97.6%

96.2%

92.6%

96.2%

94.8%

94.4%

96.8%

94.2%

97.9%

98.7%

95%

96%

95%

100%

98%

100%

Serious Incidents - No per 1000 Bed Days

0.51

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

1.4%

0.7%

0.4%

0.5%

0.8%

0.9%

0.5%

0.0%

0.5%

0.2%

0.0%

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

Number of overdue CAS and NPSA alerts

Trend

• The Trust declared two serious incidents in March 2017. • 2017/8070 – Fall - The patient was admitted for an elective right total hip replacement. During his post-operative recovery the patient fell and sustained a periprosthetic fracture and dislocation. The patient underwent a further procedure to repair the fracture and has since been discharged home. This was a late declaration of an incident which took place in December 2016. • 2017/8163 - Maternity Incident Baby was born following emergency caesarean section. The baby was transferred to a tertiary unit for therapeutic cooling, however treatment was withdrawn after four days and the baby passed away. • Safety thermometer performance continues for “All Harm” with performance improving to 98.7% for the “New Harm” measure. • The percentage of patient safety incidents causing severe harm or death was 0.0% in March 2017, within the expected range.

An Associated University Hospital of Brighton and Sussex Medical School

Patient Safety Infection Control Indicator Description

Mar-16

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

MRSA BSI (incidences in month)

CDiff Incidences (in month)

MSSA

E-Coli

Trend

â&#x20AC;¢ There is 1 case of MRSA in March 2017 and 5 cases of Trust acquired C.diff.

An Associated University Hospital of Brighton and Sussex Medical School

Clinical Effectiveness Mortality and Readmissions Indicator Description

Mar-16

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

HSMR (56 Monitored diagnoses - 12 Months)

96.1

95.8

94.4

93.7

94.8

93.7

92.1

92.9

92.7

94.3

Emergency readmissions within 30 days (PBR Rules)

6.8%

6.5%

6.6%

6.8%

7.3%

7.0%

6.3%

6.5%

6.4%

7.5%

Jan-17

Feb-17

6.6%

6.5%

Mar-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

Mar-16

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

C Section Rate - Emergency

14%

18%

14%

12%

15%

16%

17%

13%

18%

17%

C Section Rate - Elective

12%

11%

10%

11%

14%

11%

12%

13%

11%

10%

14%

Admissions of full term babies to neo-natal care

5.0%

3.9%

7.0%

2.7%

4.7%

4.5%

5.0%

7.0%

4.9%

7.6%

5.9%

4.5%

5.7%

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 STF Trajectories 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

Trajectory

90.0%

93.0%

94.0%

95.0%

94.4%

95.0%

Actual

91.3%

95.5%

96.4%

95.3%

96.0%

96.4%

95.4%

95.1%

89.8%

87.0%

90.9%

95.1%

Trajectory

85.0%

Actual

86.3%

86.0%

90.0%

86.7%

85.4%

85.6%

89.8%

89.5%

87.7%

88.3%

85.0%

Trajectory

92.0%

92.2%

92.4%

92.6%

92.8%

93.0%

92.8%

92.4%

92.2%

92.0%

Actual

92.6%

92.5%

92.7%

92.6%

92.1%

92.4%

92.1%

92.5%

90.9%

90.5%

90.0%

90.1%

Trajectory

0.6%

Actual

0.1%

0.5%

0.3%

0.4%

7.7%

10.9%

9.5%

8.3%

4.7%

0.4%

0.3%

0.2%

ED 95% in 4 hours

Cancer - 62 Day Referral to Treatment Standard

RTT Incomplete Pathways - % waiting less than 18 weeks

Percentage of patients waiting 6 weeks or more for diagnostic

• The table above shows the agreed STF Trajectories and YTD performance. • The trajectory for the ED 4hr Standard was achieved with performance of 95.1% • The Cancer 62 Day trajectories continue to be achieved in March 2017. • RTT continues to be a challenge nationally and locally with referral growth above plan / capacity gaps in a number of specialties. This has resulted in the RTT Incomplete trajectory not being achieved in March 2017 with performance of 90.1%. • The diagnostic standard and trajectory were achieved in March 2017 with performance of 0.2%.

An Associated University Hospital of Brighton and Sussex Medical School

Access and Responsiveness Emergency Department Indicator Description

Mar-16

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

88.6%

91.3%

95.5%

96.4%

95.3%

96.0%

96.4%

95.4%

95.1%

89.8%

87.0%

90.9%

95.1%

Ambulance Turnaround - Number Over 30 mins

296

231

172

168

191

145

189

224

336

253

194

249

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 achieved in March 2017 with performance of 95.1%. • Ambulance turnaround performance improved in March 2017 with 19 breaches of the 1hr standard – under 1% of the months ambulance arrivals. • 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

Mar-16

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Cancer - TWR

93.7%

91.0%

90.3%

91.7%

95.4%

93.0%

95.3%

94.8%

94.3%

94.5%

94.7%

94.4%

95.0%

Cancer - TWR Breast Symptomatic

89.8%

87.1%

91.1%

82.0%

93.9%

97.2%

95.7%

99.0%

95.8%

94.7%

95.4%

93.0%

95.7%

Cancer - 31 Day Second or Subsequent Treatment (SURGERY)

95.3%

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

96.0%

96.7%

98.5%

98.6%

98.8%

97.0%

96.0%

100.0%

97.7%

97.2%

96.8%

Cancer - 62 Day Referral to Treatment Standard

87.9%

86.3%

86.0%

90.0%

86.7%

85.4%

85.6%

89.8%

89.7%

86.6%

87.9%

85.0%

Cancer - 62 Day Referral to Treatment Screening

100.0%

87.5%

100.0%

83.3%

100.0%

93.3%

100.0%

Cancer - 31 Day Second or Subsequent Treatment (DRUG)

Trend

• All Cancer standards were achieved for the 9th month in a row with the work undertaken on TWW in June / July and investments in tracking continuing to show sustained improvement. • Business Planning for 2017/18 will focus on ensuring capacity is in place for expected growth and changes in pathways aligned to the National Cancer Strategy. • Ring fencing of capacity for Cancer has seen 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

Mar-16

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

92.2%

92.6%

92.5%

92.7%

92.6%

92.1%

92.4%

92.1%

92.5%

90.9%

90.5%

90.0%

90.1%

RTT Admitted

77%

76%

78%

79%

76%

77%

74%

77%

75%

71%

77%

RTT Non Admitted

85%

86%

87%

84%

82%

83%

82%

79%

77%

81%

86%

Percentage of patients w aiting 6 weeks or more for diagnostic

0.0%

0.1%

0.5%

0.3%

0.4%

7.7%

10.9%

9.5%

8.3%

4.7%

0.4%

0.3%

0.2%

Last Minute Elective Cancellations for non clinical reasons

119

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 90.1% in March 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 March 2017 19 patients were waiting over 52 weeks for treatment. RCAs are completed for all patients with reasons including patient choice and capacity as well as tracking system validation. • The 6 week diagnostic standard was achieved in March 2017 as actions taken over the last 6 months supported delivery. • 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

Mar-16

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Emergency Department FFT - % positive responses

95.0%

95.4%

94.9%

95.9%

94.9%

96.1%

95.3%

96.1%

96.8%

96.0%

96.3%

96.6%

96.9%

Inpatient FFT - % positive responses

96.5%

95.6%

96.0%

94.7%

95.8%

93.8%

95.4%

94.8%

95.5%

96.7%

96.2%

95.2%

Maternity FFT - Antenatal - % positive responses

95.3%

98.9%

95.4%

93.2%

100.0%

93.6%

97.6%

98.6%

95.6%

93.9%

98.5%

95.2%

95.9%

Maternity FFT - Delivery - % positive responses

94.7%

100.0%

98.8%

99.0%

97.7%

98.7%

95.6%

97.1%

96.9%

98.7%

97.8%

97.3%

98.8%

Maternity FFT - Postnatal Ward - % positive responses

93.3%

95.3%

97.6%

94.0%

91.8%

94.3%

92.8%

86.6%

96.2%

92.3%

89.0%

92.2%

97.7%

96.1%

97.1%

98.9%

98.3%

97.5%

96.4%

98.3%

92.5%

100.0%

92.0%

100.0%

89.0%

89.6%

86.7%

89.1%

88.9%

91.7%

90.2%

91.1%

91.2%

88.0%

89.7%

90.7%

90.6%

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

Trend

• ED FFT – The FFT score has increased slightly from 96.6% in February to 96.9% in March. • Inpatient FFT - The FFT score for inpatients dropped from 96.2% in February to 95.2% in March. • Maternity FFT – There has been an increase in all of the maternity FFT indicators. • Outpatient FFT – the FFT score for outpatients dropped slightly, from 90.7% in February to 90.6% in March.

An Associated University Hospital of Brighton and Sussex Medical School

Workforce Workforce Indicator Description

Mar-16

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

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

94.5%

97.3%

98.1%

97.6%

97.4%

96.9%

97.4%

97.6%

98.7%

96.9%

97.5%

96.7%

95.6%

Average fill rate – care staff (%) - Day

99.5%

98.2%

98.1%

98.2%

93.5%

95.0%

93.4%

91.1%

88.7%

92.4%

91.9%

96.4%

93.0%

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

97.6%

98.8%

98.6%

98.9%

98.3%

97.1%

97.8%

98.3%

97.7%

97.0%

97.3%

97.9%

97.4%

Average fill rate – care staff (%) - Night

97.3%

97.2%

98.2%

98.0%

95.7%

95.8%

95.2%

93.9%

92.8%

92.3%

95.4%

95.0%

94.9%

Overall Sickness Rate

4.0%

3.6%

3.2%

3.5%

3.4%

3.5%

3.3%

3.9%

4.2%

4.3%

4.1%

3.7%

3.5%

%age of staff who have had appraisal

66%

0.4%

14.7%

23.8%

41.6%

54.9%

71.0%

86.4%

95.2%

96.4%

97.0%

97.2%

97.6%

Staff Turnover rate

14.1%

14.4%

14.5%

15.3%

15.4%

14.9%

15.6%

15.5%

16.4%

16.1%

15.8%

Total Establishment (WTE)

3721

3733

3813

3820

3837

3876

3891

3937

3944

3952

3925

3932

Vacancy Rate (All Staff)

7.7%

8.4%

10.4%

12.8%

10.8%

11.3%

11.2%

11.5%

11.8%

11.0%

9.8%

9.4%

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

65.3%

62.0%

64.7%

79.7%

80.8%

80.9%

80.3%

79.9%

80.0%

80.3%

76.8%

78.0%

65.8%

Trend

• Funded Establishment has increased by 6 posts and equates to 3931. • Staff in Post has increased by 26 and equates to 3551. • Vacancy Rate across all staff groups has decreased to 9.4% and has also decreased in Nursing by 0.2% to 15.7%. • Turnover has decreased to 15.8% for all staff groups, and also decreased by 0.8% for Nursing to 16.1%. • Sickness has decreased by 0.2% to 3.5%. • MAST figures for March were recorded as 78%. • Achievement Review completion rate at end of March was 98%. The 2017 AR cycle is now active. • 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

Mar-16

Outturn £m Surplus / (Deficit) - Plan Outturn £m Surplus / (Deficit) - Forecast YTD £m Surplus / (Deficit) - Plan YTD £m Surplus / (Deficit) - Actual Outturn UNDERLYING £m Surplus / (Deficit) - Plan Outturn UNDERLYING £m Surplus / (Deficit) - Actual

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

1.6

15.2

(6.5)

15.2

0.3

5.0

1.6

(2.3)

(4.0)

(4.9)

(2.1)

(1.9)

1.8

6.2

5.0

6.8

10.1

15.2

(6.5)

(1.3)

(2.5)

(3.0)

(1.8)

0.1

2.8

2.0

3.6

2.0

3.5

3.8

7.5

(7.2)

7.5

(4.6)

(2.8)

(4.3)

YTD Savings £m - Actual

5.4

0.2

0.5

1.0

1.6

1.9

2.3

3.1

4.4

5.6

6.8

8.0

9.2

OT Risk £m Surplus / (Deficit) - Assessment

0.0

(6.8)

(7.2)

(14.9)

(4.0)

(2.5)

0.0

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

2.5

2.3

2.1

6.3

2.5

5.6

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

2.5

2.7

3.0

3.7

4.9

5.8

4.5

4.8

7.2

5.3

4.4

2.9

5.6

YTD Liquid ratio - days

(18.0)

(16.0)

(13.0)

(18.0)

(17.0)

(19.0)

(16.0)

(10.0)

(9.0)

(7.0)

(11.0)

(12.0)

YTD BPPC (overall) volume £m

47%

28%

32%

53%

62%

70%

73%

77%

79%

80%

82%

83%

YTD BPPC (overall) value £m

55%

41%

51%

58%

64%

71%

74%

77%

79%

80%

82%

Outturn Capital spend Fav / (Adv) - forecast

14.1

9.0

13.1

15.9

12.6

12.4

11.3

11.4

Trend

• The Trust’s 2016/17 plan has been profiled as below, reflecting the phasing of the £9.7m sustainability funding, clinical activity and cost improvements. Mth 1 Mth 2 Mth 3 Mth 4 Mth 5 Mth 6 Mth 7 Mth 8 Mth 9 Mth 10 Mth 11 Mth 12 £000's

£000's

In Month I&E Plan

(2,299)

(1,641)

(902)

(63)

2,820

231

3,675

4,374

(1,172)

1,804

3,240

5,133

Cuumulative I&E Plan

(2,299)

(3,940)

(4,842)

(4,905)

(2,085)

(1,854)

1,821

6,195

5,023

6,827

10,067

15,200

2,425

STP Funding (incl above) in mth

• The Trust has achieved a £3.5m [adjusted] surplus at the end of the financial year, £(11.7)m adverse to the original planned £15.2m

surplus. The final year end position included £4.9m of S & T funding (Q1 & Q2) against a planned £9.2m (no payment at Q3 or Q4). The £1.5m shortfall from the NHSi required £5m forecast position was directly due to £1.2m readmissions deductions and £0.3m non reimbursement of winter resilience funding by Commissioners.

An Associated University Hospital of Brighton and Sussex Medical School

Finance • Total agency (and NHS locum) spend amounted to £20.8m which is £(5.5)m greater than the Trust’s £15.3m agency ceiling . This spend was mainly driven by the on-going difficulties in recruiting sufficient numbers of permanent/bank nurses and junior doctors. • The Trust delivered its £9.2m savings programme. • The underlying position at the end of March is a £(4.3)m deficit, reflecting the non-recurrent £3m additional activity funding from NHSE and the non recurrent £4.9m S & T funding. • The cash balance at the end of March 2017 was £5.6m (incl. £3.5m ring-fenced for loan repayment in April 2017). The Trust has drawn down £7.3m revolving working capital in 2016/17 of which £3.8m was repaid in year and £3.5m repaid in April 2017. This cash supported on-going improvement in BPPC performance which ended the year at 83% by volume, 82% by value year, which was considerably better than the 45% by volume and 55% by value in 2015/16. • The EPR Digitise project (which was planned to be to be funded by a capital investment loan) has now been deferred into 2017/18 and, to support the national position, the Trust deferred a further £1.1m of 2016/17 expenditure into early 2017/18 and returned this CRL (not cash) resulting in a revised CRL outturn of £11.3m. This compared to the £15.9m CRL plan

An Associated University Hospital of Brighton and Sussex Medical School

Date: 27th April 2017

TRUST BOARD IN PUBLIC

Agenda Item: 5.1 REPORT TITLE:

Annual plan 2016/17 update Q4

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

Sue Jenkins Director of Strategy & KPO Lead Sue Jenkins Director of Strategy & KPO Lead Executive Committee

Action Required: Approval

Discussion

Assurance (√)

Purpose of Report: The purpose of this report is to provide assurance to the Board that the annual operating plan for 2016/17 has been delivered Summary of key issues The annual plan for 2016/17 was approved by the Board in April 2016. The original annual plan included progress against 72 actions. This reduced to 71 actions during the year. The one that has been deleted is 2.10 which relates to progressing the appointment of a heart failure specialist nurse. This business case for this role was not approved in 2016 os it has been included in business planning for 2017/19 and will be included in next years annual plan. Of the 71 actions the status for the quarter is reported as follows:Status

Q1 – April to June 2016

Red Amber Green Blue

2 47 19 4

3% 65% 26% 6%

Q2 – July to September 2016 2 18 48 4

3% 25% 66% 6%

Q3 – October to December 2016 3 4% 13 18% 47 66% 8 12%

Q4 – January to March 2017 2 3% 12 17% 38 53% 19 27%

80% of the actions have either been completed or are being delivered according to plan. There are 2 actions with a red status;  1.15 – 2 MRSA BSIs against a target of 0 avoidable. 1 avoidable MRSA BSI in NNU and one transient bacteraemia or contaminated sample. MRSA screening was 64 % during last audit  4.10 – elective activity at the end of M12 was £4m adverse to plan. This was mainly due to pressure of non elective activity. Most of the shortfall against the plan was in surgery although March saw the highest performing month to date

elective activity against plan The Q4 report highlights those actions that are not yet complete and are proposed to be carried forward to the 17/18 plan. The Board are asked to consider the format and content of the annual plan which has been in place for three years and what amendments and level of detail they would like to see included for the 17/18 plan. Recommendation: The Board are asked to confirm that this report provides assurance that the annual plan 2016/17 delivered 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

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

Attachment: Annual plan 2016/17 Q4 update

2 An Associated University Hospital of Brighton and Sussex Medical School

Annual plan 2016/17 v1.2 - Q4 update January - March 2017 RAG status key

Trend key

Work stream off track and unlikely to deliver as described

Got worse since last report

Work stream offtrack but plans in place to recover

1.2 NEW

Strategic objectives delivery plan Quality account

Consistently meet national patient safety standards and benchmark in top 20% against peers

Complete

RAG

Trend

Same as last report

SO1 - Safe - Deliver safe high quality and improving services which pursue perfection and be in the top 20% against our peers New Action Ref Source Lead director or bf Strategic objectives delivery plan Quality account 1.1 NEW Clinical strategy Divisional plans

Work stream on track and to plan

Angela Stevenson

Demonstrate 95% compliance with the safety thermometer and have Fiona Allsop as few never events as possible

Lead manager/clinician

Q4 update

To C/F Y or N

Ben Emly

Q 3 benchmark for safety complete and we benchmark overall in the third quartile nationally. Key areas for improvement relate to safety thermometer and a revised data collection process has been put in place from March

Processes to ensure consistency for ST data collection and validation commenced in March 2017. No new never events during Q4.

1.3 NEW

Strategic objectives delivery plan Quality account

Work in partnership with Virginia Mason Institute and develop a culture of continuous improvement

Sue Jenkins

Eight RPIWs have now been completed across three value streams. 32 leaders completed all six taught modules of L4L and will complete whole programme in May. 58 leaders have been recruited for cohorts 3 and 4 of L4L which commences in April 2017 25 leaders have been recruited for cohorts 5 and 6 of L4L which starts in September 2017

1.4 BF

Strategic objectives delivery plan

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

Des Holden

Continue to contribute in patient safety collaborative via AHSN

1.5 BF

Strategic objectives delivery plan

Include quality goals in all clinical staff appraisals

Des Holden

Quality goals included in all medical appraisals and where absent they are returned for completion. Consider complete

Fiona Crimmins

Prevent has continued to be high on the agenda during the past year. Following the passing of the Counter Terrorism and Security Act in February 2016, WRAP (Workshop to Raise Awareness of Prevent) training has continued during 2016/17 and the Trust is on track to be 100% compliant with PREVENT WRAP training by July 2018.

Barbara Bray

July to September data only available For knee replacements we have 0 SSIs in this quarter and none in the 4 quarters For hip replacement we had 1 in this quarter making a total of 2 in the 4 quarters For repair of NOFs we had 2 SSIs in the last quarter making a total of 7 in the 4 quarters. We continue to be under the threshold for being an outlier on this KPI

Michelle Cudjoe

Guidance now due in June 2017 but in mean time 5 new posts have been agreed to support maternity triage

Paula Tucker

Pilot of 8 wards continues with a collective improvement target to reduce the rate of inpatient falls by 20% Q4 shows an encouraging improvement in the rate of inpatients falls per 1000 bed stay days and the number of falls with harm. Multidisciplinary monthly falls focus group continue where the learning is shared.

1.6 NEW Quality account

Develop and implement plans to ensure 100% of staff have received Fiona Allsop appropriate levels of PREVENT training by July 2018

1.7

Clinical strategy Divisional plans

Maintain the low incidence of surgical site infections

1.8

Clinical strategy Divisional plans

Monitor and work towards compliance with national midwifery staffing Fiona Allsop guidance

1.9

Quality Account Quality strategy

Des Holden

Implement falls strategy and demonstrate a reduction in the number of falls that cause harm to our patients to less than 1.5 per 1,000 bed Fiona Allsop days

Pressure damage

Maintain achievement of no hospital acquired major pressure damage and aim to reduce hospital Fiona Allsop acquired minor damage to below 159 for the year

Louise Evans

Unfortunately we have not achieved our target of no hospital acquired major pressure damage this year. We have had a total of 5 patients who acquired mostly unavoidable grade 3 pressure damage. We aimed to reduce hospital acquired minor damage to below 159 for the year. We have reduced slightly or incidence to just over 60. During Q4, the Trust continued to see a low incidence of pressure ulcers, with an average of 6 per month. RCAs are carried out on any hospital acquired pressure ulcers and presented at the fortnightly Pressure Ulcer Meeting in order to share learning.

Des Holden

Ashley Flores

1 MRSA BSI in Q4. 11 cases of Clostridium difficile in Q4.

Des Holden

Barbara Bray

Compliant and reported to effectiveness committee

Ian Mackenzie

Carol Dixon

Ongoing

Lead Manager/clinician

Q4 update

Quality Account Quality strategy

1.11

Quality Account Quality Strategy

Healthcare acquired infection

Meet the DH central infection control targets of <15 Cdiff cases and no preventable MRSA blood stream infections

1.12

Quality Account Quality strategy

World Health Organisation (WHO) safer surgery checklist

Continue to audit quality of safer surgery processes and achieve 100% compliance

1.10

1.13 NEW Quality Account

Continue to maintain high standards of cleanliness and to listen and respond to feedback from patients and visitors

SO2 - Effective: As a teaching hospital deliver effective, improving and sustainable clinical services within the local health economy New Action Ref Source Lead Director or bf 2.1 NEW Strategic objectives delivery plan

2.2 NEW

Strategic objectives delivery plan Quality account

NEW Strategic objectives delivery plan

RAG

Trend

To C/F Y or N

benchmarking report at Q2 is positive for effectiveness and in top decile for readmissions. Mortality is priority for focus

Des Holden

Anne Shears

Finished the financial year with our highest ever number of participants recruited to research. A very busy final quarter contributed to annual total of 914 participants (includes 840 patient recruits) . Exceeded the KSS network target of 650 participants. Cuts in external funding for 2017-18 will bring pressures for research delivery next year.

Continue and embed discharge to assess

Angela Stevenson

Jane Griffiths

Sussex has bid via Better Care Fund for monies to support D2A programme and Surrey has identified funding for 4 beds , date for D2A to start TBC

Support and develop Integrated Reablement Unit

Angela Stevenson

Jane Griffiths

Discussion with CCG continues. Next important step will be agreement to recruit substantive staff .

Develop and implement frailty unit

Des Holden

Alison James

Currently open 5 days per week whilst recruitment continues. Will link with Ambulatory Care Unit development regarding recruitment and pathways

Progress academic appointments with Surrey University and HEKSS Des Holden

Job description is being revisited and post to be advertised again in June 2017

Y Y

Year on year recruit more research participants and ensure learning is published

Deliver services differently to meet the changing needs of patients, the local health economy and the Trust

2.5 2.6 NEW Strategic objectives delivery plan

Jonathan Parr

Achieve top 20% performance in benchmarked clinical outcomes

2.3

2.4

Des Holden

2.7

Clinical strategy Divisional plans

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

Des Holden

Ben Mearns

Continue to await outcome of bid process and feedback from commissioners

2.8

Clinical strategy Divisional plans Estate strategy

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

Angela Stevenson

Ed Cetti Mo Luqman

Complete

2.9

Clinical strategy Divisional plans

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

Des Holden

Ed Cetti Mo Luqman

Still requires agreement however key equipment e.g. Ultrasound, CT have been bought and case for MRI is under review.

Fiona Allsop

Nicola Shopland

Business case not approved in 2016. To be included in business plan for 2017/19

2.10 NEW Quality account

Demonstrate full compliance with NICE guidance for heart failure and atrial fibrillation

Progress appointment of hart failure specialist nurse

NEW Quality account

Demonstrate full compliance with NICE guidance for heart failure and atrial fibrillation

Develop and implement policy for the management of patients with AF

Des Holden

Ben Mearns

guidelines in development

Maintain â&#x20AC;&#x153;better than national averageâ&#x20AC;? mortality rating for both HSMR and SHMI

Des Holden

Jonathan Parr

Achieved Q4

2.13 NEW Quality account

Maintain positive position for all three enhanced recovery pathways

Des Holden

Jonathan Parr

Achieved Q4 and complete

2.14 NEW Quality account

Continue reporting of #NOF enhanced quality data to AHSN and demonstrate improvement in patient pathway

Des Holden

Jonathan Parr

Achieved Q4

Lead Director

Lead Manager/clinician

Q4 update

Fiona Allsop

Cathy White

Ongoing at divisional and Trust level

Fiona Allsop

Cathy White

The Your Care Matters survey is now being run by Meridian and the migration over to them (from InMoment) is nearing completion. Training dates have been arranged and circulated.

Mark Preston

Nathaniel Johnston

Complete

Fiona Allsop

Cathy White

Always event in diagnostic imaging now planned for Q1 and co design work for signage also planned for 17/18

2.11 2.12 BF

Quality Account Quality strategy

SO3 - Caring - Working in partnership with staff, families and carers New Action Ref Source or bf 3.1

3.2

Strategic objectives delivery plan Strategic objectives delivery plan

Audit how patients feel cared about and respond to issues raised by YCM, FFT and inpatient survey Show evidence of "you said we did" in all areas

Continue to develop and deliver customer care training

3.3

3.4

NEW Strategic objectives delivery plan

Treat patients, carers and their Demonstrate how patient listening families with dignity, respect and events influence service compassion development and improvement

RAG

Trend

To C/F Y or N

3.5

Continue with values based recruitment

Mark Preston

Janet Miller

Complete and in place

3.6

Work with patients and carers as part of the patient experience strategy

Fiona Allsop

Cathy White

Steering group now up and running and continuing to meet

3.7

Demonstrate how patients are involved in the planning of care

Fiona Allsop

Cathy White

Carers steering group and the Patient Experience Committee continues with good attendance from the patient/carer representatives.

3.8

NEW

Strategic objectives delivery plan

Listen to patients and their families and ensure their views shape clinical services that reflect their feedback and care needs

3.9

3.11

3.12 BF 3.13

Quality account Clinical strategy Quality Account Quality strategy

Actively seek feedback from patients, carers and their families

Fiona Allsop

Cathy White

FFT and Your Care Matters continues. The service is being run by Meridian and the migration over to them is nearing completion. Training dates have been arranged and circulated.

Engage with the voluntary sector

Gillian Francis Musanu

Colin Pink

Complete and in place

Vicky Daley ADs (Jane Griffiths) DCNs (Jane Penny)

Work continues.

No mixed breaches in Q4

100 sets of notes have been audited and data analysis underway

Develop information to cover areas and in a format that patients have Fiona Allsop influenced

3.10

Continue to ensure there are no mixed sex breaches

Angela Stevenson

Audit EoLC plan End of life care

Fiona Allsop Implement 7 day service

Jane Penny Unsuccessful recruitment process first time round so role is back out to advert

3.14

Quality Account

Nutrition

Vicky Daley

The Trust continues to make improvements to protected mealtimes. The Nutrition and Hydration steering group and the Oral Nutrition and Hydration group monitor progress with the action plan and feedback from clinical areas and make adjustments as necessary. Over recent months, the Catering Team at the Trust have been working closely with the Palliative Care Team and the Dietetics Department, to enhance the catering provision for patients at the End of Life. Additionally, work is ongoing to develop finger food boxes for patients with Dementia. The new range of nutritional supplements and fortified milk for our patients, designed to maximise their nutritional intake continue to be well received by patients.

Lead director

Lead manager/clinician

Q4 update

Continue to make improvements to Fiona Allsop protected meal times

SO4 - Responsive - Become the secondary care provider of choice for our catchment population New Action Ref Source or bf

RAG

Trend

To C/F Y or N

4.1 NEW Strategic objectives delivery plan

Develop performance and benchmarking reports to track progress against delivery of national standards

Angela Stevenson

Ben Emly

Complete

4.2 BF

Develop plans to define and deliver 7 day services

Des Holden

Chiefs (Ben Mearns)

7 day services business cases are included in business planning for 2017/19. awaiting outcome.

4.3 NEW Strategic objectives delivery plan

Using patient feedback further develop the Macmillan Cancer Information Centre

Fiona Allsop

Jane Penny

Services continue to be supported in the Macmillan centre the development of which has been supported and informed by patients .

4.4 NEW Strategic objectives delivery plan

Continue series of hot topic events with patient involvement

Des Holden

Laura Warren

Cancer Hot Topic - well attended. Diabetes (children and adults) Hot Topic event taking place 27 April

4.5 NEW Strategic objectives delivery plan

Involve patients in SASH+ work in partnership with the Virginia Mason Institute

Sue Jenkins

Eight RPIWs have been held and all bar one have included a patient representative or the voice of the patient i.e. a governor

4.6 NEW Strategic objectives delivery plan

Review and increase use of SaSH@home beds

Angela Stevenson

Initial review of SASH@home beds has been completed. Additional surgical pathways including urology have been identified as suitable pathways for this service

4.7 NEW Strategic objectives delivery plan

Complete Frontier pathology services joint venture implementation and delivery

Strategic objectives delivery plan

Work towards achieving 85% bed utilisation

4.8

4.9

NEW

Strategic objectives delivery plan

4.10

4.11

4.12

Ensure patients receive the right Work towards LOS being in top care, in the right bed, at the right 20% time, every time Deliver all elective plans

Market Development strategy

To maintain and expand market share for elective activity

Market Development strategy

To explore opportunities for new services, joint ventures, partnerships and new markets

Joint venture delivered a surplus in first year against planned deficit. Have confirmed with NHSi that consolidation in STP with other Trusts should proceed.

Bruce Stewart

Michael Rayment

Angela Stevenson

Ben Emly

Q3 93.3% Q4 94.6%

Angela Stevenson

Ben Emly

Average LOS for non elective patients in January was 6.8 days. In February this increased slightly to 6.9 days and in March this reduced to 6 days which is one of the lowest rates of the entire year

Angela Stevenson

Natasha Hare

Elective activity at end of M12 was ÂŁ4m adverse to plan, most of the shortfall was in Surgery. M12 activity reached ÂŁ4.3m and was the highest performing month YTD.

Larisa Wallis

Revised market development strategy now complete and approved by FWC Q3 has seen (% increase in elective activity and 4% increase in outpatient referrals compared with Q3 last year

Larisa Wallis

Pendleton frailty unit is providing a 5 day a week service. Joint venture with SCFT and CCGs has opened a 16 bedded step down facility in Crawley No current AQPs are being pursued by the Trust

Paul Simpson

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

Lead manager/clinician

Q4 update

Vicky Daley DCNs (Nicola Shopland)

Extensive work continues corporately and at divisional level to reduce reliance on agency including recruitment from the local area and overseas and effective Healthroster management. A nurse recruitment strategy was presented to the Executive Committee in January and work is now ongoing to imbed interventions. Staffing levels are monitored on a daily basis and mitigation put in place where required to ensure that staffing ratios remain safe.

5.1 NEW Strategic objectives delivery plan

Deliver financial plan and develop and implement a viable long term financial model

Paul Simpson

Peter Burnett

Delivered 16/17 surplus and submitted plan to Board which meets the 17/18 control total. Actively engaged in STP discussions re long term sustainability

5.2 NEW Strategic objectives delivery plan

Ensure that key service development decisions are underpinned by clinical evidence

Des Holden

Chiefs (Barbara Bray)

Evidence based used to inform all service developments

5.3 NEW Strategic objectives delivery plan

5.4 NEW Strategic objectives delivery plan

Ensure staff are involved in key service developments

Improve staff to patient ratios

Angela Stevenson

Fiona Allsop

ADs (Natasha Hare)

A number of initiatives / projects underway or completed that include consultation and active participation from a wide cross section of staff, including: - Neonatal Unit redevelopment plans - Day Surgery plans, expected to open Jul 17 - SaSH+ RPIWs underway in Cardiology (emergency referrals), Outpatient Bookings (ophthalmology, breast and health records) and the Management of Diarrhoea - Care Stream work that includes development of Medically Ready for Discharge ward - opened Dec 16 - GP working alongside ED team - Paediatric DSU plans - cross divisional and multidisciplinary input - Ambulatory Care Unit (Medicine) plans being developed, expected to open Jul 17 - Appointed an Associate Director for Integration. Post jointly funded by external partner organisations.

RAG

Trend

To C/F Y or N

5.5 NEW Strategic objectives delivery plan

Deliver ongoing staff development programmes including talent management

Mark Preston

Nathaniel Johnston

The Trust achieved its objective of 90% of staff with 12 months or more continuous service receiving an AR for 2016. Promotion of the 2017 AR cycle commenced in February 2017. The Workforce Development team review the ARs to identify relevant training and development opportunities are available and promote these to SaSH staff. We are undertaking a more focussed approach to Talent Management and succession planning in 2017/18.

5.6 NEW Strategic objectives delivery plan

Accelerate delivery of EPR and increased use of technology

Ian Mackenzie

Anna Wickenden

FBC has been approved by FWC and Board in Q4 . Loan application deferred to Q1

ADs (Alison James)

Continuing with joint project with local GPs to establish GP presence in ED 7 days per week. Awaiting outcome of bid to develop primary care streaming at the front door. working on a number of schemes with community partners to improve discharge process for patients. Ereferral / A&G work with East Surrey CCG underway. Trust have initiated a review into paed emergency demand and established a task and finish group with the CCGs to review pathways. Appointment of Associate Director for Integration. Post jointly funded by external partner organisations

5.7 NEW Strategic objectives delivery plan

Develop effective partnerships to design integrated services

Jim Davey

5.8 NEW Strategic objectives delivery plan

5.9 NEW Strategic objectives delivery plan

Lead development of STP and influence effective delivery

Michael Wilson

4 places now agreed as part of STP. Plan to recruit to senior STP leaders including a CEO and Director of Commissioning

Develop and implement a health and well-being plan

Mark Preston

Janette Barnes

CQUIN targets achieved by 31.3.17, including flu vaccination programme. Report for CCG highlighting progress, successes, and areas for development submitted. Health & Well-being Day being arranged for September 2017. HWB Strategy development on-going. New governor role agreed by the Board and in place. PPE Strategy in draft

5.10

Membership strategy

Establish and deliver engagement and communications strategy for members following FT authorisation

Gillian Francis Musanu

Laura Warren

5.11

IT strategy

Provide upgraded email solution

Ian Mackenzie

Peter Hodgetts

Technical issues have delayed migration to NHS Mail. Working on resolution with Accenture - NHS Mail provider

5.12

IT strategy

Complete Network Upgrade

Ian Mackenzie

Peter Hodgetts

OBC still being developed

5.13

Estate strategy

Deliver estates capital programme

Ian Mackenzie

Ongoing

5.14

Workforce and OD strategy

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

Mark Preston

Janet Miller

The HRBPs continue to review and develop the Divisional Workforce Plans to support the delivery of workforce objectives and service requirements

Nathaniel Johnston

On-going review of Trust policies as per agreed timetable with Staff Side representatives. Sentence added to JDs for all new staff highlighting the expectations re: SaSH+

David Vincent

This work is being developed and used as / where appropriate. A number of senior Trust appointments were made in Q4, using psychometric testing based on Trust values

Nathaniel Johnston

The Trust achieved a year end AR completion rate of 97. 58%, against a target that 90% of staff with 12 months or more continuous service will have received an AR. SASH were placed in the Top 20% nationally for the quality of appraisals in the 2016 national Staff Survey. Planning and promotion for 2017/18 AR cycle commenced in February 2017.

5.15 NEW Workforce and OD strategy

Incorporate the vision and strategy into all recruitment, induction, appraisal, working life and people related policy and activities within the Trust

5.16 NEW Workforce and OD strategy

Develop and incorporate the associated values and behaviours into job specifications and descriptions and selection processes

5.17 NEW Workforce and OD strategy

Ensure robust arrangements are in place for effective performance management and good quality appraisal of individuals

Mark Preston

5.18 NEW Workforce and OD strategy

Develop clarity on how to be an effective leader and manager in the Trust and what staff should expect from their managers and leaders

Mark Preston

Nathaniel Johnston

On-going management training is available across the Trust (i.e. Human Factors, Lead for Leaders, Effective Management, etc.). The national guidance on leadership ('Developing People Improving Care'), has been reviewed and the Trust have / are implementing relevant initiatives from this where relevant. A review of leadership development is planned for 2017/18.

5.19 NEW Workforce and OD strategy

Integrate our vision and values into our learning programmes as core Mark Preston to the way we do business

Nathaniel Johnston

The Trust continues to align all learning programmes with the SaSH Vision and Values.

TRUST BOARD IN PUBLIC

Date: 27th April 2017 Agenda Item: 6.1

REPORT TITLE:

Updated Rules of Procedure

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

Gillian Francis-Musanu Director of Corporate Affairs Colin Pink Head of Corporate Governance & Gillian Francis-Musanu Director of Corporate Affairs Executive Committee – April 2017

Action Required: Approval (√)

Discussion (√)

Assurance (√)

Purpose of Report: To provide the Board with an annual update of the Rules of Procedure. Summary of key issues The Rules of Procedure have been reviewed and updated to include the following:  Reference to NHS Improvement  Role of Council of Governors  Alignment of Trust Board Agenda to the Single Oversight Framework  Annual updates to Board and sub-committee and Executive Committee Terms of Reference. All changes have been highlighted in yellow. Recommendation: The Board is asked to review the annual updates and approve 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 Financial impact Patient Experience/Engagement

These are outlined within the report As pertaining to sub-committee terms of reference As pertaining to relevant sub-committee terms of reference

Risk & Performance Management

These are outlined within the report

NHS Constitution/Equality & Diversity/Communication

Outlined within the report

Attachment: Rules of Procedure â&#x20AC;&#x201C; Updated version for April 2017

2 An Associated University Hospital of Brighton and Sussex Medical School

Rules of Procedure Board of Directors Integrated Governance Systems

VERSION 11.0 - APRIL 2017 NEXT REVIEW DATE: APRIL 2018

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

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

Contents About Surrey and Sussex Healthcare

Chapter One

Introduction

Chapter Two

Governing our Business and Services

Chapter Three

Board of Directors

Chapter Four

Committees of the Board of Directors

Chapter Five

Council of Governors

Chapter Six

Audit and Assurance Committee

Chapter Seven

Nomination and Remuneration Committee

Chapter Eight

Safety and Quality Committee

Chapter Nine

Finance and Workforce Committee

Chapter Ten

Charitable Funds Committee

Chapter Eleven

Executive Committee

Chapter twelve

Risk Management Responsibilities

Appendix 1

SASH Code of Conduct

Appendix 2

Best practice guidance

102

Appendix 3

Principal NHS regulators and other bodies

103

Appendix 4

Executive Team Responsibilities

104

Surrey and Sussex Healthcare Rules of Procedure

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

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

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

Chapter One Introduction 1.1

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

1.2

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

1.3

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

1.4

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

1.5

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

1.6

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

1.7

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

Surrey and Sussex Healthcare Rules of Procedure

Chapter Two Governing Our Business and Services 2.1

Overview

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

2.2

Summary

The Board of Directors governs the Trust business including the delivery of the strategies it sets by seeking assurance that the managerial systems the Chief Executive Officer has in place deliver the desired outcomes and enable effective and timely reporting of significant issues that threaten its objectives. The Trust has established a Council of Governors who will work with the Trust in a variety of ways. . The responsibilities of the Council of Governors of an NHS Trust are set out in the NHS Improvement Code of Governance and the Health and Social Care Act 2012. . The CEO has aligned his accountability framework and decision making authorities to the line management structures in place that deliver the day to day business. The alignment around the line management structures provides all staff and the Board of Directors with a simple and well understood way of communicating the Board’s objectives into day to day business and receiving feedback on how it is achieved. By this he has ensured that those with the authority can exercise it and have clear escalation processes if they are unable to do so. The escalation processes lead to individual directors and the Executive Committee on the way to the CEO as the accountable officer. It further allows staff to see where they fit in the overall strategy and how their personal objectives support the Trust to deliver its objectives.

2.3

Board of Directors Committees

The Board of Directors has authorised a number of committees to scrutinise aspects of the Trust’s business relating to safety and quality of services, finance and workforce (including

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

2.4

The Chief Executive Officer

The Chief Executive Officer is accountable for the managerial delivery of the entirety of the Trust’s business and has personal responsibility as set out in the Accountable Officer Memorandum for safeguarding public funds. To enable the Board of Directors to fulfil their statutory duties in relation to quality of services, financial management and internal control he reports on managerial performance (quality, operational and financial) in the reports received from the Executive Committees (described below). The Board of Directors recognises that whilst the CEO remains the accountable officer, he has delegated day to day responsibility for managing the delivery of aspects of the business to his executive directors. The Board of Directors therefore receives reports in the relevant director’s name to ensure it has sufficient breadth and depth of information to conduct its business. However, the Board is aware that it is the CEO that is being held to account at all times for the Trust’s performance across all aspects of its business. At all levels in the Trust below Board of Directors committee level, the CEO has managerial systems in place to deliver the business. The Board of Directors governs by measuring the effectiveness of these managerial systems in delivering the required outcomes and addressing adverse performance in any area. The Chief Executive leads the Executive Team who are responsible for linking the strategic direction with operational delivery and for ensuring coordination of all functions of the Trust.

Surrey and Sussex Healthcare Rules of Procedure

Meeting on a weekly basis membership includes all executive directors and clinical chiefs of service. The Executive Team reports to the Trust Board through the Chief Executive Officer.

2.5

The Executive Committee

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

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

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

2.6

Committees and Groups

The Executive Committee is responsible for ensuring that it is enabled to take effective decisions in relation to its focus (strategy, quality and risk or performance) as it has authorised an infrastructure of groups reporting to it that provides the expert trust wide view of an aspect of the service relevant to its terms of reference. (e.g. IPCAS).

The authorised managerial groups are focused on providing expertise in an aspect of business, co-ordinating the trust wide approach especially in relation to improving systems, quality, safety and performance. These groups are either task and finish groups or advisory groups. They are not accountable for delivering trust performance of any required standard as this remains a line management accountability of day to day service delivery.

2.7

Corporate Directorates

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

2.8

Clinical Divisions

There are four clinical divisions with each one being led by a Chief of Service. The Chief of the Division has single point of accountability for all aspects of divisional performance: quality, operational, financial and workforce to the relevant executive director. The CEO has required that the Chief must be a clinician to enable clinical leadership and to ensure that they can be held accountable for quality of services.

Surrey and Sussex Healthcare Rules of Procedure

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

2.9

Staff

All staff have job descriptions that explain their responsibilities and accountabilities in relation to their roles. In addition to this staff in professional groups have additional standards and accountabilities set by their relevant professional body.

Staff are organised within the division in corporate directorates with some staff also being in clinical divisions. All staff has line managers to whom they are responsible to and who are accountable for working with each member of staff to assess their personal performance, developmental needs and impact on service users. Staff at all levels in the organisation should work within a framework of Trust policies which sets out expectations in respect of relevant trust processes.

2.10 Governance Structure SASH Corporate Governance Structure / Accountability Framework 1 Audit & Assurance

Council of Governors

Board of Directors

Safety & Quality

Finance and Workforce

Nomination & Remuneration

Charitable Funds

Board committees

Corporate governance Management

Accountability level Management Committees / Groups

CEO

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

POLICIES

Corporate Directorates

Clinical Divisions

Specialties

INFORMATION

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

Staff

Surrey and Sussex Healthcare Rules of Procedure

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

3.1

Finance and Workforce

Charitable Funds

And Workforce and Workforce

Summary purpose

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

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

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

the safety and quality of services;

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

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

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

3.2

Self-regulation

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

Surrey and Sussex Healthcare Rules of Procedure

3.3

Membership of the Board of Directors

3.3.1 Currently the Board of Directors comprises: (i) A non-executive Chairman with a second and casting vote if necessary; (ii) Five non-executive Directors (iii) The Chief Executive and Accountable Officer; (iv) Chief Finance Officer (v) Medical Director (vi) Chief Nurse (vii) Chief Operating Officer (viii) Designate non-executive Director (non-voting) (ix) Associate non-executive Director (non-voting) (x) (xi) (xii)

Director of Corporate Affairs & Company Secretary (Non-voting) Director of Organisational Development & People (non-voting) Director of Facilities and Information (non-voting)

3.3.2 The Board of Directors shall appoint one of the independent non-executive directors to be the Senior Independent Director (SID). The SID shall be available to employees if they have concerns which contact through the normal channels of Chairman, Chief Executive or Chief Finance Officer has failed to resolve or for which such contact is inappropriate. The Clinical non-executive Director has been nominated as the SID. 3.3.3 Other senior employees may be required to attend the Board of Directors for individual agenda items as the Board of Directors considers appropriate.

3.4

Roles and Responsibilities

3.4.1 Role of the Chairman As leader of the Board, the Chair has the overarching responsibility for ensuring that under his guidance the organisation meets its planned objectives for service delivery and clinical governance and has a clear understanding of its culture and values. The Chair will ensure that the Board establishes a proper communication strategy to keep all its stakeholders informed. Some of the communications which need to be established are to staff and their Trade Unions; to the local community; to reference groups established to obtain the views of patients, service users and carers; the local media; to elected representatives, including MPs and local councillors; to overview and scrutinise committees; the voluntary sector; and the wider health and social care community. The Board can only be effective if it is well informed. The Chair will facilitate the proper flow of information between executives and non-executives; between the Board and other partners in the health economy; and between the Department of Health (DoH) and the Board when new policies and priorities need to be disseminated.

Non-executives will also need regular updates on the results and outcomes of strategies to keep them abreast of the organisation’s performance. The Chair will ensure that this information is timely and sufficiently comprehensive, but without including unnecessary operational detail that the Board does not need.

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

Surrey and Sussex Healthcare Rules of Procedure

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

3.5

Chairman and Chief Executive: Division of responsibility

Chairman of the Board of Directors

Chief Executive

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

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

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

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

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

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

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

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

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

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

Surrey and Sussex Healthcare Rules of Procedure

Chairman of the Board of Directors

Chief Executive

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

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

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

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

ď&#x201A;ˇ A schedule of matters reserved to the Board of Directors for its decision; and ď&#x201A;ˇ Terms of reference for each Board Committee and other Board of Director policies and procedures.

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

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

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

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

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

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

3.6

Unitary Board

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

3.7

Meetings of the Board of Directors

3.7.1 The Board of Directors shall meet at least ten times a year (including Board Seminars). The meeting shall be held in the last week of each month1 (except December, when the meeting shall be in the second week) in order to ensure timely consideration of performance and financial information relating to the previous month. The meeting shall occur following the completion of the Board Committee meetings taking place that month (Audit and Assurance Committee, Safety and Quality Committee and Finance and Workforce Committee as programmed) to ensure that any matters that the Chairmen of these Committees believe need to be considered by the Board of Directors are done so on a timely basis. 3.7.2 The Board of Directors shall meet in public at least 6 times a year. It reserves the right to exclude members of the press and public to consider confidential business, publicity on which would be prejudicial to the public interest (as defined in the Public Meetings Act 1960). When exercising this provision, the Chairman presiding at the meeting shall summarise the nature of the business to be considered in closed session. 3.7.3 No business shall be transacted at a meeting unless a quorum is present, which requires at least one third of the total number of the Board of Directors to be in attendance including not less than one non-executive director and one voting executive director. 3.7.4 The Chairman may, if necessary, exclude any member of the press or public from a meeting if they are interfering with or preventing the proper conduct of a meeting by exercising the relevant power in the Public Meetings Act 1960.

3.8

Standing agenda of the Board of Directors

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



annual approval of strategic plan and budget;



annual approval of financial accounts;



annual approval of quality accounts;



review of Assurance Framework;

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

Surrey and Sussex Healthcare Rules of Procedure



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



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



3.9

SASH Code of Conduct

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

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

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

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

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

the names of: (a)

every member present at the meeting;

(b)

any other person present; and

(c)

any apologies tendered by an absent member;

(ii)

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

(iii)

any declaration of interest.

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

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

Surrey and Sussex Healthcare Rules of Procedure

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

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

(vii) (viii)

review of the Charitable Funds’ Annual Report; and Information Governance including toolkit attainment.

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

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

2. Membership, Chairmanship and Quorum (a)

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

(b)

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

(c)

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

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

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

(b)

Attendance

Surrey and Sussex Healthcare Rules of Procedure

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

(c)

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

(d)

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

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

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

5. Committees of the Board 

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



The Audit and Assurance Committee is constituted to provide the Board of Directors with an independent and objective review of its system of internal control. The Nominations and Remuneration Committee has delegated board responsibility for agreeing and setting the remuneration of the executive team. The Charitable Funds Committee acts independently of the Trust’s Board but shall report to the Trust’s Board for information and therefore has delegated responsibility for the Trust’ charitable funds.

 



The Finance and Workforce Committee has delegated responsibility within any budgetary restrains imposed by the Board of Directors, to appoint external professional advisors, and to commission or purchase any relevant reports, surveys or information which it deems to be necessary. Approve the initiation of projects greater than £1m The Safety and Quality Committee has delegated authority to ensure the ongoing development and delivery of the Trust’s Safety and Quality Strategy and that this drives the Trust’s overall strategy.

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

Surrey and Sussex Healthcare Rules of Procedure

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

All meetings

Quarterly

Biannually

Annually

General Business 1.

Declaration of Interests



Reports from Board Committees



Annual reports from Board Committees



Committee and Board Attendance report



Clinical Presentation & Patient Story



Strategy



Annual Plan

Foundation Trust update

Updated Estates Strategy



Updated IT Strategy



10. Updated HR & OD Strategy



11. Board Succession planning



12. Corporate Objectives



13. Trust annual report



14. Business Planning workshop



Safety & Quality 15. Staff Survey Results



16. Patient Survey Results



17. Health and Safety report



18. Quality Account



19. Security Management report



20. Emergency Planning report



Performance 21. Integrated performance & quality report (IPQR)



Finance 22. Approval of annual accounts



23. Sign-off annual budget



24. Sign-off annual capital plan



25. Auditors annual report



26. Finance report (part of IPQR)



27. Capital report (part of IPQR)



28. Review of SOs and SFIs



Trust Board

All meetings

Quarterly

Biannually

Annually

Risk and Regulatory 29. Assurance Framework & Significant Risk Register



30. Assurance Framework updated with new objectives



31. IG annual report



32. Registration update

 

33. Equality and Diversity report

Surrey and Sussex Healthcare Rules of Procedure

Board of Directors: Standing Agenda 1

General Business Chairman’s welcome and apologies for absence Declaration of interests Minutes of previous meeting and Actions Chairman’s Report Chief Executive’s Report Board Assurance Framework and Significant Risk Register

Quality of Care Clinical Presentation & Patient Story Safety & Quality Committee Chair Report Safety & Quality Indicators Safer Staffing and Care Hours Per Patient Day Serious Incident Report Other reports relating to quality of care

Operational Performance Integrated Performance Report Operational & Access Performance Indicators

Finance and Use of Resources Finance and Workforce Committee Update

Workforce Performance Indicators Finance Indicators

Strategic Change Regulatory update (e.g. CQC Risk Profile)

Update on strategic issues

Leadership and Improvement Capacity

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

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

Surrey and Sussex Healthcare Rules of Procedure

Chapter Four Committees of the Board of Directors 4.1

Key duties of Board Committees and reporting timetable

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

Board of of Board Directors Directors Audit and Assurance Audit

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

Nomination and Remuneration

For Executive Directors:

      

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

Safety and Quality

   

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

Finance and Workforce

 

  

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

Charitable Funds

   

Safe custody Compliance with legacies Accounts Income generation

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

4.2

Reporting arrangements

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

Audit and Assurance Committee

Nomination and Remuneration Committee

Safety and Quality Committee

Finance & Workforce Committee

Receives papers from:

Receives minutes from:

Submits minutes to:

Submits annual reports to:

4.3

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

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

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

■ N/a

■ Board of Governors (on establishment)

■ Board of Directors

■ On achieving FT status, NHS Improvement and Parliament

■ Board of Directors

■ Director Human Resources ■ External advisors

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

■ Executive Committee Quality & Risk

■ Executive directors ■ Senior Finance Team ■ Budget holders

■ N/a

Principles of Committees

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

4.4 31

Conduct

Surrey and Sussex Healthcare Rules of Procedure

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

4.5

Attendance

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

4.6

Appointment to Committees

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

4.7

Administration

4.7.1 Agenda for all meetings shall be reviewed by the Chairman of the Committee and shared with members ten working days ahead of each meeting unless a variation is stipulated in the Committeeâ&#x20AC;&#x2122;s terms of reference. 4.7.2 Papers for all meetings shall be made available no later than five working days in advance of each meeting unless a variation to this is stipulated in the Committeeâ&#x20AC;&#x2122;s terms of reference. Papers shall be prepared in accordance with the Board and Committee paper template. 4.7.3 Papers shall only be tabled at meetings in exceptional circumstances and by agreement with the Chairman of the Committee. 4.7.4 The agenda of the meeting shall be reviewed to ensure that only tasks defined within the Committee terms of reference are included. 4.7.5 All Committee members shall undertake defined self-assessment procedures at least annually.

4.8

Decision making

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

4.9

Minutes of meetings

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

Surrey and Sussex Healthcare Rules of Procedure

4.9.3 The record of the minutes shall include: (i)

the names of: (a)

every member present at the meeting;

(b)

any other person present; and

(c)

any apologies tendered by an absent member;

(ii)

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

(iii)

any declaration of interest.

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

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

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

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

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

NAME OF GROUP

Council of Governors 1.1.

AUTHORITY

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

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

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

•

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

•

Influence the forward plans of the Trust.

COMPOSITION OF THE COUNCIL

2.1

The Chair

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

Membership of the Council of Governors

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

Surrey and Sussex Healthcare Rules of Procedure

Elected Governors

Number of Governors

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

1 3 2 3 3 1 1 14

Patient

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

1 1 1 1 4

Total elected Governors

Appointed Governors Name

Number of Governors

Surrey County Council

West Sussex County Council

Crawley CCG

Horsham and Mid Sussex CCG

East Surrey CCG

Surrey Downs CCG

Brighton & Sussex Medical School

Council for Voluntary Services

Total Appointed Governors

Summary of Council Total Elected Governors

Total Appointed Governors

Total Number of Governors

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

QUORACY

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

Surrey and Sussex Healthcare Rules of Procedure

MEETINGS OF THE COUNCIL

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

ROLE OF THE GROUP

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

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



Influence the forward plans of the Trust.

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

5.3

Duties of the Council of Governors

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

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



Influence the forward plans of the Trust



To appoint and, if appropriate, remove the chair



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



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



To approve the appointment of the Chief Executive



Appoint the Deputy Chair of the Trust



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

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



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



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



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



Developing, approving and implementing the Trusts Membership Development Strategy



Amendments to the Constitution



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



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



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

Surrey and Sussex Healthcare Rules of Procedure



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



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



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



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



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

RELATIONSHIP WITH OTHER GROUPS AND COMMITTEES

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

DUTIES OF THE CHAIR

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

LEAD GOVERNOR

Post authorisation the Council of Governor will nominate one it its governors as the nominated lead governor. The role of the nominated lead governor is to facilitate direct communication between Monitor and the Council of Governors in the limited circumstances where it may not be appropriate to communicate through the normal channels.

SENIOR INDEPENDENT DIRECTOR

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

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

REVIEW OF THE TERMS OF REFERENCE AND EFFECTIVENESS

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

10.

MONITORING

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

Surrey and Sussex Healthcare Rules of Procedure

Chapter Six Audit and Assurance Committee Shadow Council of Governors

Board of Directors Audit and Assurance

Nomination and Safety and Remuneration Remuneration Quality

Finance and Workforce

Charitable Funds and Workforce

Conclude the adequacy of:

    

5.1

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

Summary purpose and authority

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

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

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

5.3

Assessment of effectiveness

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

5.4

Annual Report to the Board of Directors

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

5.5

Review of Audit and Assurance Committee effectiveness

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

5.6

Review of Internal Audit effectiveness

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

Surrey and Sussex Healthcare Rules of Procedure

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

5.7

Review of External Audit effectiveness

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

Audit and Assurance Committee: Terms of Reference 1.

Introduction

1.1

The AACs role is to develop, monitor and ensure development of integrated governance arrangements, providing assurance that bodies are well managed across the whole range of their activities. The AAC shall review the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the organisation’s activities (both clinical and non-clinical), which supports the achievement of the organisation’s objectives. These terms of reference build on the work of the Cadbury Committee, Greenbury Reports and the reports by Smith, Higgs and Turnbull (reference “Combined Code – Principles of Good Governance and Code of Best Practice”) and subsequent guidance and best practice in the private and public sector.

Constitution

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

3.1

Membership

The Committee shall be appointed by the Board from the non-executive directors of the Trust and shall consist of not less than three members. A quorum shall be two members.

3.2 3.3 3.4

The Board will appoint one of the members to be Chair of the Committee.

Attendance

4.1 4.2 4.3

4.4

5.1 5.2

The Chairman of the organisation shall not be a member of the Committee.

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

Frequency

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

Surrey and Sussex Healthcare Rules of Procedure

6.1 7.1

7.1

Authority

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

Duties

The duties of the Committee can be categorised as follows:

Governance, Risk Management and Internal Control

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

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

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

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

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

the Trustâ&#x20AC;&#x2122;s internal control framework, supported by the other subcommittees of the Board.

7.1.2

In carrying out this work the Committee will primarily utilise the work of internal audit, external audit and other assurance functions to ensure review is external, but will not be limited to these. It will also seek reports and assurances from directors and managers as appropriate, concentrating on the overarching systems of integrated governance, risk management and internal control, together with indicators of their effectiveness.

7.1.3

In relation to the Board Assurance Framework the committee will use this to guide its work and will provide assurance that the controls and actions taken to address any gaps are robust and support the delivery of corporate objectives.

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

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

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

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

ensuring the internal audit function is adequately resourced

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

7.3 External Audit The Board has appointed the Audit Committee as its Audit Panel which will review and make a recommendation to the Trust Board on selection of external audit provision. The Committee shall review the work and findings of the External Auditor appointed by the Audit Commission and consider the implications and management’s responses to their work. This will be achieved by: -

As the Audit Panel the Committee shall carry out ongoing review of External Audit service provision.

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

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

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

7.4 Other Assurance Functions 7.4.1 The Committee shall review the findings of other significant assurance functions, both internal and external to the organisation, and consider the implications to the governance of the organisation. These will include, but will not be limited to, any reviews by Department of Health Arms Length Bodies or Regulators/Inspectors (e.g. CQC, NHS Litigation Authority, etc.), professional bodies with responsibility for the performance of staff or functions (e.g. Royal Colleges, accreditation bodies, etc.), reports by the Trust’s local counter fraud specialist. 7.4.2 In addition, the Committee will review the work and function of other committees, working groups and senior responsible officers within the organisation, whose work can provide relevant assurance to the Committee’s own scope of work.

Surrey and Sussex Healthcare Rules of Procedure

7.4.3

In reviewing work of around clinical risk management, the Committee will wish to satisfy itself on the assurance that can be gained from the clinical audit function and outcome measures from the Trusts clinical benchmarking systems.

Management

Financial Reporting

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

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

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

changes in, and compliance with, accounting policies and practices

unadjusted mis-statements in the financial statements

major judgmental areas

significant adjustments resulting from the audit

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

10. Reporting

10.1 The minutes of the Committee meetings shall be formally recorded by the Trust Secretary and submitted to the Board. The Chair of the Committee shall draw to the attention of the Board any issues that require disclosure to the full Board, or require executive action. 10.2 The Committee will report to the Board annually on its work in support of the Annual Governance Statement, specifically commenting on the fitness for purpose of the assurance framework, the completeness and embedding of risk management in the organisation, the integration of governance arrangements.

11. Other Matters

The Secretary to the Committee shall be the Head of Corporate Governance whose duties in this respect will include the following, shall support the Committee administratively:

Agreement of agenda with Chairman and attendees and collation of papers

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

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

Advising the Committee on pertinent matters

Audit and Assurance Committee: Standing Agenda 1

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

Risk Management Board Assurance Framework Risk Management Systems

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

Specific Duties Review annual accounts Reviews losses waivers and special payments

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

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

Surrey and Sussex Healthcare Rules of Procedure

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

March 1.

Plan how to discharge Audit Committee duties

Self-assess Committee’s effectiveness

Review Committee’s terms of reference

Produce annual Audit Committee report

Private discussions with internal and external audit

May

July

Sept

Nov

Jan 

 



 













Risk Management 6.

Review the Board Assurance Framework in Full





Review the risk management system in full

Receive the Significant Risk Register



 











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







12. Review Internal Controls and work plan 13. Review specific elements of internal control



 





14. Review of other reports and policies as appropriate – for example, changes to standing orders 15. Review of audited annual accounts and ﬁnancial statements









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



Specific Duties



 



17. Review of losses and special payments



Independent Assurance 18. Receive sources of assurance of external assurance



19. Review and approve annual internal audit plan



20. Review and approve internal audit terms of reference



21. Review the effectiveness of internal audit



22. Review internal audit progress reports 23. Receive annual internal audit report and associated opinions







 



 

28. Receive the External Auditor’s annual audit letter



29. Review and approve annual counter fraud plan





 

 

32. Review the effectiveness of the Local Counter Fraud Specialist





31. Review the organisation’s assessment against CFSMS qualitative assessments

33. Receive counter fraud annual report to AAC



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

30. Review counter fraud progress reports





25. Review the effectiveness of external audit





24. Agree external audit plans and fees

26. Review external audit progress reports



 

Surrey and Sussex Healthcare Rules of Procedure

 



Chapter Seven Nomination & Remuneration

Committee

Board of Directors

Shadow Council of Governors

Audit and Assurance Nomination and Safety and Remuneration Remuneration Quality

Finance and Workforce

Charitable Funds and Workforce

For Executive Directors:

      

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

Summary purpose and authority

6.1

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

6.2

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

6.3

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

6.4

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

6.5

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

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

Nomination and Remuneration Committee: Terms of Reference 1.

Constitution

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

Membership

The Committee comprises:  

The Board Chair All Non-Executive Directors

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

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

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

Authority

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



Seek advice from whatever source it deems to be appropriate.



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

Surrey and Sussex Healthcare Rules of Procedure

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

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



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



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



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



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

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

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

Nomination and Remuneration Committee: Standing Agenda

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

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

Nominations & Terminations Selection / termination process Succession planning

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

Surrey and Sussex Healthcare Rules of Procedure

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

Nominations Committee

and

Remuneration May

Sept

Nov

√

Prepare an annual report to the Board of Directors

√

Update on Executives objectives

Update from CEO Objectives/Performance issues/concerns

√

on Executive highlighting any

Evaluation of performance and remuneration proposals

March

√

Chapter Eight Safety and Quality Committee Shadow Council of Governors

Board of Directors

Audit and Assurance Safety and Nomination and Remuneration Quality Remuneration

Finance and Workforce

Charitable Funds and Workforce

Scrutinise and review:

    

7.1

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

Purpose and authority

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

Surrey and Sussex Healthcare Rules of Procedure

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

7.2

Quality accounts

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



Review of services



Participation in clinical audits



Reviewing Reports of national and local Clinical Audits



Participation in clinical Research



Use of the CQUIN payment framework



Statements from the regulator



Data quality including clinical coding error rate

Safety and Quality Committee: Terms of Reference 1.

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

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

Membership and Attendance The members of the Committee shall be: (i) (ii) (iii) (iv) (v) (vi)

The Chairman and three non-executive directors appointed by the Board of Directors; Medical Director or Deputy; Chief Nurse or Deputy; Chief Operating Officer or Deputy Chief Financial Officer or Deputy. Clinical Chiefs of Service (6 including, Chief of Education and Chief Clinical Informatics Officer )

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

Divisional Chief Nurses Risk and Patient Safety Lead ;

Surrey and Sussex Healthcare Rules of Procedure

(iv)

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

(v) (vi)

Clinical Governance Compliance Manager Corporate Governance Manager

(iii)

(vii)

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

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

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

(ii)

becomes inquorate during the course of the meeting,

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

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

Duties The Committee shall support the Board of Directors with:

6.1.

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

6.2

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

6.3

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

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

6.4

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

Surrey and Sussex Healthcare Rules of Procedure

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

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

6.6

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

Reporting arrangements

7.1

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

7.2

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

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

Review

8.1

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

Surrey and Sussex Healthcare Rules of Procedure

Safety and Quality Committee: Standing Agenda 1

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

Strategic & Regulatory

Safety

Patient Experience

Quality

General AOB Issues to report to Board Date of next meeting

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

Quarterly

Biannually

Annually

Strategic & Regulatory 1

Approve Trust’s Safety and Quality Strategy

√

Approve Trust's Quality Account

√

Francis implementation

√

CQC Compliance/ regulatory updates

√

Safety 5

Incident management

√

Infection, prevention and control

Mortality

Claim handling

√

Safeguarding

√

√ √

Patient Experience 10

Patient Opinion

√

Complaints

√

Patient groups (by demographics or condition)

√

Quality of Care

Clinical audit programme and audit results

Progress of clinical audit programme

Evidence at point of care

NICE Compliance

Information governance

Data Quality

√ √ √ √ √ √

Surrey and Sussex Healthcare Rules of Procedure

Chapter Nine Finance and Workforce Committee

Shadow Council of Governors

Board of Directors

Audit and Assurance Finance and Workforce

Nomination and Safety and Remuneration Remuneration Quality

    

8.1

Charitable Funds and Workforce

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

Summary purpose and authority

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

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

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

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

Surrey and Sussex Healthcare Rules of Procedure

8.2

Impact on foundation trust application

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

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

Background

1.1

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

1.2

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

Authority

2.1

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

2.2

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

Membership and Attendance

3.1

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

The members of the Committee shall be:



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



Chief Financial Officer



Director of Corporate Affairs



Director of Human Resources



Director of Information and Estates



Chief Nurse

Surrey and Sussex Healthcare Rules of Procedure

ď&#x201A;ˇ

Chief Operating Officer

3.2

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

3.3

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

3.4

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

Quorum

4.1

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

4.2

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

4.3

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

4.4

Where a Committee meeting: (i)

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

(ii)

becomes inquorate during the course of the meeting,

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

Meetings

5.1

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

5.2

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

5.3

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

5.4

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

5.5

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

5.6

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

Duties

6.1

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

(i)

The volume and complexity of activity and performance against Plans

(ii)

Reasons for variances, the impact financially and correct adverse performance

(iii)

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

(iv)

Effectiveness of contractual processes, contractual notices and outputs with commissioners

(v)

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

(vi)

Cashflow management and Working Capital planning

(vii)

Major judgmental areas

delivery of actions to

The Committee shall consider and review financial reports focusing on:

6.2

(i)

Delivery to plans

(ii)

Reasons for variances and delivery of actions to correct adverse performance

(iii)

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

(iv)

Delivery of Trust savings plans

(v)

Operation of Trust budgetary procedures and compliance with SOFIs

(vi)

Major judgmental areas

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

Surrey and Sussex Healthcare Rules of Procedure

6.3

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

6.4

the Trust’s annual financial targets; and the preparation of the annual budget prior to its submission to the Board of Directors.

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

6.5

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

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

b. c.

establish the overall methodology, processes and controls which govern investments;

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

6.6

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

Other duties

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

External advice

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

Surrey and Sussex Healthcare Rules of Procedure

Reporting arrangements

7.1

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

7.2

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

7.3

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

7.4

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

Review

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

Welcome and Apologies for Absence Apologies

General

Declarations of Interest 2

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

General

Actions from Action tracker - for information 3

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

Monthly as required

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

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

Annual

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

Finance Financial Performance - for assurance

Monthly

CIP Update - for assurance

Monthly

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

Surrey and Sussex Healthcare Rules of Procedure

Monthly

Capital & Estates Capital & Estates Report - for assurance

Monthly

IT IT Report - for assurance

Monthly

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

General

Next Meeting

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

Minutes from previous meeting

General

Productivity

Quarterly

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

Monthly as required

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

Monthly Quarterly Monthly

Marketing Market Development Plan - for approval

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

Annual Monthly as required Monthly

General Any Other Business Next Meeting

General

Chapter Ten Charitable Funds Committee

Shadow Council of Governors

Board of Directors

Audit and Assurance Nomination and Safety and Remuneration Remuneration Quality

Charitable and Workforce Funds

Investment and Workforce

   

9.1

Safe custody Compliance with legacies Accounts Income generation

Summary purpose and authority

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

Surrey and Sussex Healthcare Rules of Procedure

9.2 Charitable Funds Committee: Terms of Reference 1.

Background

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

Constitution

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

Relationships

Board upwards for information only. No sub committees.

Membership

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

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

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

Attendance 

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



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



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

Administration 

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



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



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



Review Date July 2013

Frequency 

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



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



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



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

Authority

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

Surrey and Sussex Healthcare Rules of Procedure

The Committee delegates authority as follows: 

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



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



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



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



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

Monitoring Effectiveness

9. 

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

Core Duties 1.

Safe Custody •

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

•

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

•

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

Compliance •

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

•

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

•

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

•

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

•

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

Investments & fund raising •

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

•

Consider future charitable campaigns including the nature of events and objectives

•

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

Accounts and similar requirements •

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

•

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

•

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

•

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

Income generation •

Other functions •

To consider generation of funds to increase income.

To consider matters requested by the Trust Board.

Surrey and Sussex Healthcare Rules of Procedure

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

    

Committee

Strategic priorities Operational Issues Current Divisional Issues Divisional Development Plans Health and Safety

Executive Operations Committee for Quality & Risk - -

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

Sub committees

? ? ?

    

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

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

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

Membership and attendance

1.1

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

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

In Attendance:    1.2

The members of the Executive Committee for Quality & Risk (ECQR) shall be:                

Head of Communications (Executive Committee) Other clinicians and managers at the request of the committee Executive PA (notes)

Surrey and Sussex Healthcare Rules of Procedure

ď&#x201A;ˇ

The Virtual Team (Head of Corporate Governance, Head of Performance, Clinical Governance Compliance Manager, Patient Safety & Risk Lead)

1.3

The Chairman of the Executive Committee & ECQR shall be the Chief Executive. The Chairman of the committee reserves the right to delegate chairing of the meeting to any standing member on a rotating basis with appropriate notice.

1.4

If an Executive Committee & ECQR member is unable to attend a meeting, they shall send their apologies in advance to the Secretary and arrange for no more than one deputy to attend in their absence to represent the member by presenting information, reports etc.; however deputies will be able to vote on behalf of the committee member.

1.5

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

Secretary of the Executive Committee

2.1

The Director of Corporate Affairs will ensure that an agenda and action notes will be taken and circulated at least three days in advance of the meeting for both the Executive Committee and the Executive Committee for Quality & Risk.

2.2

The Director of Corporate Affairs will be responsible for developing an annual plan for the agenda with the Committee which fits with the Trusts annual business planning cycle.

Quorum

3.1

The quorum necessary for the transaction of business shall be one third of the membership of the Executive Committee with at least two Clinical Chiefs and two Executive Directors attending.

3.2

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

3.3

Where an Executive Committee meeting: (i)

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

(ii)

becomes inquorate during the course of the meeting,

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

Meetings

4.1

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

4.2

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

Notice of meetings

5.1

Meetings of the Executive Committee shall be held weekly at the request of the Chief Executive.

5.2

Unless otherwise agreed, notice of each meeting confirming the venue, time and date together with an agenda of items to be discussed, shall be forwarded to each member of the Executive Committee no later than two days before the date of the meeting. Supporting papers shall be sent to Executive Committee members and to other attendees, as appropriate, at the same time. Late papers will only be accepted in exceptional circumstances unless they have been requested by the Committee at short notice.

Decisions of the Executive Committee

6.1

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

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

6.2

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

6.3

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

6.4

The minutes of the meeting shall record only the numerical results of a vote, showing the numbers for and against the proposal and noting any abstentions. The minutes shall be conclusive evidence of the outcome. Votes shall not normally be attributed to any individual member of the Executive Committee, but any member

Surrey and Sussex Healthcare Rules of Procedure

may require that their particular vote be recorded provided that he asks the Chair presiding immediately after the item is concluded. 6.5

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

Minutes of meetings

7.1

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

7.2

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

7.3

The record of the minutes shall include: (i)

the names of: (a)

every member of the Executive Committee present at the meeting;

(b)

any other person present; and

(c)

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

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

any declaration of interest.

7.4

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

7.5

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

7.6

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

Duties

The Executive Committee shall: 1.

deliver the Trustâ&#x20AC;&#x2122;s core Strategies, national outcomes framework and local Key Performance Indicators;

at least annually, review and refresh the Trustâ&#x20AC;&#x2122;s vision, values, strategic intent and strategic objectives for agreement by the Board of Directors;

review performance against the Trust’s priorities;

review on a quarterly basis progress against the annual plan; ;

review and agree with Clinical Divisions and Corporate Directorates annual business plans and how these inter-relate;

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

review and, if appropriate, approve recommendations on new schemes that demonstrably fit with the Trust’s vision and values ; and

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

review arrangements and agree action to address variations from compliance with the regulatory and statutory regime, including contracts with commissioners; receive and review regular financial reports; receive, and review capital spend and prioritise improvement plans;

10.

oversee sound systems of internal control;

11.

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



Patient Safety Committee



Clinical Effectiveness Committee



Access and Responsiveness Committee



Patient Experience Committee



Workforce Committee

Surrey and Sussex Healthcare Rules of Procedure



Clinical Information Technology Committee

12.

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

13.

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

14.

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

15.

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

Conflicts of interest

Executive Committee members shall comply with the SASH Code of Conduct and declare any conflicts of interest in relation to agenda items. 10.

Reporting responsibilities

The Chief Executive shall determine and communicate to the Chairman of the Board of Directors how the business of the Executive Committee shall be reported to the Board of Directors and/or its Committees, which, as a minimum, shall include periodic reports on the delivery of an agreed set of corporate objectives set out in the Trust’s business plan from time to time. In the case of risk management, this shall be at least quarterly. 11.

Review

The Executive Committee shall, at least once a year, review its own performance, membership and terms of reference to ensure it is operating at maximum effectiveness. 12.

Authority

12.1

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

12.2

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

12.3

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

12.4

(i)

to obtain any outside legal or other professional advice; and

(ii)

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

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

Approve revenue business cases with an annual value up to ÂŁ1.0m (expenditure, so not net of income);

(ii)

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

(iii)

Approve capital business cases with an annual value up to ÂŁ1.0m;

(iv)

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

Reviewed: January 2017 Next Review: January 2018

Surrey and Sussex Healthcare Rules of Procedure

Chapter Twelve Risk Management Responsibilities 11.1

Introduction –Accountability and Responsibilities for Managing Risk

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

SASH Corporate Governance Structure / Accountability Framework f Board of Directors

1 Audit & Assurance

Safety & Quality

Finance and Workforce

Nomination & Remuneration

Council of Governors Charitable Funds

Board committees

Corporate governance Management

Accountability level Management Committees / Groups

CEO

Executive Committee and ECQR

INFORMATION

Corporate Directorates

Clinical Divisions

Specialties

POLICIES

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

Staff

Figure 1 – SaSH accountability framework for managing risk 11.2

Board of Directors – Level 1

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

11.3

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

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

Governing Risk

11.4.1 The role of the board According to the FTSE Company2, “The role of boards is to govern, not to manage. It is about setting overall direction, establishing boundaries and controls, recruiting and motivating talented executives and overseeing their operation of the business.” Figure 2 sets out how the management of risk is governed at SASH under the auspices of the board of directors and the board’s audit and assurance committee. The Board monitors and reviews the trust risk register taking assurance as to the organisation’s management of risk. The Audit and Assurance Committee is responsible for oversight of the entire system of internal control within SASH and, as part of this responsibility, will provide independent assurance to the board on the effectiveness of the organisation’s system for risk management.

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

Surrey and Sussex Healthcare Rules of Procedure

SIC AGS CEO

BOARD ‘Top-down’ population External Audit

Audit Committee

RISK REGISTER Location/ Management unit

Risk Ref.

1 2 3 4

Internal Audit

BAF

5 6 7

Dingley Dell Ambulance Trust

Page Risk Assessor

Bodmin Moore

ADEQUACY OF EXISTING CONTROLS

DESCRIPTION OF RISK

Back injuries to ambulance staff Patient falling out the back of an ambulance Damage (and possible personal injury) to new ambulances with power-assisted steering Dangerous exhaust fume build up in main ambulance depot Trust bankrupcy through policy of not charging for providing cover at local fairs Public outrage at charging for providing local fair cover 'Putting people at risk' at fair through inadequate ambulance cover Etc.

Date

14/10/99

RISK ASSESSMENT Consequences Likelihood

Date of 1/12/99 Review RISK RATING

RISK

(C)

(l)

(Cxl)

RANKING



3 4

4 1

12 4

3 6



A = Adequate I = Inadequate U = Uncertain

Multiple fatalities 5 Single fatality 4 Major 3 Serious 2 Minor 1 Negligible 0

Certain 5 Likely 4 Possible 3 Unlikely 2 Rare 1 Impossible 0

  

Healthcare Safety & Quality Governance Committee Committee

TRUST RISK REGISTER

‘Bottom-up’ population

Figure 2– The trust risk register and the board 11.5

The Board Assurance Framework (BAF)

The Board Assurance Framework (BAF) describes the principal risks that relate to the organisation’s strategic objectives and is intended to provide assurances to the Board in relation to the management of risks that threaten the ability of the organisation to achieve these objectives. The BAF provides the Board with information on managing principal risks that provides assurances on the management of risk in relation to key organisational objectives. Wider consideration of the Trust risk register, through suitable reporting on significant risks to the Board by the executive directors, provides the board with more comprehensive assurances on management of the totality of risk facing SASH. 11.6

The Annual Governance Statement (AGS)

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

Appendix 1 SASH Code of Conduct 1.

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

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

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

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

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

Surrey and Sussex Healthcare Rules of Procedure

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

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

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

Equality and Diversity

8.1

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

8.2

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

(i)

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

(ii)

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

(iii)

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

(iv)

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

(v)

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

8.3

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

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

10.

Conflicts of interest

10.1

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

10.2

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

Surrey and Sussex Healthcare Rules of Procedure

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

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

10.4

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

10.5

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

10.6

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

10.7

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

10.8

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

10.9

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

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

remunerated employment, office or profession other than with SASH;

(ii)

other regular sources of remuneration;

(iii)

directorships, whether remunerated or not; and

(iv)

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

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

Surrey and Sussex Healthcare Rules of Procedure

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

Gifts and Hospitality

11.1

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

11.2

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

11.3

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

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

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

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

11.4

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

12.

Board and Committee Etiquette

12.1

Showing our mutual trust, respect and honesty

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

12.2

Continuing our commitment to attending and being well prepared:

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

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

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

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

Surrey and Sussex Healthcare Rules of Procedure

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

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

Encouraging Board debate:

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

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

g. We will avoid giving offence by the style of our questioning and will apologise if we have done so. h. We will strive not to take offence at, or take personally, genuine challenge by other members of the Board. i.

We will make the best use of Board time by making our contributions concise and only raising substantive issues.

l. We will make all contributions through the Chairman, and not interrupt one another. m. The Chairman will actively encourage contributions from all members during the meeting. n. We will ensure that all challenge is fairly reported in the minutes. 0. Where senior managers or clinicians have played a significant role in the preparation of a Board paper, they should be invited by the Executive Director responsible to attend the relevant part of the Board Meeting.

4.0

Maintaining confidentiality and corporate responsibility: a. We will adhere to the NHS Code of Conduct and Accountability. b. We will treat all issues on the private agenda as confidential unless agreed otherwise by the Board. c. We will all accept the principle of corporate responsibility.

10 0

d. We will seek agreement with the Chairman and/or Chief Executive before making contact with the press on the activities of the Trust.

5.0

6.0

Attendance: 

We will plan to arrive at least 10 minutes before the scheduled start of the Board and take the opportunity to talk informally to colleagues and visitors. If we are unavoidably late, we will phone to let the Chairman/Chief Executive and let them know of our expected time of arrival.



We will attend all Board and committee meetings unless there are exceptional reasons why we cannot (we expect to attend at least 80% of the meetings)



We will turn off mobile devices / phones (or put on silent when a member is on call).



We will only utilise laptops and mobile devices for access to Board papers and supplementary information relevant to the Board meeting.



We recognise our ambassadorial role at Board and Committee meetings, the Annual General Meeting and at other events.

Reviewing our performance: At the end of each Board meeting we will review: -

Whether we used our time and resources well. Whether others should have been invited for any item. What went well or what could be improved.

The Board will participate in a review of Board skills and evaluate board performance at least once per year. If any member of the Board is unhappy with any aspect of Board conduct, he or she should approach the Chairman in the first instance or the Senior Independent Director. Responsibility for ensuring Board Etiquette is observed lies with the Chairman.

10 1

Surrey and Sussex Healthcare Rules of Procedure

Appendix 2 Best practice guidance The Healthy NHS Board: Principles for Good Governance, 2013, & 2010 www.nhsleadership.org.uk/ Monitor â&#x20AC;&#x201C; Independent Regulator of NHS Foundation Trusts The NHS Foundation Trust Code of Governance, March 2013 Compliance Framework 2013 March 2010 and July 2010 amendments Managing Operating Cash in NHS Foundation Trusts, December 2012 Best Practice in Treasury Management for NHS Foundation Trusts, June 2008 Risk Evaluation for Investment Decisions by NHS Foundation Trusts, February 2006 www.monitor-nhsft.gov.uk/ Audit Commission Corporate Governance Framework, July 2009 www.auditcommission.gov.uk/SiteCollectionDocuments/MethodologyAndTools/Guidance/CorporateGove rnanceInspectionJan09update.pdf The Commissioner for Public Appointments Code of Practice for Ministerial Appointments to Public Bodies, August 2009 www.publicappointmentscommissioner.org/webapp/plugins/spaw2/uploads/files/Code%20of% 20Practice%202009.pdf Financial Reporting Council UK Corporate Governance Code, June 2010 www.frc.org.uk/documents/pagemanager/Corporate_Governance/UK%20Corp%20Gov%20C ode%20June%202010.pdf Foundation Trust Network The Foundations of Good Governance, September 2010 www.nhsconfed.org/Publications/Documents/foundations_good_governance140910.pdf KPMG â&#x20AC;&#x201C; Audit Committee Institute (ACI) A Listing of Corporate Governance Resources, November 2007 www.kpmg.co.uk/aci/

10 2

Appendix 3 Principal NHS regulators and other bodies Principal NHS regulators 

NHS Improvement (Monitor & the Trust Development Authority)

 Care Quality Commission Third parties with statutory powers (with specific remit to healthcare) 

General Chiropractic Council



General Dental Council



General Medical Council



General Optical Council



General Osteopathic Council



Health Professions Council



Nursing and Midwifery Council

 Royal Pharmaceutical Society of Great Britain. Third parties with statutory powers (with general remit) 

Charity Commission (with respect to charitable funds associated with the NHS)



Equality and Human Rights Commission



Environment Agency



Fire Authorities



Health and Safety Executive



Information Commissioner’s Office



National Audit Office

 Public Accounts Committee Third parties with statutory role but no enforcement powers (with specific remit to healthcare) 

NHS Blood and Transplant Authority



Parliamentary and Health Service Ombudsman



Medicines and Healthcare products Regulatory Agency



National Institute for Health and Clinical Excellence (NICE)

 OFSTED Third parties with no statutory role but a legitimate interest (with specific remit to healthcare) 

Clinical Pathology Accreditation Ltd



NHS Business Services Authority



NHS Litigation Authority

10 3

Surrey and Sussex Healthcare Rules of Procedure

Appendix 4 Executive Team Responsibilities Executive Directors Role

Key Responsibilities

Chief Finance Officer

    

Chief Operating Officer

   

Medical Director

      

Chief Nurse

    

10 4

Support the creation/maintenance of an NHS Trust whose services are appropriately resourced, provide good value for money and are financially sustainable in the long term. Provide financial governance and assurance. Manage the Trust’s cash and provide effective stewardship of the Trust’s resources. Provide confidence to external stakeholders about the Trust and its financial management that enhances the Trust’s reputation. Corporate responsibilities as an executive director and the delivery of organisational success through personal leadership, effective working with the executive team, Board, and, in particular, the Chief Executive Officer. Responsible for operational performance within the Trust Responsible for the planning and delivery of capacity to meet demand Emergency and Business Continuity Planning Accountable for non-nursing budgets Responsible for ensuring good clinical governance (with the Chief Nurse) and high standards of medical care Developing and implementing modern and effective clinical leadership Clinical ambassador for the Trust Ensuring clinicians have resources and structures to deliver high quality clinical care Ensure consultants job plans meet the needs of the Trust Leading the development of the Quality Account, & Clinical Strategy Ensuring that there are robust infection prevention and control systems in place to comply with the Health and Social Care Act / Hygiene Code. Professional and regulatory lead for nursing and midwifery, ensuring that the standards of practice support safe high quality care that ensures a positive patient experience. As the Director lead of Risk & Clinical Governance has responsibility for the programmes of clinical governance in the Trust. Supporting the maintenance of effective governance systems ensuring that the trust is appropriately governed. Delivery of organisational success through effective working with Board members and senior clinical colleagues Named board member for the safeguarding of children and vulnerable adults.

Role Director of Information and Estates

Key Responsibilities     

Director of Corporate Affairs



Supporting the Chairman, Chief Executive and Board in managing corporate governance Leading the FT application process , co-ordinating the delivery of required outputs and assurances Leading the legal affairs, communications and Trust Headquarters functions Company Secretary



Employee Relations



Strategic management of Recruitment Services



Occupational Health



Learning and Organisational Development



Medical Staffing



Strategy development



Business planning



Transformation



Improvement



SaSH +

  

Director of Organisational Development & People

Director of Strategy & KPO Lead

10 5

Leading the design and delivery of the Trust Health Informatics Strategy Ensuring Trust Estate and Facilities support the delivery of Safe, high-quality healthcare Leading the development and implementation of the Trust Estate Strategy Senior Information Risk Officer (SIRO) – all Trusts must have one of these at the Board Chief Knowledge Officer

Surrey and Sussex Healthcare Rules of Procedure

Safety & Quality Committee Thursday 2nd March, 12.00-14.00 AD77, East Surrey Hospital Minutes of Meeting – Part two (public) Present: Richard Shaw Alan McCarthy Pauline Lambert Caroline Warner Des Holden Paul Simpson Fiona Allsop Ed Cetti Barbara Bray Zara Nadim Victoria Daley Paula Tucker Ben Emly Kim Rayment Colin Pink Jonathan Parr Sue Moody

RS AMcC PL CW DH PS FA EC BB ZN VD PT BE KR CP JP SM

Non-Executive Director (Chair) Non-Executive Director Non-Executive Director Non-Executive Director Medical Director Finance Director Chief Nurse Chief, Cancer & Diagnostics Chief, Surgery Chief, WaCH (attendance from 13:00) Deputy Chief Nurse Deputy Chief Nurse Head of Performance Patient Safety & Risk Facilitator Corporate Governance Manager Clinical Governance Compliance Manager Clinical Quality Manager, Horsham and Mid Sussex CCG Head of Quality/Chief Nurse, East Surrey CCG

Karen Devanny KD Apologies: Katharine Horner, Alan Hall, Sarah Rafferty, Ben Mearns, Angela Stevenson (attended part one only)

Action 1 COMMITTEE BUSINESS 1.1. Chair welcomed everyone to the meeting. Apologies noted. 1.2. Minutes of the previous meeting The minutes of the last meeting were agreed as an accurate record of the meeting. 1.3. Actions Log and matters arising

C/F 7th July 2016 • Data Quality Audit (date of death) update – prioritising some of the other audits at present so this has been delayed will be able to present to SQC next month. C/F 2nd February 2017 • Highlights from Executive Committee for Quality & Risk – update on consultation with CQC – Action closed • Quality Report – 1 to 1 care in labour to be reported – covered in annual report presentation – Action closed SQC Minutes 2

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• Quality Report – pressure damage incidents were discussed at the Patient Safety Committee in February – an action plan has been provided externally but FA felt it would be helpful to bring to SQC next month.

• Patient Experience – review of assurance report proforma – due for completion May 2017 PL queried when SQC would have an update regarding the Trauma Audit and Research Network (TARN) data and how the data is being monitored. DH stated that consultant anesthetist Mark Salmon, has recently been appointed as the clinical lead for trauma, taking over from Alan James. DH confirmed that the tools and resources are now in place; the data has been monitored and is correct. RS concluded that Mark Salmon should be invited to update the committee in 3 months (June 2017). 1.4. Highlights from Executive Committee for Quality & Risk CP talked through the report, most of the detail was discussed at Board last week. The compliance with CQC domains corporate review was time consuming but felt necessary and worthwhile. The core services are in the process of completing the exercise. CP highlighted the agreement of the dementia strategy and confirmed that the Quality Account priorities are being aligned with annual priorities.

RS asked whether there were any questions on the paper. AMcC asked why there has been a change in the provider for the ‘Your Care Matters’ platform, was the relationship good. FA summarised a number of reasons for the change including; issues regarding the interpretation of healthcare needs; and the company being less responsive to the requirements of the Trust. The new provider offers a new platform that has everything and more than the previous supplier and at a cheaper price. The Trust may still be able to call it ‘Your Care Matters’ but might need to badge it differently. KD commented that there is a similar platform being developed across primary care and it would be good if there was an opportunity to work together. FA agreed that it would be interesting to explore that suggestion. RS questioned the process of review and learning regarding the crude mortality increase in death for patients with fractured neck of femur highlighted at the Clinical Effectiveness Committee. DH confirmed that Dr I Wilkinson is reviewing the cases and care pathway, he assured the committee that the numbers are not significantly high, there were 12 in the month. RS thanked DH for his clarification and noted that the committee will take further assurance from the mortality paper due for presentation next month. 1.5. Highlights from Clinical Quality Review Meeting PS presented the report although he stated he was not present at the meeting. He highlighted that the main focus was the fractured neck of femur presentation by Dr D Royale and Dr I Wilkinson. PS stated that nothing of SQC Minutes 2

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concern was raised as far as he was aware. SM confirmed she was in attendance at CQRM and no concerns were raised. RS confirmed that the committee could take assurance from the report. 1.6. CQUIN update BE gave a verbal update and confirmed that the quarterly meeting with the 3 CCGs had taken place. A number of positive areas including, achievement of the Flu Vaccine target, early achievement of E-communications and continued progress on ED Sepsis were discussed. BE concluded that some challenges remain, particularly for inpatient Sepsis.

AMcC queried whether the good flu vaccination uptake had led to fewer cases of flu and less staff sickness. BE replied that it is not possible to accurately cross-correlate the data and make any reliable conclusions. RS thanked BE and confirmed that the committee look forward to the Q4 end of year CQUIN report. 2 QUALITY PERFORMANCE 2.1 Quality Report BE drew the committeeâ&#x20AC;&#x2122;s attention to the ED 4 hour standard (page 3) that was not achieved in January but highlighted the capacity issues that the Trust experienced during this period needed to be taken into consideration. BE noted that the cancer targets were achieved there was notable improvement in falls with harm. Bed occupancy, RTT, sickness rates and staff turnover remain a challenge.

AMcC asked whether there were knock on consequences to getting all the cancer targets right. He confirmed it is appropriate and important to focus on achieving the cancer targets but wondered what impact there is on other parts of the services, whether cancer is always the right clinical priority and how the clinical priority is assessed. BE confirmed that there is a process and mechanism in place to check the impact and possible harm when prioritising cancer, RTT and all cancellations. AMcC asked for further assurance about what the clinical prioritisation process is. FA stated that each individual case is reviewed. BB added that clinicians are contacted the day before and on the day of the procedure to review the case, with the notes on the day. There is also a process to monitor how quickly we are able to re-book the procedure; the aim is within 28 days. BE stated that the number of cancellations on the day is in the report and monitored against a national metric. EC added that the pressure is not just on surgery but also on non-cancer primary care and clinical needs regarding routine appointments, which are also assessed and monitored. AMcC stated that he was assured that a prioritisation process was in place and a number of aspects were being considered. KD highlighted that the stroke performance remains problematic with 51% SQC Minutes 2

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admitted directly to an ASU within 4 hours of arrival and other delays in reviews by a consultant in 24 hours. KD added that she attended a quality committee earlier that asked if the stroke pathway should be on the quality report and Dr B Mearns is going to look into this. KD asked whether this committee should look at this. FA commented that it was something that should go to ECQR and then be escalated to SQC as appropriate. PS added that there are other issues around proposals regarding stroke from the commissioners that would impact on the stroke pathway. These options need to be discussed in detail with the commissioners and re-assessment of the community pathway is a key aspect before decisions are made about internal reviews and monitoring processes through Trust committees. KD agreed stating she was talking only on behalf of the East Surrey CCG and at present there was no confirmation about new stroke proposals. FA drew the attention of the committee to the improvements in patient falls performance but emphasised these are just the start and the key will be achieving the long-term and sustained improvement. RS asked what the outcome was from the meeting to discuss family involvement in investigations as recommended from the Southern Healthcare inquiry. FA stated that the meeting highlighted how as a Trust we can look at doing things differently in terms of involving family in all investigations. The divisions are reviewing their current processes and aim to instigate new approaches as a result of the meeting. AMcC asked about the outcome of the recent coroners case which highlighted concerns in delays of transfer to a tertiary trust that the BBC recently broadcast. DH confirmed that he is attending a meeting at St Georges chaired by NHS England where other cases that our Trust have identified can be reviewed. DH added that a key part of these discussions is the fact that a patient is deteriorating outside of a specialist hospital which increases their risk of harm. 3 PATIENT EXPERIENCE 3.1 Duty of Candour report FA presented the report and highlighted that a structure and process is in place to support compliance with Duty of Candour including a policy; staff support resources and guidance; and training. In November 2016 a Duty of Candour audit was conducted as part of the approved internal audit plan for 2016/17 and concluded that the Board can take reasonable assurance that the controls in place to manage compliance are suitably designed and consistently applied. FA confirmed that the process works very well within the SI investigation process but we struggle with the incidents that are defined as moderate partly because a number of incidents are reported initially as moderate but on senior management review are not moderate in line with the regulation definition but there is a time delay in these being updated on Datix. FA added that staff have the initial conversation with the SQC Minutes 2

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patient but do not then follow the rest of the process such as providing the follow up letter. She feels that the phrase ‘Duty of Candour’ is not as helpful to staff as ‘being open’ and personally prefers ‘being open’. FA concluded that the report should provide assurance to the committee that compliance is being monitored monthly within the divisional governance meetings and the patient safety committee. PL queried what is meant by a notifiable incident. FA replied that these are identified in accordance with a clear definition within the Regulation. FA confirmed that a look back exercise being completed by all the divisions to catch up on the backlog and tidy up the incident data on Datix is underway. Another problem is that staff are not updating the duty of candour fields on Datix and the divisions are raising awareness and supporting staff in completion of this. FA stated that the divisions are completing weekly spot checks and have ownership of improving the compliance. FA added that a number of actions came out of the meeting to discuss the recommendations resulting from the Southern Healthcare inquiry and the implications of involving patients and families in investigations. The notes from that meeting will be shared with SQC via the patient safety committee report but some of the areas discussed were; including families in all investigations including those identified as amber; sharing interim findings with families as there is often a long time period between the start of the investigation and the completion of the final report, particularly the final SI investigation reports as they are not shared with the patient and families until after they have been closed by the CCG; how to use independent advocates; and how to share action plans or outcomes of changes and improvements made as a result of the investigation with families. FA noted that people attending the meeting identified the need to improve action planning and relevance and ability to complete the actions as well as ensuring they are completed if this is going to be shared with families. AMcC asked if there are any quality checks or feedback systems in place with families about their views of their involvement, how it was for them and whether they think the actions will make a difference. FA confirmed that there is a feedback process in place for complaints investigations but not for incident investigations, although this is often addressed if there is a meeting with the family to share the incident investigation report at the end of the process. DH confirmed that there is often good feedback received from families at the time of these meetings. RS asked how duty of candour is monitored and who has the conversation. FA replied that duty of candour is monitored at the divisional governance meetings and the patient safety committee and will also be added to the dashboard. She confirmed that it has also been discussed at ECQR but is not a regular agenda item and has been to the board as part of the incident report. FA stated that it depends on the type of incident as to who has the conversation with the patient and family it can be the clinician or a senior nurse or matron. At the initial SI declaration meeting the person who should have the conversation is identified. KD stated that in primary care it is the SQC Minutes 2

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care worker who knows that patient best who has the conversation. RS stated that the cancer division is highlighted as poor performance against duty of candour in the report. EC replied that this has been recognised and there is a need to improve within the Cancer and Diagnostic division which is being addressed. FA added that the cancer and diagnostic division is still relatively new and there is evidence that all the specialties within the division are now coming together. RS thanked FA for the report and asked that the committee should receive a snapshot quarterly update. 3.2 Bi-annual report on peer reviews â&#x20AC;&#x201C; summary of key outcomes EC introduced the presentation by stating that the peer reviews are part of a nationwide process and every cancer provider has a review every year which includes compliance against MDT standards. There are different levels of review; the first level is one of self-review and self-declaration against the national standards; if concerns are raised through this then it will be escalated to a higher level of review.

EC talked through the presentation, in May 2016, there was an external review of the cancer of unknown primary pathway, and the peer review group was made up of colleagues from the Royal Surrey County Hospitals Trust and representatives, including EC, from SASH. There were a number of positive findings but the main concern was the lack of network consultant histopathologist, although it was noted that this was soon to be rectified. EC highlighted that the other cancer areas of; breast; colorectal; gynecological; haematology; lung; skin; upper GI; and urology were all self-declaration reviews in August 2016. EC concluded that the themes of concern were identified as oncology attendance at MDT from RSCH; CNS numbers and breast radiology but assured the committee that these have been or are being addressed in this current year of 2016/17. AMcC queried whether there have been any incidents related to the lack of specialist oncologists or CNS attending MDT or the lack of pathologist authorised by SIHMDS. EC confirmed that there were not any incidents that he was aware of. DH commented that in the past a problem highlighted had been too many patients being discussed at MDT without notes available particularly in urology. EC stated that this has not been raised as a problem recently and that the availability of notes has been very good. RS thanked EC for the report and confirmed that it provided good assurance to the committee. He reminded EC that the committee is expecting the cancer division annual report to SQC in 3 months. EC acknowledged that this is in hand. 4 SAFETY 4.1 Overview of CQC gap analysis CP talked through the paper stating that a group which reports to ECQR is tasked with ensuring that assessment of compliance with standards is a live SQC Minutes 2

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process. The group set on the journey in November and includes CP; BE and JP. The aim is to achieve outstanding from our CQC visit this year. CP highlighted from the report that in order to achieve outstanding it is expected that the Trust will have to be considered outstanding in the well led domain, have an outstanding culture and be outstanding in other elements of care provided. To date no outstanding organisation has met the requirements of being outstanding in the safety domain. CP continued to describe the work completed so far, which included a detailed corporate assessment which set a baseline, and the plans going forward, which includes aligning the work with ECQR and supporting services to complete their assessments instead of deep dives. CP described how the last 2 pages of the report show how the work is being aligned with the benchmarking and dashboard reports. There is still no clarity as to the CQC scoring but the important thing is to have excellent evidence against the key lines of enquiry (KLE) to support our move to outstanding. CP concluded a framework will be developed to support annual self-assessment and the oversight governance function of SQC. AMcC asked why we are not aiming for outstanding in all areas but in some only setting a target of good. FA replied that it would be difficult to get all the services to provide the detailed and specific evidence required to demonstrate being outstanding and that no organisation has delivered outstanding in all areas or outstanding in safety yet. AMcC asked whether we are we using the same KLE and whether the CQC will use NHS led resources data. PS stated that there are a number of areas of concern about how the CQC will assess resource and financial data. There is a new costing framework being piloted and SASH is part of it. Further clarity is required from the centre. RS asked for more detail about what the self-assessment framework for SQC might look like. CP confirmed that a full assessment and some form of assurance framework will be presented to SQC in the next 3 months. AMcC asked whether there is any intelligence monitoring we have sight of. JP replied that this is being developed. FA commented that this work is part of the Trusts journey to being outstanding anyway and links with all the VMI and SASH+ work and is a healthy pathway to be on. DH added that we should not aim for good but aim for outstanding in all services and domains. CP agreed that this was the aspiration and BE is developing a framework to map what the outstanding requirements are in all domains. FA agreed that the vision should be to achieve outstanding and would be happy for the services to provide the evidence required in order to increase the levels of expectations but there needed to be an element of setting achievable targets for CQC inspection purposes. RS concluded that the work reported to date provides the committee with good assurance that compliance and preparations for a CQC inspection are underway and recognised that it is important to set ourselves a challenge but also be self-aware. SQC Minutes 2

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5 QUALITY 5.1 WaCH Division Annual Report to SQC ZN talked through the WaCH annual update presentation and highlighted a number of key achievements including the audit results showing the caesarean section rate for SASH is at or below the national average, and the reduction in the SASH still birth rate from Jan-Apr 2016 to May-Aug 2016 as part of the Growth Assessment Protocol (GAP) project. A number of challenges were highlighted including; staffing shortfall and vacancy; the risk of increased infection in the neonatal unit due to lack of cot space; and performance regarding elective cancellations due to bed occupancy. ZN commented on the top 5 risks rating 12 or higher and summarised the divisional SIs declared during 2016/17 and the number of SI actions completed. A range of resources and mechanisms used by the division for sharing lessons learnt were highlighted and an update on the progress of the audit programme with an example of a completed audit was shared. ZN finished the presentation with a summary of the quality and safety plan for 2016-18.

AMcC questioned why the risk relating to inaccessibility of IT links and maternity patient information in the community was rated so high, as it didnâ&#x20AC;&#x2122;t seem, from the description to indicate anything that would deem it as higher than the other risks described. ZN replied that the risk score is higher as there have been a number of incidents and it also covers a number of related risks involving information governance issues. AMcC asked whether it is a bigger risk than the others and ZN confirmed that it is. FA added that the high score also reflects the inadequacies of the mitigation and control measures currently in place. CP confirmed that as the risk register is a â&#x20AC;&#x2DC;liveâ&#x20AC;&#x2122; process the higher risks are fully assessed at the end of the month and those with a high rating become part of the significant risk register. RS asked how the division are planning to move the challenges to successes. ZN replied there are lots of work streams in place and all of these will move through the governance process. KD commented that there is a national drive and target to reduce the caesarean section rate as it is deemed unnecessary in many cases and poses increase risks to the mother, in current practice the rate is about 23%, she asked ZN to comment on practice in SASH. ZN replied that lots of practice has changed over the years, foetal movement is monitored and caesarean sections are safer now with more proactive monitoring and assessment and guidance in place to ensure safer practice. PL asked for clarity regarding the neonatal unit capacity leading to suspension of services and asked whether this is due to a lack of cots and facilities or staffing and resources. ZN confirmed that it is not a facility issue and the neonatal unit shuts due to a lack of capacity rather than a lack of staffing, she added that the infection control risk is related to a facility issue as there is a lack of space for the cots. SQC Minutes 2

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PS added that a bid has been submitted in relation to the risk and is going through the process. RS thanked ZN for her presentation.

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 6th April 2017 12.00 â&#x20AC;&#x201C; 14.00 AD77

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