A MEETING OF THE BOARD OF DIRECTORS WILL TAKE PLACE … · • Best Value • Accountability...

BoD July 2014: 00 PUM Agenda

A MEETING OF THE BOARD OF DIRECTORS

WILL TAKE PLACE ON WEDNESDAY 2ND JULY 2014, 9AM IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL

AGENDA

No Item Sponsor Ref

1. Apologies and Welcome

S Wragg, Chairman

2. To review the Register of Interests and receive any further declarations of interests

14/07/P-02

3. To approve the Minutes of the meeting of the Board of Directors held in public on 3rd June 2014

14/07/P-03

4. To approve the Action Log in relation to progress to date and review any outstanding actions

14/07/P-04

Strategic Aim 1: Patients will experience safe care

5. To receive and consider a Patient’s Story H McNair

Dir of Quality & Nursing

6. To receive and endorse the monthly update on Nursing & Midwifery staffing 14/07/P-06

7. To review progress on the Trust’s Mortality Ratios Dr J Mahajan Medical Director

14/07/P-07

8. To receive and endorse the latest assurance report from the Non Clinical Governance & Risk Committee

F Patton Committee Chair

14/07/P-08

9. To approve the proposed Governance restructure A Keeney

Assoc Director of Corporate Affairs

14/07/P-09

Strategic Aim 2: Partnership will be our strength

10. To note monthly report from the Chairman S Wragg Chairman

14/07/P10

11. To note monthly report from Chief Executive D Wake, Chief Executive

14/07/P-11

12. To note latest Agenda and approved Minutes of the Council of Governors

S Wragg Chairman

14/07/P-12

Strategic Aim 3: People will be proud to work for us

Strategic Aim 4: Performance matters

13. To receive and endorse exception report from the Finance & Performance Committee

F Patton Committee Chair

14/07/P-13

14. To review and approve the 2014/15 budget plan S Diggles Interim Dir of Finance

To follow

15. To review the integrated performance report (month 2) Executive Team 14/07/P-15

Cont/…

BoD July 2014: 00 PUM Agenda

No Item Sponsor Ref

16. In accordance with the Trust’s Standing Orders and Constitution, to resolve that representatives of the press and other members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted.

Date of next meeting: - 7th August 2014, 9am, at Education Centre, Barnsley Hospital

Signed: ………………………….. Chairman

Please see reference section at back of papers for key to business plan and glossary of terms/acronyms

REF: 14/01/P-02

REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT

BoD July 2014: 02(i)_Register of Interests

SUBJECT: REGISTER OF INTERESTS

DATE: JULY 2014

PURPOSE:

Tick as applicable

Tick as applicable

For decision/approval Assurance For review Governance For information Strategy

PREPARED BY: Carol Dudley, Secretary to the Board

SPONSORED BY: Diane Wake, Chief Executive

PRESENTED BY: Stephen Wragg, Chairman

STRATEGIC CONTEXT 2-3 sentences

To support the Trust’s ethos of transparency in all matters, including the financial interests of the Board of Directors and senior management.

QUESTION(S) ADDRESSED IN THIS REPORT

CONCLUSION AND RECOMMENDATION(S)

The Board is asked to review:

• the Registers of Interests of the Board of Directors, collated in accordance with the National Health Service Act 2006 (as amended by the Health & Social Care Act 2012) and the Trust’s Constitution

• the Register of Directors for the Executive Team and Clinical Directors, in accordance with the Board’s agreed good practice and as recommended by the Audit Committee.

It should be noted that whilst every effort is made to assist Directors’ declarations, it is the responsibility of each individual to ensure that his or her interests are declared in a timely and appropriate manner.

The Board may wish to note that a Register of Interests is also held for the Council of Governors.

The Registers will be presented to the Audit Committee and are available for public inspection.

BoD July 2014: 02(i)_Register of Interests

REFERENCE/CHECKLIST

• Which business plan objective(s) does this report relate to?

• Has this report considered the following stakeholders?

Patients

BCCG

Other

Staff

BMBC

Please state:

Governors

Monitor

• Has this report reviewed the Trust’s compliance with:

Regulators (eg Monitor / CQC)

Legal requirements (Acts, HSE, NHS Constitution etc)

Equality, Diversity & Human Rights

The Trust's sustainability strategy

• Is this report supported by a communications plan?

Yes

Not applicable

To be developed

• Has this report (in draft or during development) been reviewed by any Board or Executive committees within the Trust?

CGC

NCGRC

Audit Committee

Finance Commitee

ET

• Where applicable, briefly identify risk issues (including any reputation) and cross reference to risk register and governance committees

• Where applicable, state resource requirements:

Finance:

Other:

NHS Constitution: In determining this matter, the Board should have regard to the Core principles contained in the Constitution of:

• Equality of treatment and access to services • High Standards of excellence and professionalism • Service user preferences • Cross community working • Best Value • Accountability through local influence and scrutiny

The Board will also have regard to the Trust’s core vision statement: “Barnsley Hospital: Providing the best healthcare for all”

Register of Board of Directors’ Interests (June 2014) Signed: Secretary to Board Page 1 of 4 Dated: 26 June 2014

BARNSLEY HOSPITAL NHS FOUNDATION TRUST REGISTER OF BOARD OF DIRECTORS’ INTERESTS (AS AT 30 JUNE 2014)

EXECUTIVE DIRECTORS Entry No 1

DIRECTOR Date of

appointment INTERESTS Date interest registered2

Date entry reviewed

21 Dr Jugnu Mahajan – Medical Director

14 September 2009

• Governor - Secondary care doctor Governing body, Nottingham North West Clinical Commissioning Group

• Member, Medical Managers’ Committee (2013-14), British Medical Association

23 August 2012 ______________

22 July 2013

09 January 2014

24 Heather Mcnair – Director of Nursing & Quality

05 December 2011 • None

08 December 2011

09 January 2014

18 Mr David Peverelle – Chief Operating Officer

Wef 01 July 2008 • None

30 Ms Diane Wake - Chief Executive

28 October 2013 • None

08 November 2013

09 January 2014

31 Mr Stuart Diggles - Interim Director of Finance

April 2014 • Owner & Director, TASK Finance Limited 26 June 2014


BARNSLEY HOSPITAL NHS FOUNDATION TRUST

REGISTER OF BOARD OF DIRECTORS’ INTERESTS (AS AT 30 JUNE 2014) NON EXECUTIVE DIRECTORS Entry No 1

DIRECTOR Date of

Appointment INTERESTS Date interest registered2

Date entry reviewed

25 Mrs Suzy Brain England OBE – Non Executive Director

01.01.2012 - 31.12.2014 - 31.12.2017

19 January 2012 09 January

2014

• Chair, Derwent Living Housing Association

• Peer Assessor & Trainer, Institute of Directors

• Lay Chair, Yorkshire Deanery

• Founder and Director, Cloud Talking on-line Mentoring

19 September 2012

22 Mrs Linda Christon – Non Executive Director

01.01.2010 – 31.12.2012 – 31.12.2015

• Independent Board Member, St Leger Homes

26 October 2011 09 January

2014

26 Sir Stephen Houghton CBE – Non Executive Director

01.01.2012 - 31.12.2014 - 31.12.2017

• Commissioner, Audit Commission

10 January 2012 09 January

2014

• Leader, Barnsley Metropolitan Borough Council

• Chair, Barnsley Miller Partnership

• Regional Peer, Local Government Improvement (LGA)


Entry No 1

DIRECTOR Date of


Date entry reviewed

17

Mr Francis Patton – Non Executive Director & Deputy Chair

01.01.2008 - 31.12.2009 - 31.12.2010 - 31.12.2013 - 31.12.2016*

• Chairman, The Cask Marque Trust

14 January 2008

09 January 2014

• Treasurer, All Party Parliamentary Beer Group

• Senior Lecturer (part time), Leeds Metropolitan University

• Non Executive Director The BII (British Institute of Innkeeping)

23 June 2009 June 2014

• Managing Director Patton Consultancy

26 August 2010

• Non Executive Director, SIBA, The Society of Independent Brewers

September 2010

• Director, Fleet Street Communications

December 2010

• Chairman, Barnsley Hospital Support Services Limited

24 May 2012

28 Mr Paul Spinks – Non Executive Director

01.09.2012 - 31.12.2015

• Senior Technical Manager, Grant Thornton UK LLP

• Member, Technical issues Forum, Monitor

29 August 2012 09 January

2014


Entry No 1

DIRECTOR Date of


Date entry reviewed

19 Mr Stephen Wragg – Chairman

01.01.2009 - 31.12.2011 - 31.12.2014 - 31.12.2017*

• Non Executive Director, Barnsley Premier Leisure Trading

7 January 2009

09 January 2014

• Sole Director, Wragg Consulting Limited

20 May 2010

• Labour Party, Member

29 June 2011

• Director, 360 Engagement Ltd

18 October 2011

• Governor, Darton College

12 December 2011

• Trustee, Barnsley Civic

15 December 2011

Notes: 1 Entry numbers to run consecutive by date order 2 Hard copy of all updates will be required to be initialled by updating officer and retained in the office of the Chief Executive or Nominated Officer * Subject to annual review/renewal

Signed: Secretary to the Board Page 1 of 2 Dated: 26 June 2014

BARNSLEY HOSPITAL NHS FOUNDATION TRUST

REGISTER OF EXECUTIVE TEAM & CLINICAL DIRECTORS’ INTERESTS (at at 30 June 2014)

Entry No 1

NAME / POST Date of

appointment INTERESTS Date interest

registered Date entry reviewed

15 Dr Akhilesh Bowry – Clinical Director, CBU2

December 2011 2

None 02 February

2012 09 January

2014

31 Mr Jason Bradley – Director of ICT

1st March 2012 None 09 January

2014

13 Ms Hilary Brearley – Director of Human Resources & Organisational Development

1st March 2010

• Company Secretary – Poppies UK Development Ltd

• Governor – South West Yorkshire Partnership NHSFT

04 March 2010

16 July 2012

09 January 2014

23 Mrs Lorraine Christopher – Associate Director of Estates & Facilities

23 Feb 2009

Director, Barnsley Hospital Support Services Limited (BHSS) Familial interest: a) Capita Symonds Ltd

Sister = Director b) Harrison Thompson & Co Ltd

Husband = Sales Director

15 Aug 2013

25th May

2013 29th June

2013

09 January 2014

16 Miss Meenakshi Dass – Clinical Director, CBU6

December 2011 2

None 09 January

2014

32 Dr Dyfrig Hughes – Clinical Director, CBU1

March 2013 2 None 09 January

2014

21 Dr Kapil Kapur – Clinical Director, CBU3

December 20112

None 09 January

2014

35 Mrs Karen Kelly – Director of Operations

15 April 2014 None

Signed: Secretary to the Board Page 2 of 2 Dated: 26 June 2014

Entry No 1

NAME / POST Date of

appointment INTERESTS Date interest

registered Date entry reviewed

35 Mr Robert Kirton – Director of Strategy & Business Development

May 20143 a) Non Executive Director,

Medipex (acting for Trust) b) Director, BHSS

July 2013 15 Aug 2013

09 January

2014

32 Ms E Parkes – Director of Communications & Marketing

March 20144 None 09 January

2014

18 Mr Muhammad Shiwani – Clinical Director, CBU 4

December 2011 2

None 09 January

2014

30 Mr Martin Wickham – Clinical Director, CBU5

March 20122 Director, Wickham & Taylor Ltd 23 June 2014

Notes:

1 Entry numbers to run consecutive by date order 2 Where applicable Clinical Director appointment dates show date of original appointment as Divisional Director/ Divisional Medical Director;

and transitionto new Clinical Business Unit (CBU) structure 2014 3 Previously Interim Director of Transformation from June 2013 4 Previously Associate Director of Communications from April 2013


REF: 14/07/P-03

MINUTES OF A MEETING OF THE BOARD OF DIRECTORS HELD ON 3RD JUNE 2014

IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL NHSFT

PRESENT: Mrs S Brain England OBE Non Executive Director Mrs L Christon Non Executive Director Mr S Diggles Interim Director of Finance Sir Stephen Houghton CBE Non Executive Director Dr J Mahajan Medical Director Mrs H McNair Director of Nursing & Quality Mr F Patton Non Executive Director Mr D W Peverelle Chief Operating Officer Mr P Spinks Non Executive Director Ms D Wake Chief Executive Mr S Wragg Chairman

IN ATTENDANCE: Mr J Bradley Director of ICT Ms H Brearley Director of HR & Organisational Development (OD) * Mrs L Christopher Associate Director of Estates & Facilities Ms C E Dudley Secretary to the Board Ms A Keeney Interim Assoc Director of Corporate Affairs Ms K Kelly Director of Operations Mr R Kirton Director of Strategy & Business Development Ms E Parkes Director of Communications & Marketing Dr C Smith Director of Research & Development ** Ms K Watson Advanced Orthopaedic Physiotherapist ** [* in attendance until 10.40hrs; ** in attendance for part of meeting as minuted]

14/94 APOLOGIES & WELCOME

Members and attendees as noted above were welcomed. Particular welcomes were extended to Ms Keeney, attending her first meeting since joining the Trust, and Ms Watson and Dr Smith, attending to present information relating to the Patient’s Story and Research & Development (R&D) respectively. Two Governors were also thanked for attending as observers.

14/95 DECLARATION OF INTERESTS

None.

14/96 MINUTES OF LAST MEETING (14/06/P-03)

The Minutes of the meeting of the Board of Directors held in public on 1st May 2014 were received and reviewed. One amendment was agreed: the final sentence in the penultimate paragraph should state, “Linking back to the EWTR, Mr Spinks was pleased to hear that there was no suggestion of any evidence through the Deanery that doctors were being pressured into working undue hours, which provided a positive assurance.” Subject to this, the Minutes were approved as a true record.

BoD July 2014: 03_Minutes June 2014 Page 2 of 11

14/97 ACTION LOG (14/06/P-04)

The action log, showing progress on matters arising from the last and previous meetings held in public, was reviewed and noted.

14/98 PATIENT’S STORY

Ms Watson presented an overview of the Enhanced Recovery Programme (ERP). The programme was intended to support patients pre- and post- operative, educating and empowering them to be more engaged with choices relating to their treatment. To date the Trust had implemented the programme for hip, knee and some colorectal surgery. The outcomes had been very positive, with faster recovery times and length of stay reduced from an average of 5 to 3 days. Plans to roll out the programme more widely into other surgeries were being progressed.

Ms Watson explained how the programme supported patients before, during and after surgery; how it ensured that patients felt better prepared for surgery, more informed about and engaged with the choices available to them, had a greater understanding of the impact of their surgery and were more aware of what they could do to help speed up their recovery too with physio etc. She advised that record keeping systems had been revised to ensure that each patient’s information was held in one common booklet accessed by the diverse clinical teams involved at each stage of the patient’s treatment. She also advised that in response to feedback from patients, a learning DVD had been developed for use at patients’ pre-operative classes, based on the real pathway of one patient from referral to recovery. The DVD was played at the meeting and was also available on the Trust’s website. The patient featured in the DVD had hoped to attend the meeting with Ms Watson to share more about her personal experience of the programme but unfortunately was not well enough; the Board appreciated the offer and her support for the programme. Ms Watson was asked to pass on the Board’s best wishes to the patient.

Ms Wake referred to a three page article in a recent issue of the HSJ, which had reported on the growing focus and impact of ERP. She was pleased to see its role and growth in Barnsley.

Board members thanked Ms Watson for the informative presentation and update provided on ERP and expressed their support for the good work being carried out across the Trust, the positive impact on patients and the plans to develop the programme in the future.

14/99 RESEARCH & DEVELOPMENT (R&D) STRATEGY (14/06/P-06)

Dr Mahajan advised that Dr Smith had been working on the new Strategy since her appointment as Director of R&D last year. To prepare the Strategy, Dr Smith had sought input from various groups within the Trust (as well as the R&D team), including the Trust’s governance committees, the executive team and the Governors, before being bringing it to the Board for approval. The Trust’s role as a partner in the Collaboration for Leadership in Applied Health Research and Care, Yorkshire and the Humber (CLAHRC YH) and other regional networking had also been factored into the Strategy.

To support the submitted draft Strategy document, Dr Smith presented an overview of the work of the R&D team. She expanded on its twin focus of clinical trials and developmental work and gave examples of how both workstreams were implemented within the Trust and the intention to benefit patients and patients’ services. She also expanded on the four aims set out in


the Strategy and explained how the work led through the R&D department was largely self-funding and thus cost neutral (a range of grants were available, which the Trust pursued as a pro-active member of the regional R&D networks), how future plans were intended to increase capacity with links to the Clinical Business Units (CBUs) to ensure wider engagement, rather than being centred on a small number of specialities, and how this would lead to more improvements in patients’ outcomes and patients’ services in line with the Keogh and Francis Reviews. As a further illustration, Dr Smith referred to one of the latest exercises carried out by the team – an evaluation of Emergency Department attendance, copies of which had been circulated to the Board for information. Although this work had been commissioned by the Barnsley Clinical Commissioning Group (CCG), the findings would feed into the Trust’s and community-wide work on reducing attendances at A&E and improving waiting times.

The Board appreciated the presentation and the draft strategy. The principles of the strategy and the future aims for R&D within the Trust were widely supported but it was agreed that future reporting on R&D should be reviewed. Whilst it was acknowledged that some members would become more aware of the R&D work team by their involvement in the R&D strategy group to be established shortly, the Board supported the comments raised by several Non Executive Directors that there needed to be more clarity on finance and achievements in year to enable the Board to monitor progress better. Mr Diggles reminded members that a high level report on the R&D income and expenditure position was included in the regular financial reporting and also undertook to review and expand on this for future reports. It was agreed that it would be useful for a cost profile on R&D to be presented to the next meeting of the Finance & Performance Committee, and for key performance indicators (KPIs) to be identified to enable progress to be more closely monitored. Mrs Brain England also asked that more information on related communications work be shared with the Board too. Ms Wake suggested, and it was agreed, that much of this work would be led by the R&D Strategy Group. Dr Smith advised that the group could be established in July, enabling a follow-up report to be presented to the Board in August.

Following wide discussion it was concluded that:

(i) that the Strategy Plan as presented was appreciated and supported. However, it was not fully complete; it outlined the R&D team’s objectives but lacked some essential detail around finance and communications and, particularly from the Non Executives’ perspective, a robust business plan;

(ii) the presented report was approved as a strategic report in principle, with the acknowledgement that it would be underpinned by the financial reporting and KPIs which had been agreed to be developed; and

(iii) the R&D Strategy Group would lead the work on the further details required and development of reporting systems for the future and would provide a further report to the Board in August.

Dr Mahajan thanked Dr Smith for all the work she had put into the role since taking up appointment as Director of R&D. This was fully endorsed by the Board and attendees.

Dr Smith and Ms Watson left the meeting at this juncture.

SD

F&P Cttee

JM/CS

JM/CS


14/100 HOSPITAL STANDARDISED MORTALITY RATIOS (HSMR) (14/06/P-07) AND SUMMARY HOSPITAL MORTALITY INDICATOR (SHMI)

Dr Mahajan presented the latest report on the HSMR, SHMI and crude mortality ratios. Although progress towards the required improvements in the ratios remained slow, Dr Mahajan affirmed that the Trust’s action plan was beginning to make a positive impact, as evidenced by the reduction (improvement) in the reported SHMI and the Trust’s better position for HSMR (no longer the highest in the region). Crude mortality also remained below the mean.

Dr Mahajan drew attention to a number of key sections in the report, including:

a) the historical data on HSMR requested last month (appendix 1). - the Chairman raised a further query on the table included in the main report, which still did not show a clear correlation to the historic data. Mr Bradley and Dr Mahajan explained that the data was only “locked” once a year – at year end – and the rolling numbers therefore would continue to change month on month. The Board was conscious that the report was accessible to others outside the Board too and it was agreed that some form of explanatory text should be included in future reports, to help other readers to understand this position;

b) the outcomes of the external report carried out by Dr Fletcher on deaths in April 2013, a summary of which had been in the report. The full report had been reviewed by the Clinical Governance Committee (CGC). - Ms Wake had been concerned by Dr Fletcher’s comment about the increased deaths among young people in Barnsley. Mrs Christon and Dr Mahajan confirmed that this had been scrutinised by the CGC and an action plan was being developed. Two issues had already been highlighted: alcohol and cancer related deaths. The Board agreed that these needed to be reported to the local Health & WellBeing Board.

In discussion, the impact of “legal highs” (available to young people in town) was also considered. A number of hospital attendances were associated with this and it was agreed that related data should be shared with the Health & WellBeing Board too;

c) early, informal, feedback from the Advanced Quality Alliance (AQuA) review of the Trust’s work on mortality ratios. It was confirmed that no issues of concern had been identified, although some proposals for improvement would be mooted. Early feedback indicated that much of the Trust’s work was in line with that carried out elsewhere across the nation.

Dr Mahajan affirmed that all of this data would be reviewed further in the Trust-wide workshop scheduled for 13th June, which would help to develop a revised mortality action plan and drive further improvements in the mortality ratios.

The report also referred to the impact of a number of other workstreams ongoing as part of the existing action plan, including Sepsis Six and the NEWS (national early warning score). Mrs Christon queried when the current stage of the relaunch of the Sepsis Six would be complete and its impact assessed. Dr Mahajan advised that an audit review had been scheduled and undertook to check and confirm the date to members of the Board.

The report on progress to date, slight improvement in the position overall and the continuing plans to drive further improvements were noted.

JM

JM

HM

JM


14/101 CLINICAL GOVERNANCE COMMITTEE (CGC) (14/06/P-08)

Mrs Christon, as Chair of the CGC, presented the Committee’s assurance report following its latest meeting held in May. Several issues had already been raised, as noted above. Mrs Christon also drew attention to the following:

• One action point had not yet been addressed in “Compassion in practice”: to identify a board member to whom staff were able to raise concerns

This was not a mandatory requirement and it was agreed that every Board member would welcome staff raising their concerns with them. However, it was further agreed that it would be useful to formally identify one Board member with the Compassion for Practice structure and that this would be the Director of Nursing & Quality.

• The general improvement in stroke performance, with one exception - for TIAs (minor strokes). The Committee had requested a more detailed report on this issue for its next meeting.

• The quality dashboard, which had been reviewed in detail at the meeting and was attached for the Board’s reference

It was noted that the rating thresholds had been omitted and it was agreed these should be included in future for this and any reports using the RAG (red/amber/green) rating approach. The dashboard content and the role of the Quality and Safety Improvement & Effectiveness Board were also discussed. It was acknowledged that the report raised a number of questions in relation to further information which the Board presumed had been provided to the CGC (had it?) and/or actions taken. The meeting was assured that all of these points had been reviewed closely by the CGC and appropriate actions progressed. It was agreed that whilst more detail was not required to come to Board – that should remain within the remit of the governance committees – it would be useful to add a further column to the dashboard for the Board’s reference in future, to identify outliers or other pertinent key points.

• The new DNA (Did Not Attend) Policy and Procedures for Children and Young People: this had been endorsed by the Committee and was recommended to the Board for approval.

In terms of specific queries on the assurance report, Mr Spinks questioned why it stated “data not available” for dementia; Mrs McNair advised that, to be more correct, it should have stated “data not collated”. The point related to a CQUIN that had not been achieved at part 1; the position could not be retrieved in the year (2013/14) and thus the data for parts 2 and 3 had not been relevant to the report. The Board was further advised, however, that the work had continued nonetheless and a new process developed for 2014/15 to make the position clearer.

Following discussion the report was accepted and the DNA Policy and Procedures for Children and Young People was approved.

LC

14/102 ANNUAL SAFEGUARDING REPORTS FOR (14/06/P-09a&b) ADULTS AND CHILDREN & YOUNG PEOPLE – 2013/14

a) Adults The annual report on the Trust’s work in 2013/14 regarding the safeguarding vulnerable adults’ agenda was received and reviewed. Prior to discussion of its content Mr Patton referred to the cover required for all Board reports, some of which were still not being fully completed by the


authors. It was agreed that the covers were useful and should give key points on the report’s content, highlight core questions and provide clear answers too, thus enabling the Board to consider whether or not to accept or give approval to the report’s contents. It was further agreed, however, that further guidance would be useful to ensure a uniform approach and should be issued shortly.

With reference to the report itself, there was a consensus that it showed good progress and gave assurance that robust systems were in place to ensure that safeguarding adults were being appropriately supported by the hospital.

Sir Stephen sought further explanation on the training levels - 92% basic and 58% on mental health capacity. Mrs McNair clarified that the latter did not relate to the mental health assessments required for some patients admitted via the Emergency Department but the DOLs (deprivation of liberty) assessments, which applied when a patient might want to be discharged but staff believed it would not be in their best interest so to do. She confirmed that not all staff were required to undertake all aspects of the training; requirements were higher on those wards with greater need for specialised training, such as Care of the Elderly. She assured the Board that there were enough trained staff at all levels across the Trust and that the Trust had never had an issue of an appropriately trained member of staff not being available on a ward when required.

The Chairman queried reference to cases of abuse. Mrs McNair agreed that “abuse” was a difficult and often subjective term. It could include a pressure sore (which could be counted as neglect) to a delayed discharge and/or more serious issues. Whilst only some cases might have an adverse impact on the outcomes for patients, every case would be reviewed and where they were attributable to a member of staff or team, the proper action would always be taken. Where appropriate, some staff might be given retraining on relevant matters; others could be referred for more formal action to be taken – dependent on the issue. The Chief Executive advised that not all trusts reported such a wide range of issues as “safeguarding” and the Trust’s open approach could be, if taken out of context, damaging to its reputation. It was agreed that the report should be revised to include a brief narrative to clarify the Trust’s approach and explain that every referral was assessed individually against defined safeguarding thresholds before being accepted for formal investigation.

Subject to the agreed amendment, the Board accepted and approved the report.

b) Children & Young People The report on Children & Young People was also reviewed and endorsed. The Trust’s continuing involvement with child death reviews was highlighted. No serious cases had been identified in 2013/14 and two learning events had been held. The Trust also continued to be involved with the action plan developed in response to the OFSTED inspection, the follow up visit for which was due shortly.

In response to a query from the Chairman, Mrs McNair confirmed that learning was shared between the adults and children & young people’s safeguarding teams. It was reiterated that safeguarding training and awareness was an important issue for everyone at the Trust; Governors had received a refresher awareness session in May.

DW/SW /CED

HM


14/103 NURSING & MIDWIFERY STAFFING (14/06/P-10)

Mrs McNair introduced the new monthly report on Nursing & Midwifery staffing. Board had previously received regular reports on a six monthly basis but the monthly report was aligned with new national requirements. The Government’s approach required all Boards to be sighted on staffing levels for nurses and midwives and for the information to be published on NHS Choices regularly.

Mrs McNair explained the approach adopted, based on 2x 12 hour shifts (although the Trust actually operated three shifts daily) and using data from the e-roster at the start of the shift. The national reporting did not reflect any staff movement to cover shortfalls or any overstaffing on other wards albeit Mrs McNair assured the Board that it was the Trust’s normal practice to reassign staff where necessary in order to ensure safe staffing levels on all wards at all times. This was noted by the Board and would be clarified further in future reports to the Board. It could not, however, be reflected in the national reporting, which therefore showed a 3% under rostering although it was believed that the national system would be refined as it became more established. The Board was assured that the ward team(s) would not hesitate to submit an incident form if they believed safe staffing levels were at risk in any way; Mrs McNair confirmed that no incidents had been reported on care being compromised by shortage of staff. It was also agreed that whilst the report needed to reflect the national system, it would be useful to add an action column to show any mitigating actions taken (ie movement of staff to cover under rostering). In terms of vacancies, it was stressed that the Trust would not wait until newly trained staff were available in September; recruitment was continuing using other routes too.

Mrs Christon commented on the shift patterns and asked if a move to 12 hour shifts would help with ward handovers; the current three shift pattern led to a longer overlap between the morning and afternoon shifts than experienced for the afternoon and evening shifts. Mrs McNair advised that 12 hour shifts could not be mandated although some staff did adopt them and there was a school of thought that a system with all staff on longer shifts could be detrimental to quality and safety of care towards the end of shift.

It was noted that the staffing data was displayed on each ward daily. Mrs Brain England had seen and been impressed by the notices on one of the wards recently. She had also seen the posters regarding nurses’ uniforms and queried if these might be problematic for people suffering from any degree of colour blindness, although the colour schemes were also listed in writing. Mrs McNair affirmed that the existing scheme included 27 variations of uniform, which was complicated and included some very subtle differences. This would become easier with the introduction of the new uniforms, with fewer variations, currently being rolled out as the older ones came to the end of their practical life. This would, however, take time.

The Board appreciated the report and noted the content and limitations of the new reporting system. The report would continue to be received as presented pending changes in the national system, with the addition of the column on mitigating actions for the Board’s information as agreed.

HM

14/104 FRIENDS & FAMILY TEST (FFT) (14/06/P-11)

The year end report on the roll out of the FFT within the Trust was received and noted. The report outlined the Trust’s compliance with current requirements and plans for the year ahead.


Mr Spinks referred to the net promoter scores, which showed a slight slippage following good progress earlier. Mrs McNair reminded members that the report was subjective. Work was ongoing to consider how to encourage more responders to add narrative to their response, which could be helpful to the Trust (it was not obligatory and many people simply opted to answer “yes” or “no” to the questions), and to review trends as more data became available.

14/105 ADVANCE QUALITY ALLIANCE (AQuA) (14/06/P-12) - ACTION PLAN

Ms Wake presented and expanded on the latest update on the AQuA action plan. Actions to date were noted and it was agreed that things had moved on significantly since the Plan was developed in November 2013 and that other workstreams, such as turnaround plan currently being developed and the Nursing Strategy, would pick up any outstanding issues for future reporting.

It was agreed that one final report should be compiled and circulated to members to confirm actions completed or transferred to another report (and, if so, where). This would not need to be presented at Board but would be confirmed via the action log.

DW

14/106 CHAIRMAN’S REPORT (14/06/P-13)

The Chairman’s report, which provided an overview on a range of activities since the last Board meeting and items of interest, was received and noted.

Mr Spinks requested more information on the recent discussions with the CCG, including any update on the Trust’s bid for funding to support further development of 7 days services. The Chairman emphasised that his and the CEO’s meetings with their CCG counterparts were not negotiation meetings, however, Mr Kirton advised that the bid had been revised slightly in accordance with the CCG’s request and was due to be re-presented to their Governing Body in early June. Some of the funding might be dependent on support from the Health & WellBeing Board and the Board noted that the Health & WellBeing Board was holding a separate meeting on finance later that day.

No further reports were received from other members of the Non Executive team.

14/107 CHIEF EXECUTIVE’S REPORT (14/06/P-14)

The Chief Executive’s report on a range of activities and issues of interest arising since the last Board meeting was received and reviewed. The Chief Executive drew attention to three items:

- progress on key appointments to the Clinical Business Units (CBUs) to date and the arrangements in place to enable immediate transition to the new structure, before some of the new general managers were able to join the Trust after serving out notice periods at their current trusts. The first performance management meeting under the new structure had been held recently and had been quite effective albeit further work on the reporting mechanisms was still ongoing;

- the Endoscopy Unit’s successful joint agency group (JAG) accreditation, achieved in May, with a lot of work led by Dr Kapur and Mr Peverelle. In recognition of this success, the accreditation team had been awarded the BRILLIANT Staff Team award in May;


- the internal Compassion in Practice conference held recently for Health Care Auxiliaries (HCAs). It had been a whole day event, reflecting the Trust’s value and appreciation of the HCAs and had been well attended.

Before discussion of the finance and performance reports, the Chairman referred to the new agenda format, the structure of which now reflected the agreed Vision, Aims and Business Plan for 2014/15 and the Trust’s focus on quality and safety first. In view of this the reports on finance and performance have moved to the third and fourth sections of the agenda. This did not in any way imply any lessening of any focus from the Board. It was acknowledged that all agenda items were of equal importance and priority.

14/108 UPDATE ON 2014/15 BUDGET PLAN

Mr Diggles reported progress on the 2014/15 budget plan, which was now at final draft stage. Work was still required on the supporting data for CBUs and cost improvement programmes and review by external consultants to revalidate the draft plan. At this stage it was anticipated that the forecast deficit would be reduced to c£11.9m, reflecting further work carried out since the last meeting. Mr Diggles affirmed that expenditure projections were comprehensive, taking account of extra costs for the essential external support, cost pressures carried forward from last year, payroll demands, some additional costs re the CBUs (they were not more expensive than the previous clinical service unit structure but previous planning had lacked clarity in some aspects), PDC dividends (reduced payments in line with reduction in net assets) and rephased valuation on fixed assets where appropriate. Creditor payments and capital expenditure had also been restructured to ensure closer management in terms of both timing and cashflow; capital expenditure vs depreciation would be reviewed shortly. Central funding support and anticipated repayments would also be reflected in the final plan. Cash requirements and departmental budgets would be established within the next week.

Mr Bradley assured the Board that the Trust was still on schedule for deployment of a new electronic patients record system and the Board reiterated its commitment to the project. It was noted that the project team would be meeting the Department of Health’s project panel next week; Mr Spinks would be attending the meeting. Mr Diggles affirmed that the project had been factored in the future planning; phasing of some elements had been revised but the key date of 31st March 2015 was still core to the programme.

The update was appreciated and the Board noted that the final budget plan would be presented to its next meeting for approval.

SD

14/109 INTEGRATED PERFORMANCE REPORT (14/06/P-16)

The latest report on activity, finance, quality and workforce for month 1 2014/15 was received and noted. Lead Directors expanded on their respective sections:

Activity Mr Peverelle drew attention to the ‘red’ rating for breast symptomatic clinics and advised that this had since been recovered – at 99%. The earlier demands had been around a surge in demand following Government campaigns and TV coverage. He also provided an update on the A&E activity, which had been achieved in May (98.6%) as well as April and was currently at 99% for June.


Mr Peverelle referred to the exception reports provided for diagnostics (partly reflecting national shortage of sonographers but also affected by increased local demands), waiting times (as reported) and cancelled operations (up on the previous month but since stabilised). With regard to diagnostics, discussions at the CBU’s performance management meeting had highlighted increased and some inappropriate demands on the service. The Trust was in discussion with the CCG on this in terms of referral protocols, demand management and options for offsetting potential penalties in view of the increased requirements from GPs.

It was noted that DNA (did not attend) rates remained high; this had been discussed previously and a detailed report was due to be presented to the Non Clinical Governance & Risk Committee at its next meeting.

The Chairman and Mr Spinks pointed out that the report reflected a new format, showing three months data, however, not all data was complete. This was also noted in later discussions with regard to targets in the quality section. It was accepted that this could be ascribed to the change of reporting style but the Board would require all data to be completed in future reports.

Quality The outcomes for month 1 were noted. Mrs McNair highlighted a number of indicators, including the improvements resulting from the continuing work around falls and the low (zero) incidence of Clostridium Difficile recorded to date, the serious incidents reported in month and the Patient Thermometers. With regard to the latter, it was noted that whilst only one indicator on the Thermometer had a mandated target, the Trust would be required to show year on year improvements against all of the indicators and discussions were ongoing with the commissioners to determine agreed targets. As mentioned earlier, targets were not yet prescribed against all indicators; this position would be updated for the next meeting to ensure that a target was shown against each one – be it external or internally determined – or it would be made clear where targets were not applicable.

Workforce In Ms Brearley’s absence, the Chief Executive expanded on this section of the report, which showed red ratings for sickness absence and appraisals. Ms Wake referred to the additional data on sickness absence: it identified those teams with higher sickness absence levels and the actions being progressed to help them improve performance. She also commented on the reduced level of appraisals, mainly attributed to the required change to schedules. All departments had been reminded of the need to complete appraisals with the first quarter of the year, linked to the business plan, and it was anticipated that the position would improve over the next two months.

Emergency Care Pathway Action Plan (EPAP) The detailed report on the EPAP was received and noted, supporting earlier discussions on the improvements in the A&E <4 hours performance and proposals to refresh the plan shortly. Two issues were explored further in response to questions from the Non Executive Directors:

a) monies withheld through marginal rates were accrued on a community-wide basis and expenditure was overseen by the CCG through the Urgent Care Group. The funds were intended to be used to help reduce pressures on emergency care both within and outside the hospital. It was not, however, a straight forward process. Part was administered directly by the CCG as mentioned (and the Trust had received some funding through this

ET

HM


route); some elements were integral to the service contract; others were linked to the Better Care Fund and Health & WellBeing funding. It did mean that the Trust was currently running some work ‘at risk’, which would need to be closely monitored and, if necessary, stopped if funding was not forthcoming;

b) opportunity for the Board to have more awareness of the community-wide and regional work on urgent care. The Trust had disbanded its own urgent care board to link with the wider systems. Mr Peverelle expanded on the workstreams being progressed through the Health & WellBeing group and the CCG’s operational sub-group (currently chaired by Mr Peverelle), including the draft business case submitted to urgent care and the Ageing Well Programme Board. The business case had been supported in principle but the Programme Board had suggested that further action should await outcomes of the intermediate care review also ongoing. Mr Peverelle was concerned this could give rise to further delays and a lack of action in readiness for the winter pressures. The Board agreed with Mr Peverelle’s view that this issue should be escalated to the Health & WellBeing Board who were meeting, as mentioned earlier, later in the day. It was further agreed that more oversight of the work progressed through the Urgent Care Board or other community-based routes should be included in the EPAP report in future.

DWP

DWP

14/110 ANY OTHER BUSINESS & DATE OF NEXT MEETING

a) Public comments None.

b) Mr David Peverelle It was the last Board meeting Mr Peverelle would be attending prior to his retirement. On behalf of the Board, the Chairman presented Mr Peverelle with a small gift as a token of the Board’s sincere appreciation and affection. Mr Peverelle thanked the Board for their kind words.

c) Confidential matters In accordance with the Trust’s Constitution and Standing Orders, it was resolved that members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted.

d) Date of next meeting Before moving to the business of the remainder of the meeting, the Chairman confirmed the time and date of the next Board meeting: 9am on 2nd July 2014.


REF: 14/07/P-04

BoD July 2014: 04_Action log Page 1

SUBJECT: BOARD ACTION LOG

DATE: JULY 2014

PURPOSE:

Tick as applicable

Tick as applicable








The Board of Directors is asked to: a) note and approve reported progress to date, and b) review any outstanding actions.

Subject: Board Action Log Ref: 14/07/P-04


ACTIONS ON PUBLIC AGENDA Meeting date & Minute ref

Item Action Owner Action taken

June 2014 14/103

Nursing & Midwifery Staffing

Column to be added to report to Board, to show any mitigating actions taken

Dir of Nursing & Quality

Agenda item 6 refers

June 2014 14/108

2014/15 Budget Plan to be finalised for approval at July Board

Interim Dir of Finance


June 2014 14/109

Performance report Targets to be included (or clearly stated if not applicable) against all indicators

Executive Team


May 2014 14/81

Mortality Ratios Reporting format/style to be reviewed following consultation with AQuA

Medical Director


May 2014 14/84

Governance review

Criteria/guidelines to be developed for referrals to Finance Committee following dissolution of the Investment Board.

Dir of Strategy & Business Development


Feb 2014 14/33

Performance Report - general

New reporting format to be implemented from April 2014

Executive Team See agenda item 15

for developing reports (month 2) Jan 2014

14/06

Quality Account - quality and performance reporting

New reporting format for quality and performance being developed – for use from April 2014

Executive Team

Oct 2013 13/260

Integrated Performance - activity

System for appointment letters to be reviewed to ensure timely issue and reduction in DNAs (did not attend). - Report presented to Non Clinical Governance & Risk Committee (NCGRC) in February not accepted: further report presented to NCGRC June meeting

Director of Operations

Agenda item 8 refers (NCGRC)

Aug 2013 13/211

Chairman’s report - Governors’ request

Protocol for Governors’ expenses to be developed Draft policy agreed by Exec Team; reviewed at June NCGRC

Director of HR & OD


Feb 2014 14/32

CGC Review of Terms of Reference to be progressed for implementation from April 2014.

Chair of CGC/ Dir of Nursing & Quality

Agenda item 9 refers – governance restructure

Dec 2012 12/306

NCGRC Assurance report

Process for development, approval and dissemination of policies to be reviewed (“policy on policies”) May update: work progressing, due to be presented at NCGRC meeting June 2014



ACTIONS COMPLETED & CLOSED SINCE LAST MEETING Meeting date & Minute ref


June 2014 14/100

Mortality Ratios

a) Concerns around increased deaths in young people to be escalated to the Health & WellBeing Board (H&WB)

b) Data on attendances relating to “legal highs” to be shared with H&WB.

Medical Director Dir of Nursing & Quality

a) Actioned: to be picked up through the Mortality Action Plan and escalated to the H&WB

b) Completed: data sent to Chair of H&WB

June 2014 14/102

Safeguarding Adults Annual report

Narrative to be added to improve context re reported issued


Completed


Meeting date & Minute ref


June 2014 14/105

AQuA Action plan Final report to be completed and distributed to Board.

CEO Completed: distributed by email 27/6

Mar 2014 14/43

Late admissions: Emergency Department (ED)

Review of staffing and skillmix to be undertaken to ensure appropriate cover at all times


Actioned: consultant job plans for ED currently being reviewed; nursing staff on 12 hour shifts - under review. Will link to ECIST work.

Mar 2014 14/51

Governance review (Monitor documents)

Referred to Audit Committee (March 2014)

Assoc Dir of Corp Affairs

Actioned: Quality Governance Framework revised as agreed by Audit Committee; approach to Code of Governance to be revised for next Board review

July 2013 13/188

Performance report

Concerns for the Elective Care and Working Together CIPs to be recorded on the Board Assurance Framework

Dir of Finance & Information/ Assoc Dir of Corp Affairs

Actioned: will be recorded and monitored through new governance structure and escalation framework

ROLLING TRACKER OF OUTSTANDING ACTIONS (red = overdue) Meeting date & Minute Ref


June 2014 14/99

R&D Strategy

a) Follow up re reporting systems to be presented after first meeting of the R&D Strategy group (due in July)

b) Financial reporting to be reviewed

Medical Director (a) Interim Dir of Finance (b)

a) Due at August Board meeting

b) Ongoing

June 2014 14/100

Mortality Ratios Audit date on Sepsis Six to be confirmed.

Medical Director

Audit to take place in July, report to Board will follow August/September

June 2014 14/102

Generic issue: Board report format

Guidance re cover page to be issued

CEO/Chair

In progress: will be issued following agreement of new governance structure

June 2014 14/109

Performance report - Emergency Care

a) Concerns re potential delays on business case for intermediate care to be escalated to H&WB

b) More oversight on community work to be included in future reporting


a) Ongoing: issues addressed further at Urgent Care Board and Executive Team/ CCG meeting.

b) Emergency care report currently under review with ECIST support

May 2014 14/82

Medical Director’s report – EWTR/Junior Doctors

Comparative data and good practice re returns and compliance in other trusts

Medical Director

Due for next quarterly report (August)


Meeting date & Minute Ref


May 2014 14/86

Patient Flow action plan To be finalised and re-presented to the Board for approval.


Originally due June; deferred to August to be included with wider action plan supporting patient safety.

April 2014 14/65

7 Day services

Actions to be implemented if business case approved: outcome of application to CCG to be advised.

Medical Director

Presented to CCG on 07.06.2014. CCG requested to time to review the business case; subsequently requested further detail. Follow up meeting scheduled early July.

Mar 2014 14/54

Integrated performance - activity

Review of shared pathways to be presented when SLA review complete.

Dir of Finance & Info / Director of Operations

Ongoing: outcome or SLA review anticipated July-August.

Jan 2014 14/10

Emergency Care 4 hour action plan

a) Inreach model for AMU to be refined to ensure consultant ownership of each patients’ care

b) Structure of AMU to be reviewed

Medical Director


a) Review completed; subject to funding

b) Part of 2014/15 CIP programme

Jan 2014 14/14

Integrated Performance - transformation

Future reporting on EPR to include timelines

Dir of ICT Will be reflected in next report on EPR - August 2014

Nov 2013 13/299

Integrated Performance - Finance

Options for review of CQUINs to be progressed with CCG

Dir of Finance & Information

Ongoing

July 2013 13/182

HSMR Strategy to be developed Medical Director

To be progressed via Board workshop (2014), following AQUA review work. see also 14/81


REF: 14/07/P-06

BoD July 2014: 06_Nursing Midwifery Staffing

SUBJECT: MONTHLY UPDATE ON NURSING AND MIDWIFERY STAFFING

DATE: JULY 2014

PURPOSE:

Tick as applicable

Tick as applicable


PREPARED BY: Alison Bielby, Deputy Director of Nursing

SPONSORED BY: Heather McNair, Director of Nursing and Quality

PRESENTED BY: Heather McNair, Director of Nursing and Quality


The Trust Board is required to receive monthly information regarding the nursing and midwifery (trained and untrained) staffing levels across in patient areas of the Trust as per the guidance received from NHS England and the Care Quality Commission.


1. Is the Trust meeting the requirements set out by NHS England and the Care Quality Commission to review nursing and midwifery staffing levels on a monthly basis.

2. What are current nursing and midwifery staffing shortfalls across the Trust and how is this being managed?

CONCLUSION AND RECOMMENDATION(S) The paper fulfils national requirements to review staffing levels across the Trust. The paper also demonstrates planned versus actual staffing levels and mitigating action where required, for Board’s information. The Board is asked to note and support on-going mitigations being put in place to manage staffing shortfalls. Recommendations The Board is asked to note the report and support on-going mitigations being put in place to manage any staffing shortfalls.


REFERENCE/CHECKLIST



Patients

BCCG

Other

Staff

BMBC

Please state:

Governors

Monitor







Yes

Not applicable

To be developed


CGC

NCGRC

Audit Committee

Finance Commitee

ET



Finance:

Other:





Subject: Monthly update on Nursing and Midwifery Ref: 14/07/P-06

1. STRATEGIC CONTEXT

1.1 To provide the Trust Board with monthly information regarding the nursing and midwifery (trained and untrained) staffing levels across in patient areas of the Trust as per the requirements of NHS England and the Care Quality Commission.

2. INTRODUCTION

2.1 The National Quality Board (NQB) issued 10 expectations of Trusts regarding nursing, midwifery and care staffing capacity and capability in their November 2013 report “How to ensure the right people, with the right skills, are in the right place at the right time.” Expectation 7 requires Trust Boards to receive monthly updates on workforce information.

The workforce information should include: the number of actual staff on duty during the previous month compared to the planned staffing level, the reasons for any gaps, the actions being taken to address these and the impact on key quality and outcome measures.

Expectation 8 requires providers to clearly display information about the nurses, midwives and care staff present on each ward, clinical setting, department or service each shift.

In March 2014 the Care Quality Commission (CQC) and NHS England delivered further guidance regarding the implementation of these expectations, including a requirement to publish staffing data on NHS Choices.

This paper sets out the requirements to meet the above expectations and will be presented on a monthly basis to the Board.

3. BACKGROUND

3.1 BHNFT is committed to ensuring that levels of nursing staff match the acuity and dependency needs of patients in order to provide safe and effective care. Nurse staffing includes:

• Registered Nurses • Registered Midwives • Unregistered health care/midwifery care assistants • Unregistered nursing/midwifery auxiliaries.

The Trust uses an e-rostering system with duty rosters created eight weeks in advance to ensure the levels and skill mix of the nursing staff on duty are appropriate for providing safe and effective care.

This allows for contingency plans to be made where the roster identifies the planned staffing falls short of the minimum requirement, for example; where there are vacant nursing posts or staff appointed have not started in post. These contingency plans can include; moving staff from a shift which is above the minimum required level, moving staff from another ward/area which is above the minimum required level or the use of flexible/temporary staffing from the Trust’s internal bank or via an external nursing agency.

Safe staffing levels are also monitored and managed on a daily basis by the ward Sister and Matron for that clinical area. Shortfalls as a consequence of short term sickness or other unplanned leave for which cover cannot be found internally by the

BoD July 2014: 06_Nursing Midwifery Staffing Page 2

movement of staff or the use of nurse bank staff are escalated to the Heads of Nursing for authorisation of temporary staffing via a nursing agency. Details of the planned shift by shift versus the actual shift by shift staffing for the adult inpatient ward areas during May 2014 is found at appendix 1.

4. STAFFING REPORT

The planned Trustwide staffing hours for registered nurses/midwives and non-registered or care staff for days and nights in hours is summarised below.

Day Night

Registered

midwives/nurses

Care Staff

Registered

midwives/nurses

Care Staff

Total monthly planned

staff hours

Total monthly actual staff

hours


staff hours


hours


staff hours


hours


staff hours


hours 41110 33791.64 25902 24304.38 23150.25 22666.82 9174.5 9561

The average fill rates Trustwide were as follows.

Day Night

Average fill rate - registered

nurses/midwives (%) Average fill rate -

care staff (%) Average fill rate - registered

nurses/midwives (%) Average fill rate -

care staff (%) 82.2% 93.8% 97.9% 104.2%

In summary this means that 9.1% of shifts were identified as being uncovered. Of this 12.15% were registered staff shifts and 0.7% were non-registered or care staff shifts. The majority of staffing shortfalls during May were due to either short term sickness or small numbers of vacant posts. The exceptions to this are:

• Acute Medical Unit

The Acute Medical Unit (AMU) continues to have a large number of vacancies with 11 vacant nursing posts. This means that on a weekly basis 60 day shifts (7.5 hours each) were unable to be filled with the current number of staff in post during May. The unit is being supported with staff other medical wards and the use of bank and agency however there was a deficit with 15% of planned hours not being filled by this means. This situation is monitored on a day by day basis by the Matron and the Head of Nursing to ensure that the quality of care delivered is maintained. During May there have been 20 incidents reported by the risk management system (DATIX), of these 3 were related to pressure ulcers, 6 to falls and 11 to medication incidents, however incident occurrence does not correlate specifically to short staffing on particular shifts but will continue to be monitored. The vacancies were created partly due to individuals gaining promotion either in the Trust or another hospital or staffing leaving to gain further experience for professional development as well as individuals moving due to a change in personal circumstance. Although the posts have been appointed to there are a number of individuals who are student nurses who will not qualify until September 2014 and therefore the posts will

BoD July 2014: 06_Nursing Midwifery Staffing Page 3

continue to be filled using internal bank staffing or external staffing via a nursing agency.

• Care of the Elderly- Wards 19 and 20

Ward 20 has a number of vacancies that are currently being recruited to; the ward staffing is being closely monitored by the Matron and Head of Nursing and also supported by ward 28 and through the use of bank and agency. There have been 11 falls incidents reported in May however these do not correlate to shifts where the staffing was below the planned. Ward 19 has had 7 falls incidents reported in May however this does not correlate to shifts where staffing was below the planned levels.

• Trauma and Orthopaedics – Wards 33 and 34

Both of the trauma and orthopaedic wards continue to have large numbers of vacancies; ward 33 has 6.97 wte vacancies and ward 34 has 4.15 wte vacancies. Both wards continue to cover their vacant shifts through the use of the bank and agency staff however have had to utilise non registered staff in a number of instances to fill registered nurse shifts. This is being closely monitored and escalated by the Matron and the Head of Nursing and is on the risk register as a significant risk. Incidents are closely monitored and in May there was one fall and one pressure ulcer reported on ward 33 when staffing was below the plan for the number of registered nurses. On ward 34 there was one fall reported when staffing was below the planned for the number of registered nurses. Due to the risks above, and reduced demand, the Trust is currently reviewing the bed base for Trauma and Orthopaedics.

• Neonatal Unit

The Neonatal Unit is currently carrying 3.15 wte vacancies, 2.64 wte maternity leaves and 1.8 wte registered nurse sicknesses. The area is actively recruiting staff for the vacant posts.

The lead nurse covered as many of the clinical registered shifts as possible with staff being flexible in changing shifts around to maintain British Association of Perinatal Medicine (BAPM) staffing levels. Of note in May, the Neonatal Unit was quiet and the staffing was appropriate for a reduced cot capacity which happened coincidentally alongside staff short term sickness. Staffing was reviewed daily with a review of the neonates needs and where required agency/ bank staff was requested to maintain safe levels.

5. CONCLUSION

The wards display staffing levels of planned and actuals on a daily shift by shift basis. These are closely monitored by the Matrons and the Heads of Nursing and shortfalls are escalated appropriately. Following an analysis of harm to patients using the incidents reported on DATIX the only area where short staffing may have contributed is on the trauma and orthopaedic wards and the Trust has now taken action to reduce the number of beds in this area until staffing levels have increased.

Appendices:

• Appendix 1 – Nurse Staffing


APPENDIX 1

Total monthly planned staff hours

Total monthly actual staff hours







Falls (moderate and above)

Cdiff MRSA Pressure

UlcersSickness Absence

Medication Errors

14 502 - GYNAECOLOGY 1665 1612.5 870 832.5 900 900 216 216 0 0 0 0 1.26% 217 320 - CARDIOLOGY 1395 1485 1207.5 1297.5 744 744 372 372 0 0 0 0 11.35% 118 340 - RESPIRATORY MEDICINE 1560 1378.4 1162.5 1112.25 713 713 356.5 391 0 0 0 1 9.68% 119 430 - GERIATRIC MEDICINE 2025 1430.6 1627.5 1852.77 713 713 713 1026 1 0 0 2 10.89% 420 430 - GERIATRIC MEDICINE 1860 1312.5 1633.5 1695 744 744 744 828 0 0 0 1 3.24% 1

AMU 300 - GENERAL MEDICINE 3660 3112 3007.5 2760 2604 2568 1488 1512 0 0 0 2 4.59% 1123 300 - GENERAL MEDICINE 1395 1417.5 1455 1515 744 814 420 480 0 0 0 0 5.04% 224 370 - MEDICAL ONCOLOGY 1207.5 1170 855 847.5 744 744 0 0 0 0 0 0 3.30% 127 300 - GENERAL MEDICINE 1395 1395 1860 1785 744 744 744 744 0 0 0 5 5.77% 428 301 - GASTROENTEROLOGY 1672.5 1695 1380 1380 744 756 432 432 0 0 0 0 0.69% 131 100 - GENERAL SURGERY 2010 1370.35 1116 1357 713 713 713 805 0 0 0 3 10.91% 232 100 - GENERAL SURGERY 1425 1207.5 1132.5 1342.5 744 744 372 372 0 0 0 1 8.28% 133 110 - TRAUMA & ORTHOPAEDICS 1710 1312.5 1395 1560 744 744 744 744 0 0 0 2 8.47% 034 110 - TRAUMA & ORTHOPAEDICS 1620 1170 1395 1597.5 744 744 372 372 0 0 0 0 6.28% 0ITU 192 - CRITICAL CARE MEDICINE 3720 2761.25 547.5 338.5 2332.75 2139.5 0 0 0 0 0 0 1.03% 1

SHDU 192 - CRITICAL CARE MEDICINE 775 762.5 412.5 237.5 713 713 0 11.5 0 0 0 0 3.26% 0CCU 320 - CARDIOLOGY 1545 1545 465 442.5 1116 1116 0 0 0 0 0 0 1.71% 012 501 - OBSTETRICS 2940 2182.81 1590 906.09 1488 1491.32 744 480 0 0 0 0 2.28% 037 171 - PAEDIATRIC SURGERY 1575 1497.68 1395 637.76 1069.5 1264.25 0 80.5 0 0 0 0 4.03% 015 192 -CRITICAL CARE MEDICINE 2025 1602.03 930 397.76 1488 1357.25 372 372.75 0 0 0 0 10.44% 1

Labour Suite 501 - OBSTETRICS 3720 2371.52 465 409.75 2604 2200.5 372 322.25 0 0 0 0 6.41% 0Trust Total: 40900 33791.64 25902 24304.38 23150.25 22666.82 9174.5 9561 1 0 0 17 1.1891 33

Ward name Ward Specialty

Day NightRegistered midwives/nurses Care Staff Registered midwives/nurses Care Staff

REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT REF: 14/07/P-07

SUBJECT: HOSPITAL STANDARDISED MORTALITY RATIO (HSMR) AND SUMMARY HOSPITAL MORTALITY INDICATORS (SHMI)

DATE: JULY 2014

PURPOSE:

Tick as applicable Tick as

applicable For decision/approval Assurance

For review Governance For information √ Strategy

PREPARED BY: Dr Jugnu Mahajan, Medical Director SPONSORED BY: Dr Jugnu Mahajan, Medical Director PRESENTED BY: Dr Jugnu Mahajan, Medical Director STRATEGIC CONTEXT 2-3 sentences

Meets the requirement to provide high quality and safe services: Strategic Objective 1a.


1. Does the report provide an update on mortality figures for both HSMR and SHMI? 2. Does this report provide a progress report on the actions to reduce HSMR to 105 by end of

the year? 3. Does this report give an update on external reviews of mortality?

CONCLUSION AND RECOMMENDATION(S) • The Trust position for SHMI remains in the ‘as expected’ range • HSMR for the rolling 12 months up to January 2014 shows a slight reduction. • Crude Mortality has remained below the mean with significant low figures in May 2014 • A very successful workshop was held on 13th June 2014 to develop an action plan to

address recommendations of the AQuA and Fletcher reports. The action plan will be brought to the August Board.

Recommendation • Note the Trust’s performance on hospital mortality and progress against actions being

taken to reduce mortality in the Trust

REFERENCE/CHECKLIST


Meets the requirement to provide high quality and safe services: Strategic Objective 1a.


Patients

BCCG

Other

Staff

BMBC

Please state:

Governors

Monitor







Yes

Not applicable

To be developed


CGC

NCGRC

Audit Committee

Finance Commitee

ET


High mortality is a patient safety indicator and a risk to patient safety. High mortality may adversely affect the Trusts’ reputation.


Finance:

Other:




Subject: Hospital Standardised Mortality Ratio and Summary Hospital Mortality Indicator Ref: 14/07/P/07

1 STRATEGIC CONTEXT

This report covers performance on mortality ratios and action plans which relate to Strategic Objective 1c: Patients will experience safe care.

2 INTRODUCTION

2.1 This report provides the latest available mortality figures and an update on the mortality action plan.

2.2 The mortality figures presented included

• Summary Hospital Mortality Indicator values (SHMI) for October 2012 – September 2013 as pre-released by the Health and Social Care Information Centre

• the current Hospital Standardised Mortality Ratio (HSMR) position including the latest month’s data for January 2014 (12 months rolling figure). The HSMR data for February 2014 is not available as there has been delay in receiving the production of HES data nationally.

• additional information to support outstanding changes in the rolling 12 month figure, and to ensure transparency of when any individual month has a high HSMR, the monthly figures will be routinely included, as shown in Appendix one hospital’s Crude Mortality Rate including the latest month’s data for April 2014

• a summary of the action plan to date

3 SUMMARY HOSPITAL MORTALITY INDICATOR

3.1 Latest 12 Month Value is from October 2012 – September 2013

3.2 The Trust’s SHMI position for October 2012 to September 2013 is 107.2 (89 – 112). BHNFT remains in the band two ‘as expected’ group.

3.3 BHNFT's national position is 35 of 141 hospitals. BHNFT has the 4 highest SHMI in the Yorkshire and Humber region

BoD June 2014: 07_a_HSMRRatios Page 1

100

105

110

115

Apr-

12

May

-12

Jun-

12

Jul-1

2

Aug-

12

Sep-

12

Oct

-12

Nov

-12

Dec-

12

Jan-

13

Feb-

13

Mar

-13

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec-

13

Jan-

14

Apr-12

May-12

Jun-12

Jul-12

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13

Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

HSMR 114 112 113 111 112 111 111 108 110 111 111 110 111 112 113 113 112 111 112 113 112 111

4 HOSPITAL STANDARDISED MORTALITY RATIO

4.1 Latest rolling 12 Months, February 2013 – January 2014, Yorkshire and Humber Non Specialist Trusts is presented. The 12 Month rolling HSMR up to the month of January 2014 is 111. This has again fallen slightly from last month’s rolling value of 112.

4.2 This table shows the latest rolling 12 Months HSMR.

4.3 The initiatives taken so far to reduce HSMR and avoidable deaths are outlined in appendix two

4.4 The trajectories for reduction in mortality are shown in appendix three

BoD June 2014: Mortality Ratios Page 2

0.0%0.5%1.0%1.5%2.0%2.5%3.0%3.5%4.0%4.5%

2011/1

2 Q1

2011/1

2 Q2

2011/1

2 Q3

2011/1

2 Q4

2012/1

3 Q1

2012/1

3 Q2

2012/1

3 Q3

2012/1

3 Q4

2013/1

4 Q1

2013/1

4 Q2

2013/1

4 Q3

% of HSMR Admissions with a Palliative Care CodeHighest 3 and Lowest 3 Yorks & Humber Non Specialist Trusts

Rotherham NHS FT

Hull & East Yorks NHS Trust

Barnsley NHS FT

York Teaching NHS FT

Sheffield Teaching NHS FT

Bradford Teaching NHS FT

10

15

20

25

30

35

40

45

May

-07

Jul-0

7Se

p-07

Nov

-07

Jan-

08M

ar-0

8M

ay-0

8Ju

l-08

Sep-

08N

ov-0

8Ja

n-09

Mar

-09

May

-09

Jul-0

9Se

p-09

Nov

-09

Jan-

10M

ar-1

0M

ay-1

0Ju

l-10

Sep-

10N

ov-1

0Ja

n-11

Mar

-11

May

-11

Jul-1

1Se

p-11

Nov

-11

Jan-

12M

ar-1

2M

ay-1

2Ju

l-12

Sep-

12N

ov-1

2Ja

n-13

Mar

-13

May

-13

Jul-1

3Se

p-13

Nov

-13

Jan-

14M

ar-1

4M

ay-1

4

Crude Mortality Rate per 1000 Discharges* Mean Lower Control Limit Upper Control Limit

5 CRUDE MORTALITY RATES FOR BARNSLEY HOSPITAL NHSFT 5.1 Crude Mortality Rates (latest month May 2014)

Financial Year No. of Deaths No. of Discharges* Crude Mortality Rate per 1000 Discharges*

2007/08 1052 37651 27.9 2008/09 1062 40028 26.5 2009/10 1072 42583 25.2 2010/11 1051 40914 25.7 2011/12 1012 42023 24.1 2012/13 1034 42588 24.3 2013/14 1021 42551 24.0 2014/15 YTD 141 7161 19.7 * excludes Day cases unless a death

5.2 Statistical Process Control (SPC) Chart, Crude Mortality Rate, BHNFT

5.3 The table and the SPC chart, above shows the trends in Crude Mortality in the Trust.

Since the peak in mortality in April 2013, Crude Mortality rates have been on or below the mean.Crude mortality for May 2014 is the lowest seen on this 7 year SPC chart.

6. PALLIATIVE CARE CODING

6.1 These charts show the variation in the prevalence of Palliative Care and Co-Morbidity coding in the HSMR Group. It is clear that Rotherham and Hull Hospitals are delivering and coding more Palliative Care than other Yorkshire and Humber Hospitals. Variation is also seen in comorbidity coding.


3.0

3.5

4.0

4.5

5.0

5.5

6.0

6.5

7.0

2011/1

2 Q1

2011/1

2 Q2

2011/1

2 Q3

2011/1

2 Q4

2012/1

3 Q1

2012/1

3 Q2

2012/1

3 Q3

2012/1

3 Q4

2013/1

4 Q1

2013/1

4 Q2

2013/1

4 Q3

HSMR Admissions, Average Comorbidities per AdmissionHighest 3 and Lowest 3 Yorks & Humber Non Specialist Trusts

Airedale NHS FT

Hull & East Yorks NHS Trust

North Lincs & Goole NHS FT

Barnsley NHS FT

Bradford Teaching NHS FT

Sheffield Teaching NHS FT

7. OVERARCHING MORTALITY DRIVER DIAGRAM

Aim Primary Devices Secondary Devices

To reduce avoidable deaths

Reduce HSMR to 105.0 by January

2015

Clinical Care

Reliable Care Systems

Leadership

Documentation and Informatics

End of Life Care

• Implement evidence base care pathways

• Strategies to reduce harm • Ensure scrutiny of all deaths

• Implement 7 Day Services Keogh Standards

• Robust escalation systems • Reliable reporting and acting

on Never Events

• Effective communication of mortality statistics

• Clinicians take responsibility for processes – monitored by Performance Meetings

• New CBU structures to prioritise mortality as CBU business

• Improvement of competences of coding

• Improvement in Clinician – coder interface

• Improvement in documentation in notes

• Ensuring skill mix adequate in Clinical Coding

• Improve opportunities for people to die in preferred place

• Review of End of Life Care extension to 7 Day Service


7.1 Presented here is an overarching Mortality Driver diagram which outlines the primary

and secondary drivers which influence mortality. In the past year we have focused on improving care provisions in all these areas however the main priorities have been ‘Clinical Care’, implementing ‘Reliable Care Systems’ and documentation and informatics’.

7.2 With the new Clinical Business Unit (CBU) structure it is anticipated that clinical

leadership will be strengthened and organisational ‘buy in’ into this area will further improve. Further plans to improve End of Life care will also be developed in this year.

8. GOALS AND PRIORITIES TO REDUCE AVOIDABLE DEATHS IN THE TRUST 8.1 Goal 1:- Delivering Consistently Effective Care

How will we do it? Improving outcomes and effectiveness means saving lives, improving the quality of life for our patients, speeding up their recovery and reducing readmissions. The Trust will achieve the improved health outcomes through delivery of safe, effective and evidence-based care. What are our priorities?

How will we measure progress? The Trust will use SHMI and HSMR to measure progress in our reductions of avoidable deaths. The Trust will also build on learning from best practice examples to improve the quality of health outcomes for our patients. There is a commitment to continuous improvement and challenge to ensure that there is appropriate modification of key indicators of care and that reflection on the results of audits and enquires is embedded throughout the Trust. The Trust’s quality improvement and performance dashboards will continue to be used to assist the Trust in understanding the quality of care we are providing and monitor our performance against these priorities. Targets for 2014/15 • reduce the number of avoidable in hospital deaths, The Trust’s rolling 12 month HSMR value up to December 2013 is 111.8. The

Trust aims to reduce this rate further to 105.0 by January 2015 and 100.0 by January 2016.

The Trust’s SHMI latest pre-release position (12 month period, October 2012 – September 2013), is 107 and is ‘as expected’, Band 2.

• improve recognition and management of the deteriorating adult patient, The Trust implemented National Early Warning Score, (NEWS), across the

organisation in January 2014. By April 2015 the Trust aims to demonstrate 95%

• Reduce the number of in hospital avoidable deaths;

• Improve recognition and management of the adult deteriorating patient;

• Improve sepsis recognition and response; and

• Ensure scrutiny of all in hospital deaths to ensure learning is achieved where possible.

• Reduce Avoidable Deaths

• Measured by Reduction in HSMR to 105.0 by January 2015


compliance with the implementation of NEWS in the adult patient. Audit will commence in July 2014 auditing notes from 1 April 2014 – 31 May 2014 with a plan to re-audit six months after.

• improve sepsis recognition and response, As at January 2014 the Trust was 8% compliant with the implementation of

the Sepsis Six Bundle. By April 2015 the Trust aims to increase this to 95% compliance. The next Sepsis Six Bundles audit is scheduled for July 2014, auditing June’s activity, the results of this audit will be published in August 2014.

• ensure scrutiny of all in hospital deaths to ensure learning is achieved where possible From April 2014 the Trust has implemented a formal process for reviewing all in hospital deaths. By April 2015 the Trust aims to formally review 95.0% of all applicable in hospital deaths within 15 working days of the death occurring.

8.2 Goal 2:- Delivering Consistently Safe Care How will we do it? Delivering consistently safe care means taking action to reduce harm to patients in our care and protecting the most vulnerable. It means ensuring that the workforce receives the right education and training in preparation for the delivery of competent and skilful intervention. The organisation is committed to ensuring that service users are cared for in surroundings which are clean, by caring and competent staff. This organisation wants to eliminate hospital acquired, infections, medication errors, VenousThrombo-Embolism (VTE), patient falls, pressure ulcers and other examples of harm which can occur within a healthcare setting. What are our priorities?

How will we measure progress? In order to know whether we have been successful in achieving our priorities, the Trust will report progress through the Quality, Safety, Improvement and Effectiveness Board (QSIEB) in the monthly Safety and Quality Report. Information and data will also be monitored at local clinical specialty level and at Clinical Business Unit level to ensure lessons are learnt, improvements to care are identified and implemented and best practice is shared. Targets for 2014/15 • To reduce hospital acquired harms in relation to VTE, Falls, Catheter-Associated

Urinary Tract Infection (CAUTI) & Pressure Ulcers For 2014/15 the Trust aims to reduce hospital acquired harms in relation to

VTEs, Falls, CAUTIs and Pressure Ulcers with the aim of achieving the national

• Reduce Hospital acquired harms, VTE, Falls, CAUTIs & Pressure Ulcers to national average

• Reduce inpatient falls by 50% by January 2015

• To reduce hospital acquired harms in relation to VTEs, Falls, CAUTIs & Pressure Ulcers;

• Reduction in inpatient falls; • To improve clinical note keeping standards

thereby ensuring robust patient assessments and plans of care.


average for harm free care against all areas; VTEs, Falls, CAUTIs and pressure ulcers. Each area will be monitored separately.

• Reduction in inpatient falls Since April 2013, (to January 2014), the Trust has reported 895 inpatient falls.

For 2014/15 the Trust aims to reduce the number of inpatient falls by 50%. • To improve clinical note keeping standards thereby ensuring robust patient

assessments and plans of care To achieve 75% compliance with 2014/15 clinical note keeping standard audits.

8.3 Goal 3:- Enhancing Clinical Leadership How will we do it?

Embedded clinical leadership at service delivery level with a focus on improved quality of care prevents avoidable deaths. Both nursing and medical leadership along with General Manager at CBU level will ensure effective and safe care is delivered. What are our priorities? Target for 2014 • To reduce sickness absence to 3.5%. • To demonstrate 90.0% compliance with staff appraisals • To demonstrate 90.0 % compliance with mandatory training

How we will measure progress The Trust will monitor the number of appraisals undertaken to ensure that all staff have appropriate objectives aligned to Trust objectives, values and behaviours. Skill mix of nursing will be monitored and reported to the Board on a six monthly basis. A record of training undertaken by all staff will be held and areas for improvement identified. The staff survey will be used as a measure to identify improvement.

8.4 Goal 4:- Documentation and Informatics How will we do it?

We will work with each CBU to review the quality of documentation and the associated quality of coded data. The rolling programme of clinical coding audits at a specialty/department level will continue. Audit processes for the quality of documentation will be introduced. A restructure of the Clinical Coding team is planned within the next 6 – 12 months this will introduce senior posts that can provide improved audit and training functions.

• Adequate nursing members and skill mix

• New CBU structure • Supervisory Band 7 • Extended AMU

consultant cover to 16 hours (8 am – mid night) by March 2015

• Regular daily reporting of nursing members and skill mix

• Review of skill mix and team structure to ensure that we have the right people with the right skills at the right time

• Recruitment of AMU consultants to full establishment


What are our priorities? Target for 2014/15 Increase average number of co-morbidities per spell to at least the regional average. Improve documentation quality, objectives to be set after ample audits completed. Whilst this target has been set there is still an expectation that we will see a continuous increase in engagement between CBUs, Clinicians and coders throughout the year. Compliance will be identified through re-audits any lessons that can be learnt will be shared with the CBU’s.

8.5 Goal 5:- End of Life Care How will we do it? End of Life care in BHNFT is being developed in accordance with the Barnsley End of

Life Care Strategy and Vision. The strategy is inclusive of all life limiting illness and recognises that delivery of compassionate and high quality care is everybody’s business. The district wide end of life care strategy group provides strategic direction for the local developments.

What are our priorities? Target for 2014/15

Measurable targets for 2014/15 are in the process of being set. Amber Care Bundles have been introduced on four wards and the plan to roll out on a further two wards. Last days of life care pathway is to be developed in the next six months. Work has started on End of life care pathways and further national guidance is awaited.

9. ON-GOING ACTIONS 9.1 Mortality Reviews

Patient deaths are being reviewed within CBUs however there has not been a standardised approach to this throughout the Trust to date. The hospital’s revised

• Improve documentation of primary conditions and co-morbidities

• Appropriate clinical coding team skill mix

• Implement documentation reviews this will be implemented within 6 months by working closely with the CBUs

• Improve depth of coding for each clinical area

• Implement trainee posts in clinical coding

• Implement senior posts in clinical coding to include training and audit roles

• Identification of end of life care needs

• Care planning • Coordination of care • Development of high

quality care • Last days of life care • Care after death

• Introduction of AMBER Care Bundles

• Last days of life care • Last days of life care pathways


Mortality Review Process will ensure that the review of all patient deaths is standardised throughout the Trust. There will be a clear review structure that meets the duty of candour and ensures the process is open and transparent. Any lessons that can be learnt will be shared throughout the Trust, with action plans developed as required. The review process has been launched on 1st April 2014. A Mortality Case Note Review will be performed by the Consultant responsible for the patient’s care, within 15 working days of death. The Mortality Review Group, who meets on a weekly basis, has started reviewing all Mortality Case Note Reviews. Where there is any cause for concern relating to the patient’s death, the death will be referred for a ‘Clinical Business Unit Multi-disciplinary Mortality Review’. The CBU Multi-disciplinary Mortality Review will be conducted by the consultant responsible for the patient’s care and the Lead Nurse from the ward/clinical area where the patient died. This will be completed within 15 working days of referral from Mortality Review Group. This review will be presented to the CBU by the Consultant and Lead Nurse. This will constitute a peer review of the patient’s death. Lessons learnt from the mortality review will be shared across the CBU.

The Mortality Steering Group will review all Mortality Case Note Reviews and CBU Multi-disciplinary Mortality Reviews. Any lessons learnt from the mortality reviews will be shared through exception reporting to QSIEB.

9.1.1 Update from May 2014 A new Mortality Review process has been established whereby every in-patient death will be reviewed by the Consultant responsible for the patient – a standardised Mortality Review form is being used. In cases where there are issues of concern, a more detailed in-depth review will be carried out by the Consultant and the Lead Nurse of the clinical area where the patient died; again a standardised form will be used. The in-depth review will be reviewed at the CBU Governance committee (forming a peer review) and this will be presented to the Mortality Steering Group. So far the issues identified and the mitigation offered is as below. Issue Detail Mitigation • Introduction of

new system • Issues of embedding new process • Weekly Mortality

Review meeting is reviewing this

• Completion of Mortality Review forms

• Issues of embedding new process whilst previous CSU processes in place

• Weekly Mortality Review meeting is reviewing this

• Management of new process

• On–going management of the process, to ensure that the process is supported and that all deaths are reviewed within the timescale

• Weekly Mortality Review meeting is reviewing this

9.1.2 Update from July The new Mortality Review process has now been established whereby every in-patient death is being reviewed by the Consultant responsible for the patient – a standardised Mortality Review form is being used So far the issues identified and the mitigation offered is as below.

Issue: Detail: Mitigation: Introduction of new system

Process of initial Mortality Review commenced – and being completed

Weekly Mortality Review meeting is reviewing this


Completion of Mortality Review forms

Variation in completion of initial Mortality Reviews being completed and/or with deadline

CBU Clinical Directors are informed of compliance Consultants/CBU CD are being provided with monthly reporting of reviews undertaken (draft report proforma attached)

Management of new process

On-going management of the process, to ensure that the process is supported and that all deaths are reviewed within the timescale CBU Governance meetings to take in depth mortality reviews

Weekly Mortality Review meeting is reviewing this CBU structures evolving. Compliance is discussed at Performance meetings Further work is being done to improve the forms to make them more user friendly.

9.2 The Deteriorating Patient

9.2.1 National Early Warning Score (NEWS) Following completion of a pilot of the National Early Warning Score (NEWS), it was decided in January 2014 to implement NEWS across BHNFT for all adult patients. An escalation pathway was formulated to reflect national and local requirements. This has been incorporated into ‘Recognising and responding to the Acutely Ill Adult Patient: Including Sepsis Recognition and Treatment’ document. In order to ascertain that our hospital has implemented NEWS effectively a clinical audit is to be undertaken at the end of April 2014. The audit will initially cover 60 sets of patient healthcare records: 30 from medicine, 20 from surgery and 10 from the Emergency Department. This will be a retrospective audit of healthcare records from discharged patients and will include records of deceased patients. The outcome of this audit will be communicated through the quality and governance structures of the organisation. The outcomes of the audit will direct and focus further efforts in ensuring good levels of implementation and compliance. There will be an additional audit, the timeframe for which will be determined by the outcome of this initial audit. The Trust has a target to demonstrate 95% compliance with the implementation of NEWS by April 2015. Whilst this target has been set there is still an expectation that we will see a continuous increase in compliance throughout the year. Compliance will be identified through re-audits and the results of these will be reported accordingly.


9.2.1.1 Update from May 2014

NEWS was adopted for all adult patients (excluding obstetric patients) in January 2014. All areas follow the same escalation pathway for the deteriorating patient with the exception of the ED/AMU

Issue Detail Mitigation • NEWS Charts for

ED/AMU • Incorrect Charts

delivered from Printers – underlying issues following transfer of contracts

• Artwork drafted and approved – printed and suitable for use

• Use of NEWS in PACU and transfer to wards

• Patients score a 2 in PACU routinely for supplemental oxygen – generating escalation

• Task and finish group (patient safety champion from areas) formed.

9.2.1.2 Update from June 2014

NEWS was adopted for all adult patients (excluding obstetric patients) in January 2014. All areas follow the same escalation pathway for the deteriorating patient with the exception of the ED/AMU.

A Trust wide audit of NEWS and Escalation is to be undertaken in July.

Issue: Detail: Mitigation: NEWS incorporated into Corporate Training Plan

All nursing (registered and non-registered staff) to undertake online (through NLMS) eLearning module on NEWS and taught session on NEWS and BHNFT associated escalation.

Two sessions per month scheduled in Education Centre – to be booked through Education Centre. Note these sessions are also open to staff as a refresher.

Publicising NEWS and Escalation

A3 poster designed incorporating NEWS and sepsis screening

New posters to be distributed to June Patient Safety Champions (PSC) meeting

9.2.2 Patient Safety Champions (PSCs) Patient Safety Champions have been appointed for all clinical areas and specialities, they will be responsible for key projects related to patient safety, such as NEWS and Sepsis. Issue Detail Mitigation • Establishment of

PSC’s • Lead Nurses and AHP’s

appointing PSC’s • Inaugural meeting

• Representation from medical staff

• Associate Medical Director has emailed Clinical Directors to nominate staff.

• Discussed at Medical staff committee and champions have been identified.


9.2.3 Sepsis Recognition and Management Tool incorporating Sepsis Six Care

Bundle The adult observation chart incorporates NEWS and the associated Escalation Pathway, also includes the Sepsis Screening and Management Tool. A number of patients who deteriorate in the acute hospital settings have an infection and develop sepsis. Sepsis is a recognised and under identified cause of deterioration in adult patients in acute hospital settings. The Sepsis Six Care Bundle has been demonstrated to reduce mortality from sepsis. All patients identified as having sepsis should be commenced on the Sepsis Six bundle of care within an hour of recognition. The timings of this should be documented on the Fluids, Antibiotics, Blood Cultures, Urine, Lactate, Oxygen, Sepsis Six (FABULOS) stickers and page four of the Observation Chart. A pilot audit completed in February 2014 demonstrated poor compliance with the Sepsis Six Care Bundle. Patient Safety Champions from both the nursing and medical teams have been nominated in clinical areas to support the implementation of initiatives such as NEWS and Sepsis Recognition and Management Tool. Whilst this is a Trust-wide re-launch of the Sepsis Six Care Bundle there will be an initial focus on three defined clinical areas; Emergency Department, Acute Medical Unit and Surgical Decisions Area. An audit will be undertaken in these three areas in July 2014 to confirm there has been a successful re-launch of the Sepsis Six Care Bundle. Assuming the audit provides the level of assurance required, the roll out of implementation will continue in 8 weekly cycles across individual clinical areas. Each cycle of change will be supported by a re-audit. We believe that by supporting the re-launch and implementation of the Sepsis Six Care Bundle with the PDCA process; plan–do–check–act, the continuous improvement of the implement of this process will be effective and sustainable throughout the organisation. The Trust has a target to demonstrate 95% compliance with the implementation of Sepsis Six Care Bundle by April 2015. Whilst this target has been set there is still an expectation that we will see a continuous increase in compliance throughout the year. 9.2.3.1 Update from May 2014

A Screening and Management Tool for the early recognition and treatment of sepsis was introduced in August 2013. Recent audit showed compliance with all components of Sepsis Six with 1 hour to be 8%.

Issue Detail Mitigation • Sepsis Six to be re-

launched 1. Audit presented at April

QSIEB 2. Sepsis Six re-launched

from April 3. To be part of role of PSC 4. Publicity to on Intranet and

distributed to clinical areas

1. Completed 2. Ongoing 3. Ongoing 4. May 2015

• Availability of FABULOS sticker

Printers – underlying issues following transfer of contracts

Artwork drafted and approved – printed and suitable for use May 2014


9.2.3.2 Update from June 2014

A Screening and Management Tool for the early recognition and treatment of sepsis was introduced in August 2013. Recent audit showed compliance with all components of Sepsis Six with 1 hour to be 8%. In June as part of weekly review of Mortality Reviews, a case note review of all patients identified in the Review as having evidence of sepsis is undertaken. This has been circulated to Lead Nurses and will be circulated to consultants. An audit of Sepsis Six compliance is to be undertaken in July.

Issue: Detail: Mitigation: Sepsis Six to be re-launched

1. Audit presented April QSIEB 2. Sepsis Six re-launched from April 3. To be part of role of PSC 4. Publicity to on Intranet and distributed to

clinical areas 5. Sepsis Trust posters on Sepsis Six have

been distributed to June PSC meeting 6. Audit of compliance

Completed On-going On-going On Intranet June June 2014 July 2014

Availability of FABULOS sticker

Printers – underlying issues following transfer of contracts

Resolved – FABULOS stickers available to order

9.2.6 Community Acquired Pneumonia (CAP) Care Bundle

During March 2014 the CAP Care Bundle has been implemented in the ED and AMU. Plans are to implement for an additional eight weeks and then audit levels of implementation. Feedback of the audit will be reported to the Mortality Steering Group where a process of continuous audit will be monitored and actions to improve levels of compliance will be agreed.

9.2.7 Understanding our Patient Safety Culture A Staff Survey is currently running using the Manchester Patient Safety Framework to review how our staff views the organisation and patient safety. This survey can be accessed through the Intranet Homepage.

9.3 End of Life Care (Update from May 2014)

End of Life care in BHNFT is being developed in accordance with Barnsley’s End of life care strategy and vision. The district wide end of life care strategy group provides strategic direction for the local developments, within BHNFT this is led by the end of life care steering group. The Specialist Palliative Care (SPC) team provide clinical leadership for palliative and end of life care in BHNFT and they work in close partnership with Barnsley Hospice and SWYPFT end of life care team who are commissioned to provide generalist training and support for the use of nationally recommended end of life care developments across health and social care providers in Barnsley.


What are our priorities? • Identification of end of life care needs Introduction of AMBER care bundle • Care Planning Replacement of Liverpool care pathway

(LCP) • Coordination of care 7 day week working SPC • Development of high quality care Training needs analysis • Last days of life care Proactively seek bereaved carer feedback • Care after death

Targets for 2014/2015 The publication of the care of the dying audit in May 2014 has provided a benchmark for BHNFT end of life care against national Key Performance Indicators (KPI) and an action plan is currently being developed as an outcome of this audit; the above priorities will be reflected in this action plan. As a result of the recent independent review of the Liverpool Care Pathway (LCP) in July 2013 national guidance is that the LCP and adapted versions are replaced by an individualised care plan for the last days of life by July 2014. This is currently being developed and piloted with the aim to introduce in July and it is recognised that this will require significant education and clinical support and will take time to embed in practice. The AMBER care bundle is a nationally recognised tool to support identification of end of life care needs (last 1-2 months of life), good planning and recognition of a person’s preferences and wishes. The need to communicate uncertainty about prognosis is clinically challenging and education about the AMBER care bundle aims to improve this. The AMBER care bundle has currently been introduced in six clinical areas and it is aimed that it will be rolled out to all medical wards by the end of the year. Whilst it is recognised that numbers are relatively small and this project remains in its infancy early audits appear to show that it has helped recognition of end of life care need, improved communication, coordination and patient involvement and reduced readmissions for those discharged. 9.3.1 Update from June 2014

The AMBER care bundle has now been used to support 116 patients. It is being used on 6 wards (including CCU) Ward 20 the most recent ward. Training is being completed on ward 23 hopefully to start using the bundle in July. An interim report considering the first 6 months of the project has shown improvement in documentation of medical planning, and escalation decisions, improved documented communication between doctors and nurses and improved documentation of patient and carer discussions. Majority of patients had a non cancer diagnosis and 42% were discharged. The initial numbers are small so although figures suggest reduced readmissions it is difficult to establish the significance of this at present. The new care plan for last days of life care to replace last days of life care pathway is currently being piloted and will be introduced in July and the existing pathway will no longer be used. The introduction will be supported by additional education which has started across the trust. This care plan will be used by community, hospice and care home providers in Barnsley


Following the BHNFT findings from national audit for care of the dying an action plan is currently being developed.

10 INDEPENDENT REVIEW OF DEATHS IN APRIL 2013

10.1 The report of the above review performed by Dr Alan Fletcher was presented at the

Clinical Governance Committee and discussed in detail.

10.2 A combined action plan for both the reports (AQuA & Fletcher) is being developed as part of theoverall mortality action plan .

11. AQuA MORTALITY REVIEW: MARCH 2014

11.1 The final report has now been received. A top level presentation was made to the

Executive Team. A workshop was held on 13th June 2014 to review the recommendations of both the AQuA Mortality Review report and the report following the independent review of deaths by Dr Alan Fletcher. The workshop identified key actions for the Trust to implement in response to all recommendations made. A Trust-wide action plan is now in the process of being developed and will be presented in August to the Board of Directors for approval. The implementation of the action plan will be continuously monitored by the Quality & Governance Committee.

11.2 The Executive summary and recommendations of the final report is to be

communicated with all staff under the direction of the Medical Director and the Director of Communications and Marketing.

12. PERFORMANCE MONITORING HSMR AND SHMI REDUCTION PLAN FOR

CALENDAR YEAR 2014

12.1 Appendix three (Performance Monitoring HSMR and SHMI Reduction Plan for Calendar Year 2014) shows mortality indicator reduction targets and their ongoing performance. This appendix also includes the performance monitoring of workstreams likely to contribute to these reductions. This is a working document and actions will be incorporated in the action log which is reviewed and updated at the Mortality Steering Group.

Appendices: • Appendix 1 – Monthly HSMR figures • Appendix 2 – Time Line of actions completed • Appendix 3 – Performance Monitoring HSMR and SHMI Reduction Plan for Calendar Year


HSMR by Month: Current & Previous Financial Year, BHNFT [email protected]

The main report on mortality rates presents the rolling 12 months HSMR as the most stable indicator of mortality rates. Monthly HSMRs are volatile, due to the relatively small numbers involved and this is reflected in the wide confidence intervals (95%).

To provide additional information to support understanding of changes in the rolling 12 month figure, and to ensure transparency of when any individual month has a high HSMR, the monthly figures will be routinely included as an appendix to the main report.

The months highlighted in bold in the table show months that “alert” due to a high HSMR. The alert is triggered where the lower confidence interval is above 100. When an alert occurs this will be reviewed by the Mortality Steering Group and individual action taken. For example for December 2012 and April 2013, internal reviews and external reports have been commissioned to examine if there any significant contributing factors that require action to be taken.

Month HSMR Month

Number of Expected Deaths

Number of Deaths

95% Lower CI

95% Upper CI

Apr-12 115.3 74.6 86 92.2 142.4

May-12 102.7 77.0 79 81.3 127.9

Jun-12 108.3 64.6 70 84.5 136.9

Jul-12 103.7 66.6 69 80.7 131.2

Aug-12 125.0 64.8 81 99.2 155.3

Sep-12 104.8 63.9 67 81.2 133.1

Oct-12 95.8 61.6 59 72.9 123.6

Nov-12 89.0 79.8 71 69.5 112.2

Dec-12 133.7 83.8 112 110.1 160.8

Jan-13 111.8 86.8 97 90.6 136.4

Feb-13 107.6 76.2 82 85.5 133.5

Mar-13 114.0 81.6 93 92.0 139.7

Apr-13 134.7 65.3 88 108.0 165.9

May-13 109.1 66.0 72 85.3 137.3

Jun-13 123.1 63.4 78 97.3 153.6

Jul-13 104.0 66.3 69 80.9 131.6

Aug-13 113.1 63.7 72 88.5 142.4

Sep-13 100.1 66.9 67 77.6 127.1

Oct-13 100.5 68.6 69 78.2 127.2

Nov-13 107.2 69.0 74 84.2 134.6

Dec-13 115.6 77.9 90 92.9 142.1

Jan-14 108.3 85.9 93 87.4 132.7

Feb-14

Mar-14

Monthly HSMRs are volatile, due to the relatively small numbers involved. This is reflected in the wide confidence intervals (95%)

Appendix 1

mailto:[email protected]

6080

100120140160180

Apr-

12

May

-12

Jun-

12

Jul-1

2

Aug-

12

Sep-

12

Oct

-12

Nov

-12

Dec-

12

Jan-

13

Feb-

13

Mar

-13

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec-

13

Jan-

14

BHNFT Monthly HSMRs with 95% CIs Green Represents the latest 12 month period

June 2014

Produced By: [email protected]

Tel: 01226 433951

Date: 17th December 2013

Version: 1.0

File Location:

Management Information Services Report

Performance Monitoring

HSMR & SHMI Reduction Plan

For Calendar Year 2014

This report contains performance data related to workstreams which will

contribute to Barnsley Hospital's HSMR & SHMI reduction plans.

Contents

HSMR Reduction Target

SHMI Reduction Target

CCS Latest Rolling 12 Month

Serious & Safety Incidents

Sepsis Bundles

CCS Rolling 12 Months Trend

-

Barnsley Hospital NHS FT

Appendix 2

mailto:[email protected]

HSMR Reduction Target: Barnsley Hospital NHS Foundation Trust

Set December 2013

Owner Dr J Mahajan, Medical Director

Sepsis Bundles Pneumonia Bundles

Reduce Patient Safety Incidents (Severe & Moderate Harm)

Reduce Inpatient Deaths End of Life Care Amber Care Bundles

Mortality Reporting Streamline Process

Increase Clinician Involvement

Reduce Serious Incidents and Never Events

NEWS & Escalation

-A target HSMR of 105.0 for the calendar year 2014 period -Reduction from 2012/13 HSMR (110.3)

HSMR data is released monthly

90

95

100

105

110

115

Mar

-13

Ap

r-1

3

May

-13

Jun

-13

Jul-

13

Au

g-1

3

Sep

-13

Oct

-13

No

v-1

3

De

c-1

3

Jan

-14

Feb

-14

Mar

-14

Ap

r-1

4

May

-14

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

De

c-1

4

HSMR: Barnsley NHSFT Rolling 12 Month Target

Target Trajectory National HSMR Rolling 12 Month

SHMI Reduction Target: Barnsley Hospital NHS Foundation Trust

Set December 2013

Owner Dr J Mahajan, Medical Director

* Q2 2013/14 is a pre-released figure

Sepsis Bundles Pneumonia Bundles

Reduce Patient Safety Incidents (Severe & Moderate Harm)

Reduce Inpatient Deaths End of Life Care Amber Care Bundles

Mortality Reporting Streamline Process

Increase Clinician Involvement

Reduce Serious Incidents and Never Events

News & Escalation

-A target SHMI of 102.0 for the calendar year 2014 period -Reduction from 2012/13 SHMI (103.6)

SHMI is a 12 Month value released quarterly

98

100

102

104

106

108

110

Q4

20

12

/13

Q1

20

13

/14

Q2

20

13

/14

Q3

20

13

/14

Q4

20

13

/14

Q1

20

14

/15

Q2

20

14

/15

Q3

20

14

/15

SHMI: Barnsley NHSFT Rolling 12 Month Target

Target Trajectory National SHMI Rolling 12 Month

Incident Reduction - HSMR Reduction - Performance Lead: Trustwide

Start Date: Oct 2013

Incident Reduction - HSMR/SHMI Reduction - Performance

National Framework for Reporting and Learning from Serious Incidents Requiring Investigation, March 2010, NHS National Patient Safety Agency (Extracts)

Septicemia HSMR Reduction - Performance Lead: Dr P McAndrew

Start Date: Oct 2013

Action Description A Sepsis bundle is a recommended pathway to be followed following a suspected septicemia diagnosis. Chart Description Chart 1 shows the actual number of deaths in Barnsley Hospital NHSFT's Septicemia HSMR Diagnosis Group, alongside the expected number of deaths. Chart 2 shows the HSMR for Barnsley Hospital NHSFT's Septicemia HSMR Diagnosis Group. This is a ratio of the values in Chart1: (Actual/Expected) * 100

2014/15 Quarter 1

Information/Data Intervention and Actions

Apr-14

May-14

Jun-14

Mortality Group Timeline John Taylor

Principal Information Analyst

Management Information Services

Barnsley Hospital NHS Foundation Trust

(01226 433951

'Mortality Rates' final report released by 360 Assurance containing 8 recommended action points.

Alert System now being utilised from HED (CUSUM HSMR), at trust and CCS diagnosis group level.

Monthly and rolling 12 months figures now being monitored for all 56 CCS diagnosis groups

Pneumonia Bundles now operating in the Emergency Department

Action Plan Workshop: Arranged for 13th June, to discuss progression of the action points from AQUAs and Dr Fletchers Mortality reports

Report Released: Independent Review Of Deaths In April 2013 At BHNFT, Dr A Fletcher

Draft Report Released: BHNFT Mortality Review, March 2014, AQUA

HSMR data produced at specialty level for inclusion in monthly CBU Performance reports

Mortality Review team to review compliance %s for Mortality review completion.

Review of Acute Bronchitis deaths Completed: Coding Changes recommended from Acute Bronchitis Deaths Review

Action Plan Workshop: 13th June: Succesful workshops were held. Action plan to be developed and presented to the board in August 2014.

National delay in production of HES data, resulting in delayed production of HSMR data. February's data expected to be available in July 2014.

Appendix 3

REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT REF: 14/07/P-08

SUBJECT: NON CLINICAL GOVERNANCE & RISK COMMITTEE (NCGRC) – HIGHLIGHT ASSURANCE REPORT

DATE: JULY 2014

PURPOSE:

Tick as applicable Tick as

applicable For decision/approval Assurance

For review Governance For information Strategy

PREPARED BY: Francis Patton Non-Executive Director & NCGRC Chair SPONSORED BY: Francis Patton Non-Executive Director & NCGRC Chair PRESENTED BY: Francis Patton Non-Executive Director & NCGRC Chair STRATEGIC CONTEXT 2-3 sentences

The purpose of this report is to provide assurance to the Board that the non-clinical risks to delivery of the business plan as highlighted in the Board Assurance Framework (BAF) and on the risk register are being reviewed and either dealt with or mitigated to an acceptable level. Currently this is done through a thorough review of each of the risks highlighted as Non Clinical on the Board Assurance Framework and on the risk register through the provision of evidence by the responsible directors that the issue is on plan or, if not, an action plan has been put in place to rectify or mitigate any impact upon the business plan or the Trust. This is supplemented by exception reports from each of the key Committees that report through NCGRC. The NCGRC also considers other non-clinical governance issues requiring its attention, including amended policies and procedures requiring approval and new policies that require review and recommendation to the Board for approval. This is the last report from this Committee as it no longer exists within the new governance structure.


Are risks of a non-clinical nature fully identified and sufficiently assured? Have all the issues identified by this committee been passed on to the committees within the new governance structure? Are all the areas covered by this committee picked up within the new governance structure?

CONCLUSION AND RECOMMENDATION(S) Cont /….

BoD July 2014: 08_NCGRC Report June meeting


Having reviewed the BAF and the Risk register the Committee is still not fully assured that all risks have been identified and/or required mitigation actions established. The Board is asked to note that the Committee requires further assurance on the following:

1) The new governance structure needs implementing with full terms of reference. 2) A new BAF needs to be developed and assigned to the sub Committees reporting to

Board 3) Further work needs undertaking on having the correct workforce profile for the trust. 4) Assurance needs to be and will be sought from CBU’s on delivery of appraisals and

mandatory training. 5) The risk register needs to be reviewed with a sense check undertaken on the risk

described and the mitigation in place to address it. Work needs completing on allocating risks to the relevant CBU’s.

6) A fuller and proper deep dive on DNA needs to be undertaken and presented to Finance & Performance committee as soon as possible.

NCGRC recommends that the Finance & Performance Committee picks up the following issues highlighted in this report

- following through on assurance around DNA performance. - assurance from the review of the Winter plan - following through on appraisal and sickness performance.

Whilst the Quality & Governance committee picks up - assurance around on-going delivery of an appropriate risk register - resiting of the clinical coding team

The Committee further recommends that when the terms of reference for each committee are finalised, a final check is made to ensure that all areas currently under NCGRC are reallocated.

The Board is asked to:

1) ensure that the new Governance structure is fully implemented with appropriate and robust terms of reference;

2) note the areas of concern listed above and the process(es) suggested to address them; 3) accept the recommendations on where issues raised at NCGRC should now be

progressed 4) approve the Governor and Member Expenses Policy (a new policy), and 5) note the Committee’s approval of the following amended policies

• Supporting Staff involved in an accident, complaint or claim • Stress Policy • Contamination Incident policy


REFERENCE/CHECKLIST


The work of the NCRGC and this report map to the following principal organisational objectives as included in the business plan: 1.1,1.2, 1.4, 2.2 and 2.5


Patients

BCCG

Other

Staff

BMBC

Please state:

Governors

Monitor







Yes

Not applicable

To be developed

• Has this report (in draft or during development) been reviewed by any Board or Executive Committees within the Trust?

CGC

NCGRC

Audit Committee

Finance Commitee

ET

• Where applicable, briefly identify risk issues (including any reputation) and cross reference to risk register and governance Committees

The work of the NCGRC and this report map to the following principal organisational objectives as included in the business plan: 1.1,1.2, 1.4, 2.2 and 2.5. Reports are received at each meeting to provide assurance against these aspects of the BAF.


Finance: Other:





Subject: Non Clinical Governance Committee (NCGRC) – highlight assurance report Ref: 14/07/P-08

1. INTRODUCTION

1.1 The Committee receives exception reports from its reporting committees and receives assurance reports that are directly aligned to the Business Plan and Assurance framework specifically for the principal objectives where the Committee is identified as the assurance provider. It also receives the risk register with the red risks that are the responsibility of the Committee with assurance against each of those risks. This is the last report from this committee as it ceases to exist under the new governance structure. Therefore it is essential that all actions and recommendations are transferred to the appropriate committees within the new structure and that all areas covered by this committee are allocated to the appropriate committees.

2. MATTERS OF NOTE

2.1 Matters delegated from the Board

2.1.1 Deep dive report on Did Not Attends (DNAs) A third report was put into the papers for the Committee to consider, however, it was felt that this still did not address the requirements in terms of assuring the Committee that an appropriate analysis had been undertaken and that a clear action plan was in place to improve DNA performance. The Committee was told that a report would be going to the Executive Team that would achieve this objective. Therefore this needs to be picked up under the new structure and the recommendation is that it goes to the Finance & Performance committee as it does concern Performance. The Committee would expect this as a matter of urgency considering it has now been on-going for six months.

3. BAF ASSURANCE 3.1 Overview

There is now an urgent need for a new version of the BAF and for the issues within it to be allocated to the appropriate committee. In the absence of the new BAF the committee continues to use the 13/14 BAF and seek assurance on the areas allocated to them.

3.2 Issues Carried forward from previous report. 3.2.1 Review of Winter plan

A date has now been set for this which is for a full report by the end of August; the Committee felt that this could be expedited.

3.2.2 Electronic Patient Record An options paper for e prescribing was supposed to go to the next Investment Board which was cancelled but it was approved by the EPR board.

3.3 Areas of BAF allocated to NCGRC

3.3.1 Maintaining, meeting and exceeding national, regional and local regulatory and service standards. This is an area reviewed monthly by Board as well as bi-monthly by NCGRC. The Committee received the latest Monitor dashboard showing all targets green to the end of March except Breast Symptomatic Service, 18 week target, diagnostic tests waiting over 6 weeks, time to treatment and DNA rates. The

BoD July 2014: 08_NCGRC Report June meeting Page 1

Committee discussed the latest update on the plans in place to mitigate these issues. In terms of Breast Symptomatic Service the position has been resolved through the use of additional clinics. In terms of the 18 week target performance against this target will be reviewed at the monthly performance meetings and through weekly information provided to Monitor with corrective actions implemented on an on-going basis. In terms of the Diagnostic tests there is a risk of a monthly £21,000 penalty for failure to achieve target , mitigations include recruiting a locum, the Trust requesting the CCG to limit direct access through GP’s and the return of a Sonographer from sick leave in June. In terms of DNA this has already been referenced.

3.3.2 Improve availability of patient care information and transparency. The Committee received the latest report from the Director of Marketing and Communications and is sufficiently assured that we are delivering against both plan and our legal requirements.

3.3.3 Workforce Profile matches current needs of the trust and identification of future needs based on working together and strategic review of services The Committee received the latest workforce profile data which showed a number of areas where the establishment was not where it should be but turnover was now within target. Average length of recruitment is in breach of its SLA with a key issue being the exec vacancy panel taking 18 days to approve requests to recruit and/or managers taking 30 – 40 working days to complete short listing. Further analysis of recruitment data is on-going to highlight hot spots. In terms of the Golden Handcuff approach to recruitment this has been trialled with AMU consultant role which has received 1000 views of the advert but no applicants so far. The trust has also offered starting salary incentives to attract agency locums to take up substantive posts and is looking at international recruitment.

3.3.4 Implementation of appraisal, mandatory training and staff survey/wellbeing action and improvement plans. Implementation of the organisational development framework action plan. Introduction of continuous staff opinion collection system. The new appraisal system has been introduced looking for 90% compliance by the end of June. As at 31st May this was running at 32.6%. Clinical Directors were not invited to the committee to explain themselves but CBU’s will be questioned about this at the new Finance and Performance meeting. Mandatory training continues to just miss target running at 86%.

3.3.5 Health and Well-Being Strategy ensuring staff are fit and well to care Sickness levels continue to be an issue with 4 areas flagged as red and overall running at over 4.16%. Areas of concern are Estates and Facilities (5.04%), General Specialist Medicine (5.18%), Theatres, Anaesthetics and Critical Care (4.82%) and Diagnostics & Clinical Support Services (5.8%). All of these are under investigation.

3.3.6 Create a workforce engagement plan that ensures that all members of our workforce are actively involved in the Trust development, delivery and learning A number of activities have been put together through the TWWMIB (together we will make it better) working group, ensuring that we fully engage with the workforce. There has been a re-launch of communications campaign via email, e-bulletin messages and senior manager meetings.

BoD July 2014: 08_NCGRC Report June meeting Page 2 of 4

3.3.7 Develop and implement information management and technology strategy that

meets our current and future needs. This continues on plan and on budget, the biggest risk to delivery of this is the Trust’s present financial position and the need to reduce capex expenditure.

3.3.8 Deliver the full benefits of investment in technology (Electronic Patient Record EPR). This is an area for concern for the Committee with the Trust’s present financial position. We had lost two members of staff due to uncertainty but centrally funded support has now been confirmed.

3.3.9 Optimise the use of the estate to drive efficient use and identify cost reductions. The biggest risk to this is now the Trust’s present financial position. All capex spend is to be reviewed. Within the estate plan work is on-going around Space Utilisation, this work is fostering an awareness of the cost of space and is eradicating a culture which sees space as free. Once this is complete it can be used to help allocate fixed costs equitably to CBU’s and support departments.

3.3.10 To run our organisation economically and complying with principles of sustainability with our local partners. This is on plan.

3.3.11 Development of Commercial Partnerships The Board of BHSS is in the process of finalising is strategic plan which will come to the August board meeting.

4. Risk Register

4.1 Overview The risk register was presented with red risks only but again for both Clinical and Non Clinical. The committee again felt that more work needed undertaking in this area. At the last Board of Directors Mrs Mcnair was asked to circulate the top 5 risks by CBU. On reviewing the risks currently on the risk register it became apparent that further work was required to update and reallocate these appropriately to the new CBU structure as oppose to the 14 CSU’s. This work is now almost completed and the risk registers will be updated and made relevant to each CBU by the end of June. This needs combining with a review of non clinical departments’ top risks.

One risk that was highlighted as an issue was related to Pathology where 1 year warranty extension to support hardware is running out in November which is a major risk. The committee sought assurance that this was being addressed and post meeting were told that Laboratory Partnerships and Barnsley IT representatives were to meet with Clinisys to clarify the offer and ensure that all necessary requirements and licenses are included and achieve a firm quotation. The Pathology Board Executives were then to take the outline proposal costs to their Trusts respective capital planning groups to seek outline approval. The final agreed quotation has been received from Clinisys and re-submitted to the two Trusts capital planning groups. The Pathology and OCT teams are meeting with the supplier on the 9th of July and the supplier has said that they can deploy in less than the 6 months stated in the paper which is needed to get this in place by November


5. Exception/Additional Reports

5.1 Clinical Coding team There continues to be a delay in resiting the clinical coding team to the main hospital, which still requires resolution. As this was deemed essential to help improve coding the Committee was disappointed that it remains unresolved

5.2 Equality and Diversity The Committee accepted the annual Equality and Diversity report, in the context that this will be followed by a report back to the Trust in September about the outcomes and recommendations of the externally commissioned Equality & Diversity review. A summary of the report finding and action will be presented to Board via the Finance & Performance Committee in November.

6. Policies

6.1 The following policy was reviewed, supported and is recommended to the Board for approval:

• Governor and Member Expenses Policy This is a new policy, instigated at the request of the Governors to support good governance and set out clear protocols and expectations.

6.2 The following policies were reviewed and approved for the Board to note:

• Supporting staff involved in an accident, complaint or claim • Stress policy • Contamination incident policy

6.4 The Board may wish to note that work is continuing on the Policies & Procedures Framework. A final draft will be presented to the first meeting of the Quality & Governance Committee and subsequently to the August Board meeting for approval.

Appendices:

• Appendix 1 – Governor and Member Expenses Policy


Date Completed: January 2014 Review date: January 2016

POLICY CONTROL SHEET (updated September 2012)

Policy Title and ID number: Governor and Member Expenses Policy Sponsoring Director: Director of Human Resources and Organisational Development

Implementation Lead:

Impact:

(a) To patients Yes / No

(b) To Staff Yes / No

(c) Financial Yes / No

(d) Equality Impact Assessment (EIA) Completed: Yes / No

(e) Counter Fraud assessed Completed: Yes / No

(e) Other Training implications: To be incorporated into induction: Yes / No

Date of consultation:

Approval Process Date Local Consultation Date

Executive Led Committee/Board Joint Partnership Forum

Board Committee: Local Negotiating Committee

Clinical Governance Infection Control Committee:

Non Clinical Governance & Risk Health & Safety Board

Audit Committee Quality Safety Improvements & Effectiveness Board

Finance Committee

RATS Investment Board

Trust Board Approval / Ratification Patients Experience Board

Other: Information Governance Board

Workforce Board

Approval/Ratification at Trust Board: Version Number:

Date on Policy Warehouse: Team Brief Date:

Circulation Date: Date of next review:

For completion by ET for new policies only:

Additional Costs

Budget Code: Revenue or Non Revenue

(a) Training £

(b) Implementation £

(c) Capital £

(d) Other £

Date Completed: January 2014 Review date: January 2016

Governor and Member Expenses Policy

3 Date Completed: January 2014 Review date: January 2016

1. Introduction This policy is specifically for Public, Partner and Staff Governors on the Council of Governors of the Barnsley Hospital NHS Foundation Trust (BHNFT).

The Trust’s Constitution and the NHS Act 2006 do not allow the Trust to pay a salary or honorarium to individuals for being a Governor. If a Governor has a query as to how this policy applies to them, they should contact the Governors Office.

2. Governors

Expenses will be paid to Governors for their attendance at any of the following;

a. Council of Governors’ meetings

b. Induction

c. Any other pre-authorised training for Governors

d. Members meetings/events organised by the Governors Office at which the Governor’s presence has been requested

e. Any other meetings requested by the Trust 3. Types of expenses which can be claimed

Buses Fares Paid on a like for like basis. Claim must be supported by a valid ticket.

Mileage Paid at the agreed Governors rate of £0.40 per

mile return journey. Note: You are advised to check with your car insurance provider, that your cover is adequate for this use.

Taxis The use of a taxi must be agreed in advance

with the Governors Office and must only be used in exceptional circumstances. Taxis must be booked through the Governors Office.

Parking Charges Will be reimbursed if supported by a valid

ticket/receipt. No traffic or parking fines will be reimbursed by the Trust.

Child Care/Carer Costs Will be reimbursed with prior agreement of the

Governors Office. Reimbursement will occur where it has been necessary to employ a registered carer to look after a child or dependent. Reimbursement will be on the minimum wage hourly rate and on production of a valid receipt or invoice.

Interpretation/Advocacy/ Will be reimbursed in full on production of a

4 Date Completed: January 2014 Review date: January 2016

Companion valid receipt or invoice from either an individual or organisation. All invoices will be paid through the Trust’s normal invoice system. Subsistence Where the care is away from home for more

than five hours for the purpose of attending a designated meeting or training event, and where o refreshment is provided paid at the Trust rate of £5.

Other Any other costs incurred and claimed by a

Governor will only be paid with prior agreement of the Governors Office.

*Mileage reimbursement rate correct at time of publication (January 2014). Note: All claims and invoices should be submitted to the Governors Office no later than three months after the expense has been incurred.

4. Submission Of Claims

Governors must use The Governors Expenses Claim Form (Appendix A) which is available from the Governors Office. The Governors Office is responsible for ensuring that all claims are legitimate and accurate before being submitted to the Finance department. The Governors Office is also responsible for keeping an accurate record of all claims submitted. Original receipts must be attached where necessary. The form should be signed by the Governor and authorised by the Governors Office. Expenses will usually be paid by cheque which will be sent to the Governor’s registered home address. Records of all payments will be kept by the Governors Office. Any queries regarding payments should be directed to the Governors Office in the first instance.

5 Revised version February 2013

Equality Impact Analysis Template

The purpose of Equality Analysis is to ensure that the Trust does not unwittingly discriminate against any groups recognised under the Equality Act 2010. These are: Age, Disability, Gender reassignment, Sexual Orientation, Race, Religion or Belief, Sex, Sexual orientation, Marriage & Civil partnership, Pregnancy and Maternity. An EqIA is a process which ensures the Trust eliminate unlawful discrimination, foster good relations between others and promote equality of opportunity in the take up of its services and employment practices.

Division/Department

Governors/Secretary to the Board

Policy/Service

Policy

Is this policy/service New/Existing

New

Name of Assessor(s)

Beverley Powell

Date of EqIA

January 15th 2014

Aims/Objectives/ Purpose Of Policy/Service

Governor and Member Expenses policy

Associated Objectives for this Service e.g. National frameworks, Equality Act.

NHS Act 2006

Does this policy/service Affect patients or the workforce?

Public, Partner and Staff Governors on the Council of Governors of the Barnsley NHS Foundation Trust

What outcomes do you want to achieve from this process?

Equality Governor and Member Expenses


What factors could contribute/detract from the effective delivery of this policy/service?

Contribute Detract

Public, Partner and Staff Governors on the Council of Governors of the Barnsley NHS Foundation Trust unaware of the policy or process

Are there any concerns that this service or policy could have a differential impact on or due to the following:

Race

Yes/no

What existing equality evidence either presumed or otherwise do you have for this response?

Age Yes/no

No

Disability Yes/no

No

Gender Reassignment Yes/no

No

Religion/Belief Yes/no

No

Sexual Orientation Yes/no

No

Pregnancy Maternity Yes/no

No

Marriage Civil Partnership Yes/no

No

Sex Yes/no

No

Human Rights Yes/no

No

If you have answered yes to any of the above, please describe or attach any evidence of action which will mitigate your EqIA and ensure your policy/service will be able to show:

It is expected that as part of the initial screening process this policy will form part of the consultation arrangements put in place and include the group of people it will directly affect.


Eliminate discrimination Promote equal opportunities Foster good relations between others Should the EqIA proceed to a full EqIA for the areas identified for attention?

Yes No Comments

Comments

Send to: Equality and Diversity Advisor for signature and authorisation

Beverley Powell - E&D Advisor

Send to: Line Manager for signature and authorisation

Please insert appropriate Line Manager in this section

Head of Department Responsible for policy or service

Hilary Brearley Director of HR&OD

When is the next review (please note review should be immediate on any amendments to your policy etc)

1 Year January 2016

2 Year

3 Year


REF: 14/07/P-09

BoD July 2014: 09a_Governance structure

SUBJECT: PROPOSED GOVERNANCE RESTRUCTURE

DATE: JULY 2014

PURPOSE:

Tick as applicable

Tick as applicable


PREPARED BY: Angela Keeney, Assoc Interim Director of Corporate Affairs

SPONSORED BY: Diane Wake, Chief Executive Office

PRESENTED BY: Angela Keeney, Assoc Interim Director of Corporate Affairs


To build on the Trust’s governance structure to ensure clear and robust governance reporting and escalation arrangements are in place, supporting all aspects of the Trust’s service delivery.


• Is the new structure robust and fit for purpose? • Do the proposed Terms of Reference for the Board’s Committees sufficiently define the

composition, membership and remit of each Committee? • Are the reporting and cascade lines clear? • Will the escalation framework provide sufficient assurance and alerts to the Board on risk

issues? • How will the new systems be implemented?


The new structure and supporting framework will build on existing arrangements and further reinforce the Trust’s governance structure. It will provide a clearer system for escalating and thereby give greater assurance to the Board regarding the identification and reporting of risks. The terms of reference and revised structure set out clear reporting lines and responsibilities and also provide a mechanism for cascading feedback and learning as well as escalation. It will also be closely aligned to the Trust’s Board Assurance Framework and Risk Registers.

The new system builds on existing arrangements and is aligned to the newly introduced Clinical Business Units. Implementation therefore will be instant in terms of the main Committees to the Board. Similarly, the groups reporting directly into the Committees will be quickly established under the leadership of the Executive Team and the restructuring and/or establishment of the revised sub-groups will follow through shortly. The bulk of the new structure should be fully in place by end of July, with completion in August for those groups that meet less regularly.

The Board is asked to review the attached report and approve the proposed structure and supporting terms of reference and escalation framework.

BoD July 2014: 09a_Governance structure

REFERENCE/CHECKLIST


Underpins all elements of the Trust’s business plan.


Patients

BCCG

Other

Staff

BMBC

Please state:

Governors

Monitor







Yes

Not applicable

To be developed


CGC

NCGRC

Audit Committee

Finance Commitee

ET



Finance:

Other:




1

Governance Structure

2

Contents:

Escalation Policy Terms of Reference: Finance & Performance Quality & Governance Audit

3

Barnsley Hospital NHS Foundation Trust

Assurance and Escalation Framework

4

1.0 Introduction / Background

The Trust acknowledges governance as an integral process to services which ensure that there are demonstrable systems in place. This links strategic and operational activities and supports on-going critical appraisal and review.

It is important that the Board of Directors has processes in place to monitor the implementation of strategic objectives set out in its business plan.

To ensure it receives assurances through its Committee Structures that the strategic goals are being met or concerns are escalated.

The Governance Structure described in this framework aligns quality, risk and performance and how they are monitored

2.0 Content of framework

2.1 Organisational governance structure (Appendix A)

Within the governance structure there are Sub committees and groups, each having a delegated responsibility to deliver the Trusts strategic goals and objectives, via compliance with performance and quality indicators and monitoring of associated risks.

The governance structure clearly demonstrates the reporting and accountability mechanisms i.e. task and finish groups report to groups, groups report to committee and committees report to the board.

This is supported in all of the Terms of Reference and outlined in Table 1. Terms of reference for all committees are available through the Chair of the relevant Committee.

5

Table 1: Accountability arrangements within the corporate governance arrangements

Reporting to

Committee Groups Task & Finish Groups

Board Committee Groups

Terms of Reference reviewed

Annually

Annually

On establishment

Membership

Membership must include executive directors, non executive directors, clinical staff, senior managers

Membership should include executive directors, clinical staff, senior managers,

Membership will be relevant staff co-opted to deliver specific time limited pieces of work

Performance

Annual work plan informed by key performance indicators/evidence and risks against strategic objectives

Progress against the Committee work plan

Measured by the specific deliverable for the work stream

Accountability

Responsible for the performance management of the group structure and their work plans

Responsible for the performance management of the Task and Finish groups,

Need to report specific deliverables to appropriate Group

Reporting

mechanism against work plan

Minutes and Chairs log to Trust Board- risks reported to Risk Management Group for inclusion on the BAF

Minutes and Chairs Log to Committees – risks reported to Risk Management for inclusion on the Risk Register

Progress reports to appropriate groups.

6

There is a demonstrable inter- relationship between the committees, via sharing of minutes and the production of a chairs log, which outlines key issues being discussed at committee meetings. The Chairs log is a standing agenda item on all governance meetings, at all levels, reporting up to the Trust Board.

During Board meetings there are discussions with challenge regarding the data produced and the reports by the Non Executive and Executive team members. This is recorded through minutes of the committees and references in the chairs log.

2.2 Escalation of Key Issues through the Governance Structure (Chairs Log Appendix C)

All committees will use the Trust’s Chairs Key Issues model to:

• Escalate risk over the threshold delegated to the committee (in accordance with delegation or identified through other issues presented at the committee)

• Escalate decisions outside the delegated authority of the committee

• Communicate positive assurance and gaps in assurance

• Commission tasks for groups

• Integrate issues which cross the Terms of Reference of different committees

• Forward plan

Chairs Key Issues will be reported to the next meeting of the committee / Board and will be presented by the Chair of the reporting committee.

3.0 Trust Monitoring / Assurance Processes

3.1 Board Assurance Framework

The Board Assurance Framework (BAF) is the Boards ‘tool ‘for the management and monitoring of the strategic risk. Having identified the Trusts strategic objectives, the Board will identify the key risks to the delivery of the strategic plan and the key controls in place to manage the risk, The BAF will be managed in a Quarterly cycle,

7

• Associate Director of Corporate Affairs will have oversight of the BAF; ensuring risks are assigned to each Board Committee.

• Each Committee will review the BAF at formal meetings and provide update assurances on assurance/gaps on control and positive/gaps in assurance

• Updates sent to Risk Management, for revision of the Corporate BAF,

• BAF risks greater than 12 will be presented to Trust Board

The Audit Committee will review the controls involved in the management and monitoring of the BAF in order to provide assurance of effectiveness to the Board.

The BAF is audited by Internal Audit on an annual basis.

3.1.1 The key features of the BAF are described in the table overleaf.

8

Assurance Obtained on Controls Board Action Plan

Ob. No

Principal Risk

Priority

Likelihood/ Impact

Key Controls

Positive Assurance

Gaps in Control

Gaps in Assurance

Action Plan Responsible Director

Responsible

Committee

6 month forecast (Sept 14)

Year End forecast

(what should prevent this objective being achieved)

(what is the likelihood of the risk occurring and consequence/ impact if it occurs)

(what controls/ systems do we have in place to ensure we deliver our objectives)

(what evidence shows the risks are being managed and objectives are being delivered

(Where are we failing to put controls in place? Where are we failing to make them effective)

(where are we failing to gain evidence that our systems/are effective)

9

3.1.2 Sources of Assurance

The Board of Directors gain its assurance from the internal and external sources listed below, this is not an exhaustive list.

Internal External assessments, reviews and benchmarking

Trust Board Performance Report Health and Safety inspections

Performance Reviews External Audit Reports

Key Performance Indicators Patient Related Outcome Measures

Chairs Log – Key Issues CQUINS (Commissioning fro Quality and Innovation)

Minutes- Quality and Governance Committee and individual CBU Governance meetings

External Accreditation

Clinical Business Units governance and risk reports

Independent Reviews

Risk Register CQC assessments

Quality Accounts Clinical Specialty Peer Reviews

Internal Audit Reports National Audits

Local Counter Fraud Reports National Staff Surveys

Staff Survey Results Patient Choices

Patient Satisfaction Surveys Friends and Family Test

Staff Survey Results Specialist External Reviews

Safeguarding Serious Case Reviews National patient surveys

Serious Incidents Investigations MHRA Inspections

Clinical Audit

Clinical Presentations

10

Complaints, litigation reports through the Risk Management Group

Nursing Indicators and Nursing Quality Audits

Compliments

Policies and Procedures – monitoring of compliance

Key Performance Indicators

Compliance Reports

Information Governance Toolkit

Corporate Performance Report

Mock CQC inspection reports

Executive/ NED walk rounds

Internal staff survey

3.2 Risk Register

The Risk Management Strategy sets out how risks are identified at all levels of the Trust. It describes in detail how risks are escalated through the Clinical Business Units (CBU) and Corporate Governance Structures. A summary of the process id detailed below:

Each CBU/ department and Corporate Services Department will be aware of the detail of the risks that would prevent them meeting their or the Trusts objectives. CBU level risks are managed at a local level and monitored ta the CBU Performance Review and at the Corporate Operations Group.

CBUs and Corporate Services/ Departments will present their full risks register on a six monthly basis to the Risk Management Group.

The Director of Nursing and Medical Director sit on the Risk Management Group where risks are discussed and reviewed and are supported by the Risk Manager.

11

During this review the Risk Management Group will consider:

• Mitigating actions and timescales to determine whether the risk score is appropriate

• Whether additional mitigations are required to manage a risk

• Whether there are links between identified risks, which point to broader corporate issues

• Whether identified risks represent risks to the trusts strategic aims and should therefore be escalated to the BAF (Trust Board)

Risk Management Groups observations and required actions will be communicated to the committee / Board via the Chairs Key Issue Model as assurance, escalation, integration (through inter disciplinary work) or the commissioning of additional actions or monitoring by a specific group.

Following the review by the Risk Management Group, reporting to Trust Board will be based on any rating >15.

On-going to Trust Board on risk through the Clinical Governance Overview Report which will inform the Board of risk >15 on the Risk Register and 12 on the BAF.

The Audit Committee will review the controls involved in the management and monitoring of the BAF in order to provide assurance of effectiveness to the Board.

3.3 Internal and External Sources of Assessment / Assurance (Internal Audit, Clinical Audit, Peer Review)

The Trust has internal structure in place to ensure reporting on progress or concerns. This ensures that clear two way communication or information and identifies the systems in place to escalate concerns and ensure that they are responded to and, where required, challenged.

Internal and external sources of assessment/ assurance cover the range o the Trusts activities and include:

• Care Quality Commission (CQC) Inspections

• HED Data

• Internal/External Audit

• Independent Reviews

• External Accreditations

12

The Trust also commissions external reviews of its activities where the needs for additional independent assessments /assurances are identified.

3.4 Quality Strategy

The quality goals set out in the strategy have objectives which reflect and support the Trust strategic objectives.

The quality strategy is aligned with Quality Governance Framework.

The quality strategy is aligned to the Trusts strategic objectives and support the vision and values by ensuring that clear performance indicators which are measurable and reported monthly through the Integrated Performance Report to the Trust Board.

3.5 The Trust Cost Improvement Programme

3.5.1 Weekly Review process fro CIPs

Each CBU is responsible for the monitoring and delivery of their CIP schemes. All schemes are subject to a weekly review process. The review is undertaken by members of the Executive Team, including the Chief Executive, Director of Nursing, Director of Operations, Director of Finance and Director of Strategy. Each CBU is represented by the General Manager, Head of Nursing and appropriate members of the team from within the CBU structure.

Schemes are assessed at the outset for any potential impact on quality and throughout the scheme whenever there is a change. Each CBU has support from the PMO in delivering and maintaining traction with each scheme.

3.5.2 Finance and Performance Committee

The progress of all schemes is reported to the Finance and Performance Committee on a monthly basis and through the Turnaround Tracker.

The Tracker reports progress against plan for the year to date position and the forecast outturn. Each CBU has a deliverable RAG rating system.

3.6 Key Performance Indicators

In holding the Executive Team and the CBUs to account fro the delivery of the strategic objectives and the operational performance of the trust: the Board will oversee a range of Key Performance Indicators (KPIs). The KPIs will cover the

13

breadth of the Trust activities. The Board KPIs are determined in part by external regulatory framework egg CQC Essential Standards.

More granular reports are reviewed by committees, groups, and individual CBUs.

The Board may also identify and monitor KPIs associated with the delivery of the strategy or the monitoring of identified risk. These indicators may change over time as particular issues come to the fore for the Trust.

The Board may also assign monitoring of a particular KPI to a committee. If the Board does assign the monitoring of a specific KPI there will be explicit concerning the conditions fro escalation back to the Board.

3.7 Culture

The Trust is developing and open and learning culture and encourages monitoring of, and comments and concerns about its performance from a wide range of internal and external sources. These sources include:

• Staff

• Patient / Carers

• Internal and external sources of assessment/assurances ( internal audit, clinical audit peer review)

• The Trusts monitoring/ assurances processes

• Regulatory Bodies

• The Trusts Council of Governors

3.8 Staff

The Trust has a number of policies and systems which encourage staff at all levels to be involved in performance monitoring and to raise concerns about any risk issues. These include

• HR policies such as Grievance and Disciplinary

• Safeguarding Policy (Children and Adults)

• Line Management Processes

14

• Executive Walkabouts

• Staff Surveys

• Governance Policies

• Risk Management Strategy and Risk Assessment methodology

• Joint Partnership Forum

• Induction Programme

• Mandatory Training

• Risk Assessment Procedures

4.0 Associated Documents

The framework sets out or signposts the Trusts policies, systems and process and should in particular be read in conjunction with the Trusts:

Terms of Reference for:

The Executive Management Team

The Finance and Performance Committee

The Audit Committee

The Quality and Governance Committee

Trust Strategies

Quality Strategy

Risk Management Strategy

Trust Processes

Performance Management Framework

Appendix A

Board of Directors

Quality and Governance Committee

Audit Committee

Finance & Performance Committee

Capital Operations Group

CIP Steering Group

Research & Development Group

Patient Safety & Quality Group

Workforce Group

Patient Experience Group

Health & Safety Group

Risk Management Group

IP&C Dementia Mortality Safeguarding VTE CQC

Litigation Review Group Consent Risk Registers Resilience & Emergency Planning NHSLA

Learning from Experience

Radiation Med Device Decontaminations Med Gases Waste Management

Resus SI Reviews Medicines Management

Eq + Diversity Education / Mandatory Training

LNC Joint Partnership Forum

Fire Sharps Moving & handling Theatre User Group

Corporate Operations Group

Organ Donation Group

Remuneration Committee

Committee of the Board

Groups (direct reports to Board Committees)

Working Groups/Task and Finish Groups

Estates & Procurement Group

17.06.2014

Sustainability Procurement Space Utilisation Catering Cleaning

Information Governance Group

16

Template for all Trust Action Plans – Appendix B

Aims/ Targets/ Objectives

How this will be achieved

What expected outcome will be

What evidence will support this

Who will lead this

Timescales this will be achievd within

Where this will be reported/ monitored to : i.e Committee/ Group

RAG rating

KEY RAG Rating

Green

Complete Amber

On track for delivery Red

Behind paln and action neede to bring back on target

17

Chairs Key Issues and Assurance Model – Appendix C

Committee / Group Date Chair

Agenda Item Issue and Lead Officer Receiving Body e.g. Board or Committee

Recommendation/ Assurance/ mandate to receiving body

[Type text]

FINANCE AND PERFORMANCE COMMITTEE

Terms of Reference

CONSTITUTION

1. The Board of Directors approved the establishment of the Finance and Performance Committee (known as “the Committee” in these terms of reference) for the purpose of:

a) providing detailed scrutiny of financial matters and operational performance in order to provide assurance and raise concerns (if appropriate) to the Board of Directors.

b) making recommendations, as appropriate, on financial and performance matters to the Board of Directors.

2. The Committee is accountable to the Board of Directors and any changes to these terms of reference must be approved by the Board of Directors.

DUTIES

3. In particular the Committee will provide assurance, raise concerns (if appropriate) and make recommendations to the Board of Directors in respect of the Committee’s role in:

Financial matters

a) undertaking detailed scrutiny of monthly, quarterly and year to date financial information, including performance against the cost improvement programme;

b) undertaking detailed scrutiny of the financial forward projections;

c) considering proposal for financial plans and estimates;

d) considering the annual budget for the Trust

e) approving business cases

1

[Type text]

Performance management

e) receiving assurance from the Executive Directors in respect of Clinical Business Units (CBU) performance against:

• annual budgets, capital plans and the cost improvement programme,

• quality, innovation, productivity and prevention plans,

• commissioning for quality and innovation plans (CQUIN),

• clinical activity and key performance indicators,

• corporate governance activities and responsibilities;

Contract negotiation and performance

f) overseeing the negotiation of contracts with the organisation’s commissioners;

g) receiving assurance from the Executive Directors in respect of the organisation:

• meeting the contractual requirements and expectations of commissioners;

• meeting the legislative / regulatory requirements of regulators and other bodies;

Risk management and internal control

h) receive the Board Assurance Framework and take lead responsibility for identified risks in respect of non-clinical matters and standards:

• receiving reports and assurance from the Executive Directors in respect of risks, considering the recommendations as appropriate from the Executive Directors as to those risks which are strategically significant and need to be included in the Board’s Assurance Framework,

• overseeing the Executive Directors role in ensuring CBU Action Plans to mitigate risks and gaps in controls and assurance are implemented,

• liaise with the Quality and Governance Committee to consider the impact of these non-clinical risks against all the risks facing the organisation;

i) agreeing, with the Executive Directors’ Group, the annual programme of work of the Trust Management Board;

j) work with the Audit Committee and the Quality and Governance Committee advising on the non-clinical aspects of the Risk Management Group

2

[Type text]

k) liaising with the Risk Management Group to ensure compliance with the organisation’s risk management systems and processes and to identify those risks (and risk mitigation action plans) which need to be brought to the attention of the Board of Directors;

Business cases

l) considering the recommendations of the Executive Directors when considering business cases in respect of:

• major service and strategic developments from the Executive Directors

• new consultant or clinical posts submitted by the appropriate Executive Director.

MEMBERSHIP

4. The Committee will include the following members:

a) Non Executive Director (Chair);

b) Non Executive Director

c) Chief Executive

d) Director of Finance (Deputy Chair)

e) Director of Strategy & Business Development

f) Director of Nursing

g) Director of Operations

h) Medical Director

i) Director of Human Resources

j) Associate Director of Estates & Facilities

5. All members listed above have voting rights.

The Chair of the Committee is the Non Executive Director appointed by the Chair of Barnsley Hospital NHS NHS Foundation Trust.

• the Medical Director may nominate a Deputy Medical Director to attend on their behalf. A Deputy Medical Director attending in such circumstances will not have the right to vote;

3

[Type text]

• the Director of Nursing may nominate a Deputy to attend on their behalf. A Deputy Director Of Nursing attending in such circumstances will not have the right to vote;

• the Director or Finance may nominate the Deputy Director of Finance to attend on their behalf. The Deputy Director of Finance attending in such circumstances will not have the right to vote

• the Director Of Human Resources may nominate the Deputy Diorector of HR to attend on theor behalf. The Deputy Director of HR attending in such circumstances will niot have the right to vote.

ATTENDANCE

7. a) CBU representation through, General Manager, Clinical Director with relevant CBU finance officer

b) other members may also nominate a deputy. Such deputies will be in attendance and will not have voting rights.

9. The Chair of the Committee may also extend invitations to other personnel with relevant skills, experience or expertise as necessary to deal with the business on the agenda. Such personnel will be in attendance and will have no voting rights.

RESPONSIBILITY OF MEMBERS

10. Members of the Committee have a responsibility to:

a) attend at least 80% of meetings, having read all papers beforehand;

b) act as ‘champions’, disseminating information and good practice as appropriate;

c) identify agenda items, for consideration by the Chair, to the Lead Director / Secretary at least 10 days before the meeting;

d) prepare and submit papers for a meeting, at least 8 days before the meeting;

e) if unable to attend, send their apologies to the Chair and Secretary prior to the meeting .

f) when matters are discussed in confidence at the meeting, to maintain such confidences;

g) declare any conflicts of interest / potential conflicts of interest in accordance with the Barnsley Hospitals NHS Foundation Trust’s policies and procedures;

4

[Type text]

h) at the start of the meeting, declare any conflicts of interest / potential conflicts of interest with the Barnsley Hospitals NHS Foundation Trust’s policies and procedures.

QUORUM

11. A quorum will normally be four members. Of these members, there should be:

a) at least one Non-Executive Director; and

b) at least one Executive Director.

12. When considering if the meeting is quorate, only those individuals who are members can be counted, deputies and attendees cannot be considered as contributing to the quorum.

FREQUENCY

13. Meetings will normally take place monthly,allowing for this meeting to report to Board of Directors

14. The business of each meeting will be transacted within a maximum of three hours.

AUTHORITY

15. The Committee is authorised by the Board of Directors:

a) to investigate any activity within its terms of reference and produce an annual work program or forward plan;

b) to approve or ratify (as appropriate) those policies and procedures for which it has responsibility

c) to promote a learning organisation and culture, which is open and transparent;

d) to establish and approve the terms of reference of such sub-committees, groups or task and finish groups as it believes are necessary to fulfil its terms of reference;

16. The Committee does not have the authority to commit financial resources. Any matters requiring a decision on the use of resources are to be referred to the Trust Board and the Director of Finance.

5

[Type text]

DECISION MAKING

17. Wherever possible members of the Committee will seek to make decisions and recommendations based on consensus.

18. Where this is not possible then the chair of the meeting will ask for members to vote using a show of hands, provided that nothing in the way of business is conducted is prohibited by the standing orders of the Barnsley Hospital NHS Foundation Trust.

19. In the event of a formal vote the chair will clarify what members are being asked to vote on – the ‘motion’. Subject to meeting being quortae a simple majority of members present will prevail. In the event of a tied vote, the chair of the meeting may have a second and deciding vote.

20. Only the members of the Committee present at the meeting will be eligible to vote. Members not present, deputies and attendees will not be permitted to vote, nor will proxy voting be permitted. The outcome of the vote, including the details of those members who voted in favour or against the motion and those who abstained, shall be recorded in the minutes of the meeting.

REPORTING

21. The Committee will have the following reporting responsibilities:

a) to ensure that the minutes of the meeting are recorded and available,as an appendix, to the Chairs Key Issuses and Assurance Log for the attention of the Board

b) to produce those assurance and performance management reports listed in the Committee’s annual work programme which has been agreed with, and are required by, the Board of Directors;

c) any items of specific concern, or which require the Board of Directors’ approval, will be subject to a separate report;

d) to provide exception reports to the Board of Directors highlighting key developments / achievements or potential issues;

e) to produce an annual report for the Board of Directors setting out:

i. the role and the main responsibilities of the committee

ii. membership of the committee

iii. number of meetings and attendance

iv. a description of the main activities during the year

6

[Type text]

v. a completed annual self-assessment (the format to be approved by the Audit Committee) and the identification of any development needs for the Committee

REPORTING GROUPS

22. The groups identified below will be required to submit the following information to the Committee:

a) their terms or reference for formal approval and review;

b) the minutes of their meetings, together with a Chairs Key Issues and Assurance Log prepared by the chair of that group outlining the key issues discussed at the meeting and those issues that need to be brought to the attention of this Committee;

c) to produce those assurance and performance management reports listed in the individual group’s annual work programmes which have been agreed with, and are required by, this Committee;

d) an annual report setting out the progress they have made and future development; and

e) any report or briefing requested by this Committee.

23. The groups are:

a) the Executive Directors

b) the CIP Steering Group

c) the Capital Operations Group

d) any Task and Finish Group set up by the Committee to assist them in carrying out their duties

ADMINISTRATIVE ARRANGEMENTS

24. The Lead Director, the Director of Finance, is a member of the Committee and has corporate responsibility for:

a) liaising with the Chair on all aspects of the work of the Committee, including providing advice;

b) ensuring the Committee acts in accordance with standing orders and the scheme of reservation and delegation;

c) identifying an officer to undertake the role of Secretary;

7

[Type text]

d) overseeing the delivery of the Secretary’s duties.

25. The Secretary of the Committee will be responsible for:

a) attending the meeting;

b) ensuring correct and formal minutes are taken in the format prescribed in the Governance Strategy and, once agreed by the Chair, distributing minutes to the members

c) keeping a record of matters arising and issues to be carried forward via an action log;

d) producing an action log following each meeting and ensuring any outstanding action is carried forward on the action list until complete;

e) producing a schedule of meetings to be agreed for each calendar year and making the necessary arrangements for confirming these dates and booking appropriate rooms and facilities;

f) providing appropriate support to the Chair, Lead Director and Committee members;

g) providing notice of each meeting and requesting agenda items no later than 14 days before a meeting;

h) agreeing the agenda with the Chair and Lead Director prior to sending the agenda and papers to members no later than 7 days before the meeting;

i) ensuring the Annual Work Programme is up to date and distributed at each meeting;

j) ensuring the papers of the Committee are filed in accordance with Barnsley Hospitals NHS Foundation Trust’s policies and procedures.

REVIEW

26. Terms of Reference will normally be reviewed annually, with recommendations on changes submitted to the Board of Directors for approval.

8

[Type text]

Date Approved

Version Number

Next Review

To be reviewed by : Finance & Performance Committee

To be approved by: Board of Directors

Executive Responsibilty: Director of Finance

9

Terms of Reference

Quality & Governance Committee

1. Purpose

The purpose of the Quality & Governance Committee is to assist the Board in

obtaining assurance that high standards of care are provided and any potential

or actual risks to quality are identified and robustly addressed at an early stage .

The committee will work with the Audit Committee to ensure that there are

adequate and appropriate quality governance structures, processes and

controls in place throughout the Trust to:

Promote safety and excellence in patient care Identity, priorities and manage

risk arising from clinical care

Ensure efficient and effective use of resources through evidence based clinical

practice

The Committee is responsible for the following;

Receiving assurance that robust Quality and Governance structures are in place

Scrutinising and challenging quality indicators and ensuring that themes and

organisation wide learning and improvement are taking place. Ensuring that potential and actual risks to quality are proactively identified and

robust action plans are in place and implemented to address these, providing

assurance to the Board.

Authenticating the information to the Board, in the case of in depth reviews,

staff from the locality could be invited to attend

Demonstrating direct dialogue with patients

Ensuring implementation of the National Patient Safety Agency Reporting

requirements to achieve the standards of compliance

Compliance with statutory and regulatory requirements e.g. CQC, NHSLA and

Health & Safety. Overseeing the development and the implementation of the

Quality Strategy and achievement of quality indicators

10

2 Duties

2.1 To ensure that there are robust systems in place across all services and all

levels within the Trust, to enable the Trust to effectively monitor quality

performance and to have an assurance process to improve the quality of care .

2.2 To ensure that the Trust's Quality Governance system is in line with Monitor's

Risk Assessment Framework and the Governance Quality Framework and that

this is reviewed annually or in line with any updates.

2.3 To oversee the system within the Trust for obtaining and maintaining any

licences relevant to clinical activity in the Trust.

2.4 To scrutinise, robustly discuss and challenge information and reports in relation

to quality to ensure that themes, organisation wide learning I improvement are

being addressed

2.5 To approve the Trust's Quality Reports before submission to the Board.

2.6 To ensure that all statutory quality governance requirements are adhered to

within the Trust including the requirement of our regulators, Monitor and the

Care Quality Commission.

2.7 To promote within the Trust a culture of open and honest reporting of any

situation that may threaten the quality of patient care in accordance with the

relevant policies.

2.8 To seek assurance that robust and timely systems and processes are in place to

proactively ensure compliance with the CQC essential standards of Quality and

Safety and that any remedial action is taken in a timely and outcome focused

way.

2.9 To ensure the delivery of the Trust strategies relating to Clinical Effectiveness,

Patient and Public Involvement and the Trust agreed priorities published in the

Trust Quality Account.

2.10 To oversee the Trust's policies and procedures with respect to the use of

clinical data and patient identifiable information to ensure that this is in

accordance with all relevant legislation and guidance including the Caldicott

Guidelines and the Data Protection Act 1998

2.11 To seek assurance that robust and timely systems or programmes are in place

in respect of Patient Safety, including:

Effective systems for the reporting, scrutiny and implementation of actions

11

arising out of adverse incident and external enquires Safeguarding (Children and Adults) including training and lessons learnt and

action plans implemented

Infection Control including policies, training, audit and inspection

Procurement, management and maintenance of Medical devices monitoring

and compliance with national patient safety, medical device and drug alerts

effective management and learning from clinical claims/complaints/SUis

Early Warning Trigger tool exception report

Annual review of the Health & Safety report

2.12 To seek assurance that robust and timely systems or programmes are in place

in respect of Clinical Effectiveness, including:

Effective Medicines Management

Timely review of NICE Guidance, technology appraisals and other national

guidelines or regulations and the implementation of action plans

Effective delivery of the Trust Annual Clinical Audit programme and the

implementation of actions to improve standards and quality effectively

Development and implementation of Clinical outcome measures and care

pathways

To approve deviation from Nice Guidance where it is deemed appropriate and

necessary to do so

To agree annual clinical audit programme including the risk based approach

those pertaining to NICE Guidance and to ensure this is a continuing cycle.

2.13 To identify potential risks to quality and ensure that these are being reported

via the risk register and that there are robust plans to mitigate the risk

2.14 To regularly review risk register items pertaining to Quality, Clinical Governance

2.15 To ensure the delivery of the Trust priorities published in the Quality Account

2.16 To provide assurance to the Audit Committee on the management of key

quality and governance risks and issues to ensure an integrated approach to

governance.

12

To oversee the process for developing and implementing quality priorities To seek assurance on the Trust's arrangements for actively engaging patients,

staff, or members and key stakeholders on quality, including their patient

experience.

3.0 Membership

3.1 The membership of the committee will consist of: Non Executive Directors (2) (one of whom will chair the committee)

Medical Director

Director of Nursing and Quality Director of IT

4 Attendance

Deputy Director of Nursing

Head of Quality and Clinical Governance

Senior Representation from each Clinical Business Unit

The Chair ofthe Committee may extend invitations to other personnel with

relevant skills, experience or expertise as necessary to deal with the business

on the agenda. Such personnel will be in attendance and will have no voting

rights.

5 Responsibility of Members

Members of the Committee have a responsibility to:

attend at least 80% of meetings, having read all papers beforehand;

act as 'champions', disseminating information and good practice as

appropriate;

identify agenda items, for consideration by the Chair, to the Lead Director I Secretary at least 10 days before the meeting;

prepare and submit papers for a meeting, at least 8 days before the meeting;

if unable to attend, send their apologies to the Chair and Secretary prior to the

13

meeting . when matters are discussed in confidence at the meeting, to maintain such

confidences;

declare any conflicts of interest I potential conflicts of interest in accordance

with the Barnsley Hospitals NHS Foundation Trust's policies and procedures;

at the start of the meeting, declare any conflicts of interest I potential conflicts

of interest with the Barnsley Hospitals NHS Foundation Trust's policies and

procedures.

4.0 Quorum

4.1 The committee will be deemed quorate to the extent that the following are

present:

At least one Non Executive Directors

Medical Director or their representatives

Director of Nursing or a representative

As a Board Committee, only Non Executive Directors or Executive Directors

have the delegated authority to make decisions

5.0 Frequency of Meetings

5.1 The committee shall meet monthly

6.0 Authority

The Committee is authorised by the Board of Directors: to investigate any activity within its terms of reference and produce an annual

work program or forward plan;

to approve or ratify (as appropriate) those policies and procedures for which it

has responsibility

to promote a learning organisation and culture, which is open and transparent;

to establish and approve the terms of reference of such sub-committees,

groups or task and finish groups as it believes are necessary to fulfil its terms of

reference

7.0 Decision Making

14

Wherever possible members of the Committee will seek to make decisions and

recommendations based on consensus

Where this is not possible then the chair of the meeting will ask for members to

vote using a show of hands, provided that nothing in the way of business is

conducted is prohibited by the standing orders of the Barnsley Hospital NHS

Foundation Trust.

In the event of a formal vote the chair will clarify what members are being

asked to vote on- the (motion'. Subject to meeting being quortae a simple

majority of members present will prevail. In the event of a tied vote, the chair

of the meeting may have a second and deciding vote.

Only the members of the Committee present at the meeting will be eligible to

vote. Members not present, deputies and attendees will not be permitted to

vote, nor will proxy voting be permitted. The outcome of the vote, including

the details ofthose members who voted in favour or against the motion and

those who abstained, shall be recorded in the minutes of the meeting

8.0 Reporting arrangements into the Board

The Committee will have the following reporting responsibilities: to ensure that the minutes of the meeting are recorded and available,as an

appendix, to the Chairs Key Issuses and Assurance Log for the attention of the

Board

to produce those assurance and performance management reports listed in the

Committee's annual work programme which has been agreed with, and are

required by, the Board of Directors;

any items of specific concern, or which require the Board of Directors'

approval, will be subject to a separate report;

to provide exception reports to the Board of Directors highlighting key

developments I achievements or potential issues;

to produce an annual report for the Board of Directors setting out:

i. the role and the main responsibilities of the committee

ii. membership of the committee

15

iii. number of meetings and attendance iv. a description of the main activities during the year

9.0 Reporting Groups

The groups identified below will be required to submit the following

information to the Committee:

their terms or reference for formal approval and review;

the minutes of their meetings, together with a summary prepared by the chair

of that group outlining the key issues discussed at the meeting and those issues

that need to be brought to the attention of this Committee;

to produce those assurance and performance management reports listed in the

individual group's annual work programmes which have been agreed with, and

are required by, this Committee;

an annual report setting out the progress they have made and future

development; and

any report or briefing requested by this Committee .

The groups are:

Patient Safety & Quality Group

Patient Experience Group

Health & Safety Group

Risk Management Group

Organ Donation Group

Information Governance Group

10 Monitoring Compliance, Effectiveness and Review Date

10.1 The Committee shall, at least once a year, review its own performance against

the agreed terms of reference to ensure it is operating at maximum

effectiveness, complying with NHSLA Standards and recommend any changes it

considers necessary to the Board for approval.

16

10.2 The Committee will provide an Annual Report to the Trust Board, which will

summarise its performance against the delivery of its work programme setting

out the challenges and successes over the year, it will also report on

attendance during the year. It will provide an annual plan for the programme of

work for the forthcoming year. In particular, the annual programme coverage

will incorporate all key areas within the Committee's duties, as set out in

section 2 of its Terms of Reference.

Date Approved: June 2014

Version Number :

Next Review:

To be reviewed by: Quality Governance Committee


Executive Responsibilty: Director of Nursing and Quality

17

TERMS OF REFERENCE

AUDIT COMMITTEE

1 Purpose

The Audit Committee is responsible for providing assurance to the Board of

Directors on the Trust's system of internal control by means of independent

and objective review of financial and corporate governance, and risk

management arrangements, including compliance with law, guidance, and

regulations governing the NHS.

2 Duties

2.1 The Committee is responsible for the following aspects of Risk Management

-to 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), that

supports the achievement of the Organisation's objectives.

The Audit Committee provides an oversight of the activities of internal audit,

external audit and the local counter fraud service and the assurance on

internal control, including compliance with the law and regulations

governing the Trust's activities .

2.2 In particular, the Committee will review the adequacy and effectiveness of:

All risk and control related disclosure statements (in particular the Annual

Governance Statement and declarations of compliance with the Care Quality

Commission's Core Standards), 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 regulatory, 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 and as required by the Counter Fraud

18

and Security Management Service.

2.3 In carrying out this work the Committee will primarily utilise the work of

Internal Audit, External Audit and other assurance functions, but will not be

limited to these audit functions. 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

2.4 This will be evidenced through the Committee's use of an effective

Assurance Framework to guide its work and that of the audit and assurance

functions that report to it.

2.5 Internal Audit The Committee shall ensure that there is an effective internal audit function

established by management that meets mandatory NHS Internal Audit

Standards and provides appropriate independent assurance to the Audit

Committee, Chief Executive and Board. This will be achieved by:

Consideration of the provision of the Internal Audit service, the cost of the

audit and any questions of resignation and dismissal.

Review and approval of the Internal Audit strategy, operational plan and

more detailed programme of work, ensuring that this is consistent with the

audit needs of the Organisation as identified in the 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 that the Internal Audit function is adequately resourced and has

appropriate standing within the organisation.

Annual review of the effectiveness of internal audit.

The Head of Internal Audit shall have a direct reporting line to the

Committee and its Chair

2.6 External Audit The Committee shall review the work and findings of the External Auditor

appointed by the Trust and consider the implications and management's

responses to their work. This will be achieved by:

Consideration of the appointment and performance of the External Auditor .

19

Discussion and agreement with the External Auditor, before the audit

commences, of the nature and scope ofthe audit as set out in the Annual

Plan.

Discussion with the External Auditors of their local evaluation of audit risks

and assessment of the Trust and 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.

The External Auditor shall have a direct reporting line to the Committee and

its Chair.

The Council of Governors has the responsibility to appoint or remove the

Foundation Trust's External Auditors.

2.7 Standing Orders, Standing Financial Instructions and Standards of Business

Conduct

To review on behalf of the Trust Board the operation of, and proposed

changes to the Standing Orders and Standing Financial Instructions, Codes of

Conduct and Standards of Business Conduct; including maintenance of

registers of interest.

To examine the circumstances of any significant departure from the

requirements of any of the foregoing.

To review the Scheme of Delegation

2.8 Other audit related issues

To review performance indicators relevant to the Committee. To examine any other matter referred to the Committee by the Trust Board

and to initiate investigation as determined by the Committee.

To annually review the accounting policies of the Trust and make

appropriate recommendations to the Trust Board.

Identify annual objectives of the Committee, produce an annual work plan in

the agreed Trust format, measure performance at the end of the year and

produce an annual report.

3 Membership

20

Full membership of the Committee is limited to Non-Executive Directors,

whom the Board appoints on the recommendation of the Chairman of the

Trust.

The Chairman may not be a member of the Committee. At least one of the

Non-executive Directors should have recent and relevant financial

experience.

The formal membership of the committee shall comprise the following core

members:

• Chairman of the Committee, Non-executive Director

• Vice-Chairman of the Committee, Non-executive Director

• Non-Executive Director

The Chief Executive, Director of Finance, ?Associate Director of Corporate

Affairs, Internal and External Auditors shall generally be in attendance at

routine meetings ofthe Audit Committee.

In line with best practice the Chairman of the Board of Directors is not a

formal member but may be in attendance at committee meetings

The Audit Committee may sit privately without any non-members present

for all or part of the meeting if they so decide.

4. Attendance

It is expected that all members will attend 3 out of 5 committee meetings

per financial year ..An attendance record will be held for each meeting.

The Chief Executive and other Executive Directors should be invited to

attend, but particularly when the Committee is discussing areas of risk or

operation that are the responsibility of that Director.

The Chief Executive should be invited to attend, at least annually, to discuss

with the Audit Committee the process for assurance that supports the

Annual Governance Statement.

5 Quorum

A quorum for any meeting of the Committee shall be attendance by two

core members of Non-executive Directors

6 Frequency of meetings

21

Meetings of the Audit Committee shall be held at least five times per year

and at such other times as the Chairman of the Committee shall require,

subject to agreement with the Chairman of the Trust and the Chief

Executive.

The External Auditors shall be afforded the opportunity at least once per

year to meet with the Committee without Executive Directors present.

7 Reporting Arrangements into Trust Board

7.1 The minutes of Audit Committee shall be formally recorded and

available,as an appendix, to the Chairs Key Issuses and Assurance Log

for the attention of the Board

The Chair of the Committee will report to the Board at least annually on the

completion of its work in support of the Annual Governance Statement.

7.2 The Chair of the Committee will report to the Board at least annually on the

completion of its work in support of the Annual Governance Statement.

8 Administration

The Audit Committee will be supported by a nominated lead Executive

Director, do we need to specify DoF who will facilitate administaratyion

support.

9 Date Approved: June 2014

Version Number:

Next Review: To be reviewed by: Audit Committee


Executive Responsibilty: Director of Finance??

22


REF: 14/07/P-10

BoD July 2014: 10(a)_Chairs report

SUBJECT: CHAIRMAN’S REPORT

DATE: JULY 2014

PURPOSE:

Tick as applicable

Tick as applicable


PREPARED BY: Stephen Wragg, Chairman

SPONSORED BY:





The Board of Directors is asked to: a) receive, note and support this report b) invite and note any further reports on their activities from the wider Non Executive team.


REFERENCE/CHECKLIST



Patients

BCCG

Other

Staff

BMBC

Please state:

Governors

Monitor







Yes

Not applicable

To be developed


CGC

NCGRC

Audit Committee

Finance Commitee

ET



Finance:

Other:




BoD July 2014: 10(a)_Chairs report10(a)_Chairs report Pg 2

Subject: CHAIRMAN’S REPORT Ref: 14/07/P-10

1. INTRODUCTION

1.1 This report is intended to give a brief outline of some of the work and activities undertaken as Trust Chairman over the past month and highlight a number of items of interest.

1.2 The items reported are not shown in any order of priority.

2. TRUST POSITION

2.1 There are more detailed reports on our financial plans, improvements in performance against the A&E target and plans to refresh and reinforce our governance structure in other reports on the Board agenda but in view of our continued position of breach against Licence, I still feel I too must comment in my report.

2.2 A team from HQ met with Monitor earlier this week and we will continue to do so on a monthly basis. The meeting was generally positive, with some initial – but by no means definitive – comments on the thrust of our turnaround plan.

2.3 By the time of the Board meeting, the turnaround plan will have been submitted to Monitor. A programme is in place to cascade more information about the plan across the Trust as soon as it has been formally accepted.

2.4 I do appreciate the tremendous support I am meeting everywhere I visit across the Trust. I must reiterate the need to continue to give confidence to the population of Barnsley and our key stakeholders that care will not be compromised and that we will turn this current situation around. We are making progress but there is still a long journey ahead of us and it’s important that we take it at the right pace, making the right decisions, with our staff, patients and governors alongside.

3. COUNCIL OF GOVERNORS

3.1 The Chief Executive, interim Director of Finance, Director of Strategy & Business Development and I gave a briefing to the Council of Governors in June on the Trust’s position and our response to the enforcement notice. We shared as much information as possible to give assurance on the work progressed to date and the plans being put in place to take us forward. The Governors asked some very pertinent questions, which we answered as frankly as we can at this time. The Governors have an important role to play in holding the Non Executive Directors to account - and through them, the Board. This is one of their key statutory responsibilities. We have always adopted an approach of sharing as much information as possible with them and will certainly continue this in the future. We must also, however, review how we work with the Governors, ensuring that they have the right information at the right time to enable them to fulfil their duties.

3.2 Details of the Governors’ General Meeting held in June are provided separately (agenda item 12). I would also encourage you to look at the full meeting papers, available on the Trust’s website, including the Minutes of the Governors’ sub-group meetings so that you can read more about the wide range of topics their meetings cover, the questions they raise and the training and briefings they receive in-house.


3.3 Discussions at Governors’ meetings in June included enquiries about the Trust’s response to the growing incidence of TB nationally; continued support for our focus on HSMR; questions about how we provide translation for hard of hearing patients and other languages, our approach to recruitment and some observations on the changes made to the Trust’s schedule for staff appraisals. They were also very pleased to receive briefings on the PREVENT programme and an update on the “Learning From Experience” system (based on the same presentation as received at Board last month). They constantly challenge the Board on how we can improve services for patients and how we support staff, particularly during these extraordinary times.

3.4 The General Meetings are open to everyone and the sub-group meetings are always open to directors; the Governors really appreciate the opportunity to talk to us and hear from us direct. They know we will always answer their questions to the best of our ability, even if we have to bring back further information at a later date.

3.5 The feedback and challenge we get from our Governors is a real asset to us. Together with their work as ambassadors for the Trust, the Council illustrates one of the huge benefits of being a Foundation Trust.

4. HEART AWARDS

4.1 Having mentioned earlier how much we appreciate and value our superb staff, I am pleased to be able to repeat this with reference to this year’s HEART Awards.

4.2 We had over 100 nominations for the Awards – every one of which would have been a worthy winner! The evening itself was hosted by Harry Gration (Look North) and was another great success. It was a real celebration of our staff and a fabulous opportunity to recognise just some of the excellent people working across the hospital who continue to do so much to support our patients and improve our services.

4.3 My sincere thanks to everyone who attended and helped to make the event such a success and to the people who worked so hard behind the scenes, in particular Carole Ellison, Executive Assistant to the Chief Executive, and Emma Parkes, Director of Marketing & Communications.

4.4 After this Board meeting, several of us will be presenting the BRILLIANT Awards (for June) to a few more staff whose efforts are recognised by their colleagues and managers. I am delighted that we are able to express our thanks to staff and teams in this way each month.

5. NEWS & EVENTS

5.1 Last month’s Board meeting took place just before the NHS Confederation’s Annual Conference. The Conference was informative and several speakers emphasised the tough times facing the NHS and the continuing need to look at new ways of working differently. It was encouraging to hear the views of the NHS Commissioning Board’s new Chief Executive about the value of small district general hospitals and it will be good to hear more about how he intends to support hospitals such as ours in the future.

5.2 At the start of June, I was a guest at the Barnsley District Football Association’s (BDFA) Annual Awards Dinner and was presented with a donation of £500 to the hospital’s Charity. The BDFA has been a long standing supporter of the Barnsley Hospital Charity and their continuing generosity is greatly appreciated.


5.3 I also attended the Mayor’s Civic Service in mid-June. It marked the start of the new Mayor’s term of office, Councillor Tim Shepherd.

5.4 On 17th June, I attended the Foundation Trust Network’s (FTN) national conference for Chairs and CEOs. The major talking points throughout the day focussed on financial issues across the NHS. For information, I have attached a copy of the presentation from the FTN’s new Chief Executive, Chris Hopson, on strategic and policy issues affecting NHS providers (appendix 1).

5.5 Towards the end of the month the Chief Executive and I attended the Barnsley College Excellence Awards evening, one of which the Trust has sponsored for the past few years. This too was a tremendous way of celebrating success in our community.

5.6 Several staff and Governors attended the Equality Forum Celebration event in the Town Centre on 21st June

5.7 It is great that our Trust is represented at these – and many other – events across the borough. I believe it helps to demonstrate our commitment to the people we serve and our active role as part of the community.

5.8 At the end of June I was very pleased to welcome attendees and our guest of honour, Joanne Harris MBE, to the official opening of the Birthing Centre. It is a superb facility and the staff working there, and those who worked so hard to get it up and running, are justly proud of it.

6. BARNSLEY HOSPITAL CHARITY

6.1 Donations to the Charity for the first quarter of 2014/15 amounted to nearly £30,000. These donations help the Charity to support enhancements to patients’ services, benefitting our patients and staff. The generosity of our supporters continues to be fantastic. The Charity has a growing number of commercial sponsors too, including Sainsbury and the Alhambra Shopping Centre, which is invaluable and also helps to raise the Charity’s profile across the region.

6.2 The Charity’s office has now been relocated to the outpatients entrance. This enables the team to talk to visitors who call in whilst at the hospital, tell them more about the Charity’s work and raise awareness of the diverse range of activities being led by this small but dedicated team.

6.3 The office is also used as an outlet to sell merchandise for the Charity. It is generally staffed between 10-3pm Monday to Friday and plans are progressing to extend the opening hours in future.

Stephen Wragg CHAIRMAN July 2014

Appendices Appendix 1: FTN CEO’s Policy Update (Chairs & CEO Network event, June 2014)

FTN Chairs and CEOs Network Policy update Chris Hopson

17 June 2014

Overview

Seeds of optimism • Financial and overall strategic

situation continues to deteriorate • The Simon Stevens effect • NHS system leadership, having

grasped scale of problem, now starting to move towards planned, realistic, strategic, systematic response

• Critical mass of NHS providers beginning to take bolder concrete strategic steps away from existing models towards long term sustainability

What’s changed since we last met: mood music • Finances worsening: e.g. full scale of impact of extra post Francis and CQC

inspection regime staffing decisions; prospects for 2015/16 • Growing signs of pressure abound: RTT and elective waits; summer A&E

“crisis”; CAMHS; mental health beds; • Simon Stevens beginning to set out a path to a sensible NHS forward vision

and change model • First cut of 2 and 5 year plans • More members beginning to take significant strategic steps towards a

more sustainable future • Pre-election gearing up: a change in approach from Government / Jeremy

Hunt and discussion inside Labour on the path to integration

Strategy and planning

Finances

Issues of Day / FTN update

Three sections: each has presentation followed by table discussion and then plenary Q&A /dialogue


Finances



• The Simon Stevens effect • The NHS Five Year Forward View • The two and five year planning process • What we see members doing to ensure long

term clinical and financial sustainability • Risks and issues

Topics covered Ap

pro

ach

C

om

pet

itio

n

The Simon Stevens effect Starting point • Not tied to existing thinking • Doesn’t need to justify what he has inherited • Has NHS history but free to think and act on his own terms, as

he sees and finds the NHS today Forward Vision • Clarity needed on NHS strategic framework setting out

direction of travel • Need for rapid change moving to new models of care • Change driven by local leaders • Meeting local health needs and allowing variation • Harnessing medical and technological advances • NHS England as commissioner

Outlook • Opportunity not challenge • Optimism that required rapid change is deliverable

The NHS Five Year Forward View CONTENT • Overall strategic direction for NHS • Small number of models for changing how care is delivered (see later) • Change model: centre / local roles; required changes to NHS framework • Five year financial view including transition fund

PROCESS • Led by key statutory bodies: NHSE; Monitor; TDA with CQC input • Largely independent of DH and politicians • Supported by key stakeholders • Produced by end October 2014

WHAT IT MEANS • A framework that will set strategic context: neither top down plan nor 1000 flowers

blooming • Need for local leaders to then set out changes to align with framework • Enabling and facilitating changes to NHS operating framework • A forward view on money / service performance scenarios NHS can align behind

Emerging View of Building Blocks Required FROM THE CENTRAL LENS • What should the care models look like: developing six NHSE strategic themes (see

over) and how much flexibility / variability is allowable? • How does centre / local relationship work e.g. enabling rapid locally led change? • 5 Year Financial View for PES review: what is deliverable for what levels of money? • How do commissioning, primary care reform & health/ social care interface work? • How do key enablers work: information technology; medical and clinical advances?

FROM THE LOCAL LENS • How to drive rapid local change e.g. fast track collaborative local system leadership? • Creating an investment fund to invest in change • Building local change capability • Balancing requirements for future change delivery and today’s operational delivery • Preserving provider autonomy and building on / developing the FT model

Current NHS England Six Strategic Planning Themes • Citizen inclusion and empowerment

• Wider primary care

• A modern model of integrated care

• Access to highest quality accident and emergency care

• Step change in elective care productivity

• Specialised services concentrated in centres of excellence

NHS Two and Five year planning process: today • Two year plans: already submitted

o Plans concentrated on 2014/15 rather than 2015/16 o 2014/15 looking very difficult financially (see later) o 2015/16 hockey stick improvement: assumptions appear unrealistic

• Five year plans: due in shortly

o Very difficult to make long term assumptions o Major long term sustainability questions right across sector o Meaningfulness of process and tension between what system wants

(line of sight on degree of challenge and strategic approach to long term sustainability) and what you will be able to give.

The NHS planning process: summer & beyond • NHSE, Monitor and TDA will examine two year plans and then

publish a carefully judged summary • They will look at alignment between commissioner and provider

plans: significant misalignment will be taken as a key risk indicator • Five year plans will be assessed for signals about long term future

direction; degree of challenge; realism of plans for sustainability • NHSE heading for asking CCGs to do a late Autumn five year re-plan

within new NHS Five Year forward view framework • Reasonable to assume that providers will be asked to do a late

Autumn five year re-plan too

Emerging new models: principles • Many members already heading in likely direction of five year forward view • Ensuring long term financial and clinical sustainability • Rapid move from existing models • Greater emphasis on:

o integration, collaboration, co-operation o out of hospital care o different care models for frail elderly and more effective long term

condition management o better patient self management and prevention

• Embedding systematic approach to improvement • Greater efficiency e.g. clinical processes; “running the business” • Use of new technologies / harnessing clinical and medical advances

New Models & Approaches: ten examples (1) • Telemedicine / tele health: Airedale

• Integrating primary and secondary care: Northumbria, Newcastle and

Southern Healthcare

• Creating a single accountable care organisation: Chelsea and Westminster

• Integrating health and social care across organisational boundaries using alliance commissioning: Yeovil

• Horizontal integration / merger: Ashford and St Peters and Royal Surrey; Frimley Park and Heatherwood and Wexham

New Models & Approaches: ten examples (2) • Embedding improvement methodology / Lean : Tees, Esk and Wear Valley

• New clinical models: South East Coast Ambulance Service

• Rationalising service lines and creating partnerships: Dartford and

Gravesham

• Creating new ventures to pool services: South West London Elective Care

• Sharing back office and other services: Yeovil / Dorset County

Note link to Dalton Review (see later)

Risks and issues around this whole area • Potential clash of NHS five year forward view with General Election run up • Getting alignment between statutory bodies • The role of the Department and arms length bodies • Landing the new nuanced approach to centre / local e.g. how the centre

enables local change • Getting credible answers to the money issues: five year finances and

transition fund • Ensuring consistent rapid delivery of local change: e.g. creating local

change capacity and capability; operational vs change delivery • Alignment between two and five year planning process and Five Year

Forward View • Speed of change vs need

Questions / dialogue • Does this view of the world resonate with you?

• What do we as providers particularly need from the five year

forward view? • Is there anything else you particularly want the FTN to do?


Finances



Topics covered • The current position: system level and trust level • 2014/15 outlook • 2015/16 outlook including the Better Care Fund and

15/16 tariff • The five year view • A further challenge to providers

Deteriorating NHS system level position • 2010/11 to 2012/13: frequent large underspend of between £1.4

billion and £2.2 billion: 2% underspend • 2013/14: estimated £150m underspend on a £106bn budget: 0.15%

underspend “landing a jumbo jet on a postage stamp” • 2014/15: on the edge of balance again • 2015/16: currently working out how to close a c£5-7bn gap Driven by: • Flat cash – NHS ring fence but no real terms increase • 4% increase in demand and costs • Better Care Fund and 15/16 PES settlement • Aggregation of system level deficits and ALB pressures

Deteriorating FT / Trust Level Position • NHS provider aggregate: £700m drop in a single year

o 12/13 surplus £591m; 13/14 planned surplus: £183m.; 13/14 outturn: deficit of £108m

• 66 trusts ended 13/14 in deficit compared to 48 in 2012/13 including 41% of all acute trusts

• Some worrying 13/14 FT sector statistics: o Deterioration across sector more important than growing

deficits o For first time ever EBITDA margin dropped in Q3/4 and was a

long way off plan – staff numbers o Small acute EBITDA dropped from 4.7% to 2.9%

• You get what you pay for: finances / quality link

Drivers of deteriorating FT / Trust position

2014/15 Expectations • Whilst whole NHS system spend may balance, looking very difficult

for individual trusts with key drivers being: o 4% tariff efficiency factor o Commissioner squeeze: CCG and specialised commissioning o Huge extra investment in staff (for FTs in 2013/14 16k higher

than planned and 24k or 4% higher than 2012/13) o “The more traditional internal cost reduction efforts have been

all but exhausted” Kings Fund

• More deficits expected for 2014/15

2015/16 – The Potential Cliff Edge

“Bringing the affordability challenge to an unprecedented peak in 2015/16” • Pensions: revaluation of public sector pension contributions and reforms of state

pensions: still unclear how much of funding pressure will be met by NHS and degree to which they will be recouped through tariff changes

• Better Care Fund: top slice of £1.9bn of CCG funding to pool into BCF

2015/16 – Proposed System Response Three elements being worked on – • DH central planning including stakeholder engagement

• Better Care Fund risk management

• 2015/16 tariff

Need to be fast tracked and brought together as a single plan

2015/16 – DH Central Plan • Decrease input costs: pay; drugs; primary care; agency usage;

procurement • Reduce overheads: commissioning cost admin; trim central budgets • Internal productivity improvements: still sketchy • Activity diversion: holding growth in general and acute activity to

1.4% as opposed to last year’s 2.2% • Extra income / other: migrants; better cost recovery; reducing

litigation costs and fraud

FTN: need to get through 14/15; need for realism on deliverability including speed / lead time and focus required to deliver lots of small items.

2015/16 – Better Care Fund Risk Management

• Some have now produced deliverable plans; many still a long way off

• Current plans say they deliver £250m NHS savings; scrutiny suggests £100m

• Ministers now reluctantly accepting scale of problem

• Work now underway on “risk sharing” • Early stages of what “risk sharing”

means: different answers from different players

• Constraints: PES settlement; local government; rewarding failure

• Watch this space in Autumn

2015/16 – Tariff • Very difficult task but key to creating a deliverable 2015/16 plan • Strong focus on efficiency factor and service development uplift factor • Radical alternatives being canvassed to keep within envelope:

o Introduction of marginal rate for elective care o Bundling outpatient attendances

• Looking to future: o Funding integrated care o Creating prototype transformation fund from CQUIN / provider fines /

primary care incentives o Supporting innovative forms of contracting (e.g. alliance contracting)

• FTN: set out priorities in our own document and engaging early • Consultation document due out 15th July 2014-ish

2015/16 – FTN overall approach and tone • Constructively engage in trying to create a deliverable plan… • …which must be in place sufficiently far in advance of April 2015 to be

actionable… • …on basis of only publicly supporting something that is deliverable

• Current strong sense of pessimism that this is achievable… • …c£2bn gap widely thought to be “unsurmountable”

• We are arguing that this has to be made clear and transparent... • …with choices openly debated and, if no more money forthcoming, a clear

and open debate and then decision about where the risk should fall

• Full downside scenario: tariff efficiency factor of c6.5%.

Longer Term: Next Parliament

• Deficit elimination: only 40% complete o Growing economy makes little

difference to task o All parties committed to deficit

elimination • PES settlement 2015 key • General Election debate • Transformation Fund • Longer term post 2020:

o Constraint of future debt payments (£31bn in 09/10 to £75bn in 18/19)

“The settlements we will need to make following the General Election will be

the toughest facing an incoming Labour Government for a generation”

Chris Leslie, Observer 15 June 2014

Even with successful defence of NHS ring-fence

To eliminate deficit & preserve NHS ring fence, NHS share of Department spending needs to increase from 29% to 45% from 2010 to 2019

Fraser Nelson analysis of OBR data, 2014

A further challenge for NHS providers

• Perception that NHS providers are significantly behind rest of public sector, let alone private sector, in areas such as:

o Procurement o Embedding improvement methodology o Running back office effectively e.g.

sharing back office services o Using customer facing technology to

increase efficiency o Driving wider change through

technology • We need progress and a narrative here!

“Before I ask my constituents to pay any more money for the NHS, I have

to be able to assure them that we are squeezing every last drop out of what they are currently giving? Can I

do that today? The answer is no” Andy Burnham, NHS Confederation

Conference 2014

Questions / dialogue • Does this view of the world resonate with you?

• How are we going to address perceptions that we are seriously

lagging behind on efficiency? • What more do you want the FTN to do?

• Do we have the tone on provider finances right?


Finances



Issues of the Day • Dalton Review • Specialised commissioning • FT pipeline • RTT / elective waiting list and U&EC money announcement • Small hospitals • General Election

FTN update

• From “you all need to be in management chains” to “developing and publicising models of provider collaboration and co-operation”

• Models being considered: multi site trusts; joint ventures; service level chains; federations; management contracts; provider led integrated care organisations; multi service chains

• Identify barriers and implementation success factors then promote & publicise

• Timelines: • FTN / Kings Fund document July • Final report: October to align with

NHS 5 Year Forward View • FTN well represented on expert panel

Dalton Review

• Size of overspend seen as key threat to NHS financial stability

• Major interim project to bring firm, rapid, grip to “out of control” area

• Playing hard ball on the money • Simon Stevens brings new strategic

take: o Shift to co-commissioning o Less commitment to rapid

centralisation to 15-30 centres • FTN: leading on provider

engagement; narrative needed on provider perspective

Specialised Commissioning

4 Key Facts on 13/14 Specialised Commissioning Budget

• £834m overspent • Covered by £457m one off use of

reserves and contingency and £377m overspend

• Key elements of overspend: - £258m baseline / legacy issues - £238m activity over performance - £158 growth / QIPP slippage - £108m drugs & devices overspend • 76 providers (26% of those in

receipt) account for 80% of spend

• Still a strong commitment to getting as many trusts through the pipeline as possible as quickly as possible

• A key point in process: CQC pilot inspections complete and “held up” acutes and pure community trusts now at Monitor

• Growing demand for clarity and less “Grand Old Duke of York”

• Weston and George Eliot announcements – NHS preferred?

• Growing nervousness that some may want to linger under TDA umbrella as strategic weather worsens

• FTN continuing to monitor and lobby hard including thought leadership on FT model

FT Pipeline

Kingston Hospital NHS FT: the last trust through the FT pipeline, on 1 May 2013

Urgent & Emergency Care • Last year’s £400m (£250m + £150m) • Capitation based – to all – via u&ec working

groups • Plans needed including how withheld 70% MRET

to be used RTT /Elective Care • New £250m to cut waiting lists by Autumn • Targeted where waiting lists longest • Accompanied by rigorous performance

management as with u&ec funds last winter • Opposition to principle of regulatory performance

management versus grudging acceptance FTN: welcome but mainstream funding

Elective care and U&EC Funding Announcement

• Monitor economics team report into small hospitals published 13 June

• “encouraging that small size does not in itself preclude hospitals from achieving sound performance”

o small trend for lower EBITDA% at smaller trusts

o size (beds, turnover) explains only a limited amount of variation in financial performance between hospitals

o wider impact of service line reductions • Poorer sector performance linked to higher

proportion of work undertaken under the NHS national tariff & multiple sites

• Clear evidence on wider adverse impact of tariff efficiency factor and MRET

• FTN continuing virtual small hospitals group

Small hospitals

Small hospitals • Debate needed on NHS future and financing

• Limited political appetite for funding debate

• NHS Five Year Forward Look and 2015 Challenge

• Labour and Tory tensions: path to integration and conservatism or radicalism

• FTN: o Influencing manifestos via dinner

programme and party conferences o Provider manifesto: significant piece

of thinking for post election agenda

General Election

What I Haven’t Talked About • Rose Review • CQC inspection regime and special measures • Increasing performance management by regulators • HEE consultation on reducing overheads and LETB independence • Urgent and emergency care pathway redesign • 7 day services • Pay and current consultant negotiations

FTN update Strategic objectives Influence, voice, support, professional FTN Top current priorities • Money and provider finances • Contributing to NHS strategy and planning work • Election influencing and post election political thinking Also specific work on: • Specialised commissioning

FTN: going well • Addition of new Chair • Rebalancing voice and influence: maturing into system player whilst

retaining sharper edge where needed • Thought leadership: e.g. on FT model via Annual Lecture and Seizing

Opportunity document • Growing support offer: mental health; new strategy and COO/ Ops

Director networks • Building offer for clinical audience: first quality conference • Governance role: GovernWell feedback; governance conference

Thank you for your support, particularly increased subscriptions which will enable us to significantly enhance the service we offer you

Questions / dialogue

Any questions on themes of the day / what I didn’t talk about and FTN? What more do you want the FTN to do? Any feedback on the FTN?

WHAT I TALKED ABOUT • Dalton Review • Specialised commissioning • FT pipeline • RTT and U&EC money • Small hospitals • General Election

WHAT I DIDN’T TALK ABOUT • Rose Review • CQC Inspections / Special Measures • HHE cuts and LETB independence • More regulatory intervention • U&EC pathway redesign • 7 day services • Pay and consultant negotiations


REF: 14/07/P-11

SUBJECT: CHIEF EXECUTIVE’S REPORT

DATE: JULY 2014

PURPOSE:

Tick as applicable

Tick as applicable


PREPARED BY: Diane Wake, Chief Executive


PRESENTED BY: Diane Wake, Chief Executive


To report particular events, meetings or publications that the Chief Executive would like to bring to the Board’s attention.



The Board of Directors is asked to receive and note this report.

BoD June 2014: 11_CEO Report

REFERENCE/CHECKLIST



Patients

BCCG

Other

Staff

BMBC

Please state:

Governors

Monitor







Yes

Not applicable

To be developed


CGC

NCGRC

Audit Committee

Finance Commitee

ET



Finance:

Other:




BoD June 2014: 11_CEO Report

Subject: CHIEF EXECUTIVE’S REPORT Ref: 14/07/P-11

1. INTRODUCTION

1.1 This report is intended to give a brief outline of some of the key activities undertaken as Chief Executive since last month’s report and highlight a number of items of interest.

1.2 The items below are not reported in any order of priority.

2. NHS NATIONAL CONFERENCE LIVERPOOL JUNE 2014

2.1 This year’s Confederation was attended by Stephen Wragg, Chairman; Diane Wake, Chief Executive; David Peverelle, Chief Operating Officer and Karen Kelly, Director of Operations. The key speakers for the Conference including representatives from all the main political parties, speaking particularly in anticipation of the election next year. This included the Secretary of State, Mr Jeremy Hunt; the Shadow Health Secretary, Andy Burnham and for the Liberal Democrats, Norman Lamb.

2.2 In addition, the Conference also heard the inaugural speech from the new Chief Executive of the NHS, Simon Stevens who gave a wide ranging review of the challenges facing the NHS.

2.3 Also the Confederation heard from the new NHS Confederation Chief Executive Rob Webster who outlined a challenge for all the political in relation to a plea for all political parties to settle on a “10 year NHS funding settlement” with real terms of growth of the budget over that period with a £2 billion annual transition pot to pay for service change. Also he sought parity of esteem between physical and mental health services and also specifically for mental health patients to be given new rights to access services in a set time limit regards to their choice of service with similar targets being set to those found in the acute sector.

3. WORKING TOGETHER STEERING GROUP MEETING 2 JUNE 2014

3.1 The last meeting was held on the 2nd June and was attended by David Peverelle, Chief Operating Officer on behalf of the Trust.

3.2 The programme is still progressing, albeit under auspices of the new consolidated management arrangements following the transition from Finnimore’s Project Management. The new Project Director, Jeanette Watkins has now taken over from the Interim Director, Chris Linacre, who retired at the end of March.

3.3 There has been some consolidation of the programmes as a result, these include focus on • informatics • specialty collaboration working,( including (Oral Maxillofacial surgery, Ear Nose

and Throat and Ophthalmology) • Radiology Services • Children Services, • Gastro Intestinal Bleeds Services • Procurement ( a main area of focus)

BoD June 2014:CEO Report Page 1

4. MEDIA COVERAGE

4.1 As expected, the Trust saw a significant amount of media coverage following Monitor’s announcement. This was mainly in the local and regional media on Friday 6 and Saturday 7 June, with BBC Look North, ITV Calendar, BBC Radio Sheffield, Hallam FM, Yorkshire Post and Sheffield Star all picking up the story.

4.2 On a national level, the Health Service Journal also ran the story. Nearly all publications included the Trust’s statement in response to Monitor’s concerns.

5. BARNSLEY HOSPITAL CHARITY HEART AWARDS 2014

5.1 As reported in the Chairman’s report, the fifth annual Barnsley Hospital HEART Awards were held at the Holiday Inn on Friday 6 June 2014. The event was a great success and was attended by almost 300 guests. This year the Chief Executive’s Award was introduced and was won by the Critical Care Team.

6. WORKING TOGETHER RADIOLOGY PROGRAMME

6.1 A Working Together Radiology Workshop was held on 18 June 2014. There was very impressive level of engagement, useful discussion and clear will to work collaboratively. Workstreams with task and finish groups have been identified and further meetings are being arranged for August, September and October.

7. NICE CLINICAL GUIDANCE DEVELOPMENT GROUP – SEPSIS

7.1 NICE are currently undertaking a nationwide study on Sepsis; the aim of the study is to identify and explore avoidable and remediable factors in the process of care for patients with known or suspected sepsis. The study’s objective is to examine organisational structures, processes, protocols and care pathways for sepsis recognition and management in hospitals from admission through to discharge or death, and to identify avoidable and remediable factors in the management of the care for a sample of adult patients with sepsis. In the study, a sample of patients identified as having sepsis in the two week data collection period; will be identified for an in-depth case review by a multidisciplinary group of Advisors. The Trust’s Corporate Matron, Julian Newell, has been appointed as one of the Advisors on the study, due for publication in 2015.

7.2 NICE have been asked to develop a clinical practice guideline on Sepsis - the recognition, diagnosis and management of Severe Sepsis (due to be published 2016) for use in the NHS in England, Wales and Northern Ireland. NICE has commissioned the National Clinical Guideline Centre (NCGC), hosted by the Royal College of Physicians, to produce a clinical guideline on Sepsis: the recognition, diagnosis and management of severe sepsis. Healthcare professionals were invited to apply to be considered for membership of Sepsis Guideline Development Group (GDG). The GDG members will work closely with the NCGC technical team, who will be responsible for reviewing and presenting the evidence to the GDG. Julian Newell has been successful in applying for membership of the Sepsis Guideline Development Group.

BoD June 2014:CEO Report Page 2 of 3

8. CLINICAL TEACHING AWARD 2014

8.1 Dr Eltrafi has been awarded a Clinical Teaching Award by the Medical School, University of Sheffield Medical students were asked to nominate individuals who fulfil the following criteria: • has provided teaching of the highest quality within a clinical setting over a

sustained period • inspires and supports students through close engagement with them and by

being and excellent role model • enables students to feel part of their clinical team and enables other members of

their team to help with their development • creates an environment in which students feel empowered to engage with clinical

medicine.

8.2 Awards were made to NHS staff in General Practice, Psychiatry, each of the four Associate Teaching Hospitals and Sheffield Teaching Hospitals.

8.3 Congratulations go to Dr Eltrafi on this award. Diane Wake Chief Executive July 2014

BoD June 2014:CEO Report Page 3 of 3


REF: 14/07/P-12

BoD July 2014: 12(a)_Council of Governors

SUBJECT: COUNCIL OF GOVERNORS

DATE: JULY 2014

PURPOSE:

Tick as applicable

Tick as applicable



SPONSORED BY: Stephen Wragg, Chairman



The role and responsibilities of the Council of Governors and the Board’s responsibilities of working with and providing support to the Council.


Is the Council of Governors holding the Non Executive Directors to account and, if so, how? Is the Board providing sufficient and timely information to the Governors? Is the Board listening and responding to questions and comments from the Governors? Is the Board providing appropriate training to Governors?

CONCLUSION AND RECOMMENDATION(S) The latest agenda and approved minutes attached illustrate how the Board and Governors work together to support development of services to patients. They also reflect some of the ways in which the Governors and Board meet the requirements:

- for the Board of Directors to listen to and take account of the view of the Council of Governors

- to provide both information and training to governors - for the Council of Governors to hold the Non Executive Directors to account

The Board is asked to receive and note this report.

BoD July 2014: 12(a)_Council of Governors

REFERENCE/CHECKLIST



Patients

BCCG

Other

Staff

BMBC

Please state:

Governors

Monitor







Yes

Not applicable

To be developed


CGC

NCGRC

Audit Committee

Finance Commitee

ET



Finance:

Other:




GENERAL MEETING OF THE COUNCIL OF GOVERNORS OF BARNSLEY HOSPITAL NHS FOUNDATION TRUST

5.30-7.30pm, 11TH JUNE 2014

IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL

AGENDA

Part 1: in public

1. Apologies & Welcome

2. To invite comments from members of the public

3. To receive any declaration of interests

4. To approve the Minutes of the Meeting held on 9th April 2014 ENC 4

5. To consider any matters arising from the Minutes of the last meeting

6. To receive and endorse Membership Office update report ENC 6 - Mrs D Myers, Membership & Communications Officer

7. To receive an overview of the Patient Flow pathway action plan Presentation - Mr B Kirton, Director of Strategy & Business Development

8. To receive a report from the Trust’s Chairman, Mr S Wragg ENC 8

9. To receive a report from the Lead Governor, Mr J Unsworth ENC 9

10. To receive an update report from the Trust’s Chief Executive, Ms D Wake ENC 10

11. To review and endorse the report of the Council of Governors’ sub-groups ENC 11 – Mr D Brannan (Strategy & Performance), Mrs C Robb (Patients’ Experience), and Mr A Conway (Staff & Environment)

12. To receive and note reports from the Board of Directors ENC 12 – latest Board Agenda and approved Minutes (meetings held in public) – latest integrated monthly performance report

13. To consider issues raised by Governors: – WiFi charges for patients- Mr D Sykes, Public Governor

14. Any other business, including: – matters raised by the public – date of next General Meeting, 13th August 2014 (5.30-7.30pm)

15. To resolve that representatives of the press and other members of the public be excluded from the final part of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest in accordance with 8.13.2 and 8.13.3 of the Trust’s Constitution.

Signed: ……………….….. Chairman

COUNCIL OF GOVERNORS – JUNE 2014 REF: CG/14/06/04

04

MINUTES OF A GENERAL MEETING OF THE COUNCIL OF GOVERNORS HELD ON 9TH APRIL, 5.30PM

IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL

Present: Mr P Ardron Partner Governor, Sheffield Universities Mr D Brannan Partner Governor, Voluntary Action Barnsley Mrs P Buttling Public Governor, Barnsley Public Constituency Mr A Conway Staff Governor, Volunteers Mr A Dobell Public Governor, Barnsley Public Constituency Mrs J Gaines Public Governor, Barnsley Public Constituency Mr A Grierson Public Governor, Barnsley Public Constituency Mr M Jackson Partner Governor, Joint Trade Unions Committee Mr W Kerr Public Governor, Barnsley Public Constituency Mr P Lleshi Partner Governor, Barnsley Together Ms G Morritt Staff Governor, Nursing & Midwifery Mrs L Neasmith Partner Governor, Barnsley College Mrs J O’Brien Public Governor, Barnsley Public Constituency Cllr J Platt Partner Governor, Barnsley MBC Mr J Ramsey Staff Governor, Non Clinical Support Staff Mr R Raychaudhuri Staff Governor, Medical & Dental Mrs M Richardson Public Governor, Barnsley Public Constituency Mrs C Robb Public Governor, Barnsley Public Constituency Mrs L Sanderson Staff Governor, Nursing & Midwifery Mr H Spence Public Governor, Barnsley Public Constituency Mr T Smith Public Governor, Barnsley Public Constituency Mr D Thomas Public Governor, Barnsley Public Constituency Mr J Unsworth Lead Governor & Public Governor, Constituency A Mr N Woodcock Public Governor, Constituency D (arrived 6.10pm) Mr S Wragg Trust Chairman

In attendance: Ms T Bostwick Learning Disabilities Liaison Nurse (Minute 14/22) Mrs S Brain England Non Executive Director Ms C Dudley Secretary to the Board Mr R Kirton Director of Strategy& Business Development

Mrs D Myers Membership Officer Ms D Wake Chief Executive

Apologies: Mr B F Leabeater Public Governor, Barnsley Public Constituency

Mr L Steenson Public Governor, Public Constituency O (out of area) Mr D Sykes Public Governor, Barnsley Public Constituency

CG/14 17 APOLOGIES & WELCOME

The Chairman welcomed governors, guests, directors and senior managers to the meeting. Particular welcome was extended to Ms O’Brien attending her first General Meeting since appointment to the Council, and Mr Lleshi, nominated partner governor for Barnsley Together.

Action

CoG June 2014: 04_CoG Apr 2014 Minutes (pum) page 2 of 9

Apologies were noted as above.

CG/14 18 COMMENTS FROM THE PUBLIC

None.

CG/14 19 DECLARATIONS OF INTEREST

None.

CG/14 20 MINUTES OF LAST MEETING (Enc 4)

The Minutes of the General Meeting held on 12th April were received and accepted as a true record.

CG/14 21 MATTERS ARISING

• Minute CG14/02 – Council of Governors’ Register of Interests A small number of updates to the Register had been received and entered since the last meeting. Copies were available on request.

• Minute CG14/03 – Non Executive appointments The re-appointments for Mrs Brain England, Sir Stephen Houghton and Mr Wragg had been offered as agreed by the Council of Governors and had been accepted.

• Minute CG14/06 – Quality Account As agreed, the draft QA had been referred to the Strategy & Performance sub-group, who had reviewed and supported the proposed priorities and indicators, including one to be closely monitored by the Governors. Further details were available in the draft minutes of the sub-groups Meeting (agenda item 11 referred) .

• Minute CG14/10 – Chairman’s report

o Sub-group Chairs/Vice Chair appointments Further to approval for the appointment of Mrs Robb, Mr Conway and Mr Smith to the vacancies in the Governors’ sub-groups, Mr Conway and Mr Smith had been confirmed as the Chair and Vice Chair respectively for the Staff & Environment sub-group and Mrs Robb as Vice Chair for the Patients Experience sub-group.

o Correspondence with Governors Letters had been sent to Ms Johnson, Mr Kerr and Mr Woodcock as requested.

• Minute CG14/12 – Chief Executive’s report In terms of actions from the Chief Executive’s update to the last meeting, it was noted that the action plan following the Bed Utilisation review would be presented to the Governors in June; feedback from the staff survey had been shared with and reviewed by the Staff & Environment sub-group, and an update on the Working Together programme was in the Chief Executive’s latest report.

CG/14 22 ACTIONS ON LEARNING DISABILITIES

Ms Bostwick, the Trust’s Learning Disabilities Liaison Nurse, gave a comprehensive overview of the systems in place within the Trust to support patients with learning disabilities when attending or in hospital and ongoing


work to build on this further. A copy of the presentation is attached. The systems and support to patients with learning disabilities were appreciated. It was acknowledged that the system currently relied on Ms Bostwick’s expertise and on patients’ needs being reported at the time of referral. Ms Bostwick advised that training had been developed and would be expanded further to enable more staff to identify patients with learning disabilities more quickly. This would help to ensure all patients were supported throughout their time in or attending hospital and enable more staff to offer the necessary support from within their own teams, not having to be dependent on one person. Ms Bostwick outlined the work ongoing to establish better continuity across the community in terms of both referrals into the hospital and referrals to community services for follow up services. Governors were also pleased to note that, where possible, the Trust worked closely with patients’ families, friends and carers; concerns were often greater for patients without such support.

Cllr Platt and Mr Spence enquired about the higher incidence of deaths among people with Learning Disabilities. Ms Bostwick advised that, nationally, the major cause for the higher death rate amongst such patients had been identified as health screening, with patients often less aware of or experiencing more difficulties gaining access to screening programmes. Respiratory problems and epilepsy were also known related issues.

Before leaving the meeting, Ms Bostwick was thanked for attending to provide a useful update on the Trust’s work to support patients with learning disabilities, and for her leadership and commitment to this important work.

CG/14 23 2014/15 BUSINESS PLAN

Mr Kirton tabled a copy of the agreed vision and aims for the Trust’s 2014/15 business plan, built around “4Ps”:

• Patients will experience safe care

• Partnership will be our strength

• People will be proud to work for us

• Performance matters

The paper also outlined the key strategic objectives underpinning each of the four strands. Mr Kirton stressed that all of the aims were interlinked to ensure a comprehensive approach and the objectives would be SMART (simple, measurable, actionable, realistic and with defined timelines). Delivery would be closely monitored throughout the year through the restructured Clinical Business Units and new performance framework, ensuring clear lines of accountability. The plan had been launched trust-wide and at a recent Board meeting with counterparts from key community partners. Support from staff and partners would be critical to the plan’s success, together with engagement and learning from patients and members of the public.

Governors were assured that any actions outstanding from last year’s objectives would be progressed until completed, in addition to the objectives agreed for 2014/15. It was noted that there was a smaller number of objectives for this year; this did not reflect a less ambitious plan but a different approach and focus. The new approach would also make it


easier to assess progress throughout the year. The Chairman confirmed that the Board expected all of the objectives to be achieved within 2014/15.

The Governors appreciated the report and affirmed their support for the plan.

CG/14 24 QUALITY ACCOUNT (Enc 7)

As stated in the report, a copy of the draft Quality Account (QA) for 2013/14 had been issued to all Governors by email; printed copies were available at the meeting or could be mailed out on request. The Council of Governors had been invited to comment on the QA and the Trust’s approach to quality throughout the year. It was proposed and agreed that the Strategy & Performance sub-group be mandated to lead the work on drafting a response letter on behalf of the Council. The draft letter would be circulated to all Governors for comment before being finalised by the sub-group at their meeting in early May and submitted to the Trust on behalf of the Council of Governors. Any comments and contributions to the draft response would be appreciated and could be submitted via the Chairman, the sub-group Chair (Mr Brannan) or the Secretary to the Board.

S&P

ALL

CG/14 25 CHAIRMAN’S REPORT (Enc 8)

The Chairman’s report was received and noted. It provided commentary and updates on a range of activities, items of interest and Board discussions since the last General Meeting.

The Chairman reported that Dr Balac had resigned as partner governor for Barnsley Clinical Commissioning Group (CCG); he had taken this step to avoid any conflict of interest. The Chairman had invited the CCG to nominate another representative in order to retain their seat on the Council.

Other issues highlighted from the report included:

• By-election for a new staff governor (Clinical Support): One nomination had been received and confirmed as the new governor, with effect from 1st May 2014 – Ms Rachel Hewitt, advanced physiotherapist. The Council looked forward to welcoming Ms Hewitt at the next General Meeting.

• Annual review of the Terms of Reference for the Council’s sub-groups and the role of the Lead Governor: It was agreed that, as last year, these should be referred to the Strategy & Performance sub-group for review. Governors were asked to submit any comments to the sub-group Chair or Secretary to the Board in good time for the sub-group’s meeting.

• Annual review/appointment of sub-group Chairs & Vice Chairs: The recommendation proposed by the Chairman, to continue with the current appointments, based on performance to date and to support continuity following several changes in year, was approved.

• Governwell training: Governors agreed it would be useful to attend training locally, in Sheffield, to be hosted by either the Sheffield Children’s or Sheffield Teaching Hospitals trusts in the summer. Dates would be advised when confirmed.

S&P

All


• HEART Awards: Nominations were now open and tickets would go on sale in May. The meeting was reminded that one of the Awards had been named in memory of Mr Bob Ramsay, who had been a public governor until his death in November 2013.

CG/14 26 LEAD GOVERNOR’S REPORT (Enc 9)

The Lead Governor’s report on activities since the last meeting and items of interest for the Council was received and noted. Mr Unsworth highlighted a number of points, including

• the latest briefing booklet issued by the Foundation Trust Governors’ Association (FTGA), copies of which were available at the meeting, on the FTGA website or on request from the Secretary to the Board;

• the FTGA forthcoming event for new Governors (final details awaited);

• the annual PLACE (patient led assessment of care environment) inspection was imminent and Governors had been invited to be involved if available on the dates recently announced;

• the internal quality & safety visits, which Governors had helped to instigate. Mr Unsworth shared some positive feedback from the latest visit he had been involved with. Ms Morritt also commented on the same visit, which she had attended as matron representative. It was confirmed that feedback from every visit was reviewed by the Trust-wide Patient Experience Group and would also be shared with the Governors’ Patient Experience sub-group

Mr Brannan and Mr Smith provided feedback from the FTGA spring development day they had attended in March. Both had found it a very interesting session with some useful learning, which they were pleased to share. They encouraged other Governors to attend future events, for the shared learning from the diverse and interesting speakers, the valuable networking opportunities and useful information on what was and was not working well nationally (Lord Hunt had reported that 39 trusts are currently in financial breach), and assurance in terms of the good relationship and transparency between Governors and the Board at Barnsley.

Mr Smith reported on the Independent Advisory Panel for Governors, set up by Monitor. This would become an increasingly important panel for Governors. It was agreed that it would be useful for the Governors to hear more about the panel, perhaps at a future meeting of the Strategy & Performance sub-group.

SW

CG/14 27 CHIEF EXECUTIVE’S REPORT (Enc 10)

The Chief Executive’s report was received and noted, and Ms Wake expanded on a number of points:

• The contract with Barnsley CCG, the Trust’s main commissioners, was not yet finalised. It was important to ensure the Trust had the right settlement for the year before it could be signed off.

• The Trust had done well in delivering on nearly all national targets in 2013/14. Highlights included another year of zero cases of MRSA and year on year improvement (reduction in cases) of Clostridium Difficile


(C.Diff). Governors asked that their commendation be passed on to the Infection Prevention & Control team for the continuing good outcomes around MRSA and C.Diff.

• The Trust had not achieved the A&E performance for the year (95% target for <4 hours to discharge or admission). The agreed action plan was now beginning to deliver improvements and the target had been achieved in March. Ms Wake expected this to be maintained going forwarded, supported by the huge amount of work being progressed.

• The restructuring from 14 clinical service units to 6 clinical business units (CBUs) had continued, with the CBUs beginning to operate in shadow form and all appointments to key roles expected by the end of May. It was important the right governance structure was in place to support these changes and extensive reviews were ongoing

• The CEO’s monthly column in the Barnsley Chronicle continued to receive a positive response. Governors welcomed this as evidence of the improved relationship with the local media, albeit it was appreciated that the media still had a role to challenge the Trust and report on that – good and bad. Mr Jackson advised that JTUC had opted not to speak with the Chronicle for several years as they had been misquoted in the past, which had been unhelpful. JTUC had appreciated and would continue to observe the improved relationships between the press and the Trust.

This was the first written report presented by the Chief Executive and several Governors had found it to be useful in addition to the verbal update provided at the meeting. Lead Governor Mr Unsworth endorsed this view; he also appreciated the frankness within the Chief Executive and Chairman’s reports to Governors, which had not been curtailed by the current difficulties facing the Trust around its financial position and A&E. He appreciated the CEO’s comments on the achievements in 2013/14 too.

CG/14 28 SUB-GROUP REPORTS (Enc 11)

The draft minutes and reports from the latest sub-group meetings were received and noted, as chaired by Mrs Buttling (in Mr Brannan’s absence), Mr Ramsey and Mr Conway (first meeting as Chair). The meetings continued to be open to all Governors and any questions or comments would be welcomed by the sub-group Chairs at or outside the meeting.

• Mrs Buttling drew attention to the Strategy & Performance sub-group’s work to identify a priority/indicator for the 2014/15 quality report – which had been agreed to focus on reduction in hospital acquired harms, and would be closely monitored by the sub-group throughout the year. The group had also focussed its discussions on mortality ratios and the latest quarterly report to Monitor (quarter 3).

• Mr Ramsey reiterated the group’s appreciation of the presentation from Dr McAndrew, which had provided some useful insight into the impact of and the Trust’s work on Hospital Standardised Mortality Ratios. Progress on the wayfinding project (with new signage now in place and good feedback to date) had also been noted.

It had, however, been difficult to manage all of the business within the time allotted to the meeting and the sub-group would be considering options for a longer meeting and/or an abridged agenda in future.


• Mr Conway’s first meeting as newly appointed Chair of the Staff & Environment sub-group had included training on crisis management. Mrs O’Brien stated that she had found this particularly useful in terms of the Trust’s readiness and the opportunity for governors to come on site in the event of a crisis and be able to help constructively. Mrs Richardson reminded members of her involvement with a nearby residents’ association and advised that she had offered the group’s help as a local resource for such needs too (discussions were ongoing with the lead officer to take this up).

The Chairman was pleased to note the continuing good feedback from the sub-group meetings, reflecting on the training, information and discussions received at the groups.

CG/14 29 NOMINATIONS COMMITTEE (Enc 12)

Based on the outcome of the interviews held in March, as outlined in the report, the Council received and endorsed the Committee’s recommendation not to proceed with appointment of an additional Non Executive Director.

The proposal would be revisited at a more appropriate time.

CG/14 30 BOARD OF DIRECTORS (Enc 13)

The agenda (April), approved Minutes (March) and latest integrated performance report presented to the Board of Directors meeting held in public in April 2014 were received and noted.

CG/14 31 ANY OTHER BUSINESS

• Comments were invited from attendees to the meeting

a) Financial position Mr Millington, a member of the public, expressed his concerns regarding the Trust’s reported financial deficit and the contrast to the position reported previously. He queried the financial management and the assertion at the Board of Directors’ meeting in February that the Trust was a well run organisation. His concerns were noted and the Chairman and CEO assured him that they were shared by the Board, the management team and the Council of Governors. The Chairman advised that the situation had been reported to Monitor immediately it had come to light. Monitor had been involved in agreeing the terms of reference for the external investigation which the Board had commissioned immediately, in addition to the internal investigations ongoing within the Trust and Monitor’s own investigation. At this stage of the various investigations, the Board could not be categorical about how the deficit had arisen without concerns being reported to the Board earlier. The Chairman emphasised that the Board was a unitary board and as such took collective responsibility for the Trust’s performance. Extensive work was ongoing both to establish the full extent of the position and take the Trust forward to recovery as quickly as possible, whilst maintaining and protecting high quality and safe services for patients.


b) Toilet facilities Mrs Bevis, a hospital volunteer and member of the public, asked if there had been a response to her previous observations regarding the lack of female toilet facilities for staff on the ground floor. As Chair of the Patients Experience sub-group, Mr Ramsey had made enquiries and had written to Mrs Bevis with the feedback, although the letter had not yet been received. He had been advised that the estates team had reviewed the position and had confirmed that there sufficient toilets were provided for all staff.

c) Nightwear for patients Mrs Bevis queried the lack of nightwear available for patients. She was aware that, despite notices and requests for it to be returned, patients often went home in and retained the nightwear provided by the hospital resulting in shortages for new patients. Mr Kerr advised that he had heard similar reports about hospital linen, sometimes involving patients transferred to other care organisations too, amounting to significant losses over the years.

Governors raised some suggestions to encourage the return of more items, including a deposit on any garments taken off site or options to return them via local centres nearer to patients’ homes. It was reported that some staff had advised patients there was no need to return items and it was agreed that it would be useful to ask management to ensure staff awareness was raised as the situation needed to be addressed in terms of ensuring that (i) nightwear was more readily available to patients when needed and (ii) losses and costs were reduced.

It was resolved that representatives of the press and other members of the public be excluded from the final part of the meeting having regard to the confidential nature of the business to be transacted.

DW

04/06/2014

1

Tracey Bostwick

Learning Disability Liaison Nurse

Barnsley Hospital

Key Reports

• 2004 Treat Me Right (Mencap)• 2007 Death by Indifference (Mencap)• 2008 Healthcare for All (DOH)• 2008 Six Lives (Parliamentary & Health

Service Ombudsman)• 2009 Valuing People Now (HM Government)• 2010 Six Lives Progress report (DOH)• 2012 Death by Indifference – 74 deaths and

counting (Mencap)• 2013 Confidential Inquiry (DOH)

Confidential Inquiry – Key Findings

• People with a Learning Disability (LD) die on average 16 years sooner than people without a LD

• Men 13 years younger• Women 20 years younger

• For every one person in the general population who dies from an unavoidable cause of death, two people with LD will do so

• For every one person in the general population who dies from a cause of death that could be prevented by good quality care, three people with LD will do so

Confidential Inquiry Recommendations

18 recommendations were made in total.

Some of the recommendations which are particularly relevant to the trust are:

• 1) Clear identification of people with learning disabilities on the NHS central registration system and in all healthcare record systems

• 2) Reasonable adjustments required by, and provided to, individuals, to be audited annually and examples of best practice shared across agencies and organisations

Confidential Inquiry Recommendations

• 7) People with learning disabilities to have access to the same investigations and treatments as anyone else, but acknowledging and accommodating that they may need to be delivered differently to achieve the same outcome.

• 12) Mental Capacity Act training and regular updates to be mandatory for staff involved in the delivery of health or social care

• 13) Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) guidelines to be more clearly defined and standardised across England

NHS EnglandNHS Outcomes Framework 2014/2015

Reducing Premature Deaths in people with a LD

Excessive under 60 mortality rate in adults with a LD

04/06/2014

2

NHS England

Dominic Slowie (National Director, LD) suggests that, on future inspections, the following four questions are asked:

1) Can this hospital at this moment in time tell the inspectors who is in with a Learning Disability ? (flagging system)

2) Do you have a Learning Disability Liaison Nurse (LDLN)?

3) What Reasonable Adjustments are the trust making?

4) Are we conducting Audits around LD patient mortality/care?

Local Picture

BHNFT have a flagging system in place using the current Patient Alert System (PAS)

Currently 1064 patients with LD have a PAS alert, and there are a further 416 to be added.

Our register is aligned with the Local Authority LD Register and the GP’s LD register.

Figures Relating to Barnsley Hospital Attendance

Emergency Department Attendances from April 2013- March 2014

• 680 ED attendances in total

• 270 People with LD (with PAS Alert)

• 64 people with 3 or more ED attendances in this period


In Patient Admissions from April 2013- March 2014

• 307 Inpatient admissions

• 163 people

• 32 people with 3 or more inpatient admissions in this period

I saw 105 people as inpatients

I knew about 124 inpatients (but did not see them all)


Out-Patient Appointments from April 2013- March 2014

• 1897 Out-Patient Appointments

• 360 People

• 187 DNA’s – 123 patients Discharged

Figures Relating to Barnsley Hospital (April 2013- March 2014)

• 10 patients with LD have died

• 6 died in hospital (involved in 3)

• 4 died at home (involved in all)

04/06/2014

3

Plans for 2014-2015

• CQUIN – numbers, reasonable adjustments, patient experience

• Audits – care of patients with LD in past year; review team includes myself, Community LD Matron, Hospital Matron and Hospital Doctor

• Workstreams – ED, Inpatients, Outpatients

Plans for 2014-2015

• Patient Experience

• Reasonable Adjustments – bid for equipment, record and share all RA good practice

• Training – continue with LD awareness training using real patient stories

• Accessible Information - Website

Thank you for listening

Do you have any questions?


REF: 14/07/P-13

BoD July 2014: 13_Finance & Perf Escalation Report June 14

SUBJECT: FINANCE AND PERFORMANCE COMMITTEE ESCALATION REPORT

DATE: JULY 2014

PURPOSE:

Tick as applicable

Tick as applicable

For decision/approval √ Assurance √ For review √ Governance √ For information √ Strategy

PREPARED BY: Michael Wright, Deputy Director of Finance

SPONSORED BY: Francis Patton, Non Executive Director, Chairman of the Finance & Performance Committee PRESENTED BY:

STRATEGIC CONTEXT 2-3 sentences The current financial environment is extremely challenging. It is essential that the Board is assured that the financial and general performance of the Trust is effectively managed and that the Trust remains viable.

The Finance & Performance Committee provides assurance to the Board of Directors in relation to complex financial and operational matters following detailed analysis and challenge of both the financial and operational reports received.


Have clear terms of reference been set for this new governance committee? What issues arising at the Finance & Performance Committee on 26th June 2014 require escalation to Board?


The critical issues to escalate to Board following the inaugural meeting of the Finance & Performance Committee meeting relate to:

• Terms of Reference (ToR) and committee membership / attendance

• Reporting to Board

• Business Case Approval Process

• Advisory Reports - Project Allerton

It is recommended that the Board notes the issues identified for escalation and endorses the levels of delegated authority for business case approval.

BoD July 2014: 13_Finance & Perf Escalation Report June 14

REFERENCE/CHECKLIST



Patients

BCCG

Other

Staff

BMBC

Please state:

Governors

Monitor







Yes

Not applicable

To be developed


CGC

NCGRC

Audit Committee

Finance Commitee

ET

Where applicable, briefly identify risk issues (including any reputation) and cross reference to risk register and governance committees


Finance:

Other:




Subject: FINANCE AND PERFORMANCE COMMITTEE EXCEPTION REPORT

Ref: 14/07/P-13

BoD July 2014: 13_Finance & Perf Escalation Report June 14 Page 1

1 INTRODUCTION

1.1 The Committee convenes monthly, providing detailed scrutiny of financial matters and operational performance in order to provide assurance and raise concerns (if appropriate) to the Board of Directors

1.2 The Committee makes recommendations, as appropriate, on financial and performance matters to the Board of Directors.

1.3 This was the first meeting of this Committee within the new governance framework and therefore a key part of the agenda was to look at the Terms of Reference and constitution of the Committee to ensure that all matters covered previously by the Finance, Clinical and Non Clinical Governance & Risk Committees were now covered by the Finance & Performance Committee or the Quality & Governance Committee.

2 MATTERS FOR ESCALATION TO THE BOARD

2.1 At the inaugural meeting of the Finance & Performance Committee, the current financial position was reviewed in addition to the future information requirements of the Committee. The Committee also received reports in relation to cost improvement plans and business case approval processes. Following review of the information provided and subsequent discussions, four specific issues were identified as requiring escalation to Board, which included:

2.1.1 Terms of Reference (ToR) and Committee membership / attendance It was agreed that the Committee would seek assurance on finance and performance at Clinical Business Unit (CBU) and non-clinical/support department level and key areas of scrutiny were also agreed. The Committee also agreed that CBUs would be required to attend the Committee meetings to discuss CBU performance.

Directors unable to attend meetings will be required to send well briefed deputies. The Interim Associate Director of Corporate Affairs was tasked with pulling together a final set of Terms of Reference for the July meeting, which the Committee could sign off and recommend to the Board for approval. As part of this, the Chair would meet with the Chief Executive and Director of Finance to finalise future agendas.

2.1.2 Reporting to Board It was agreed that the Director of Finance would provide the appropriate level of detail within the finance section of the Integrated Performance Report. This would be supplemented by a report on Matters for Escalation submitted by the Chair of the Committee.

2.1.3 Business Case Approval Process The Committee noted and supported the proposed business case approval process subject to specific changes including:

13_Finance & Perf Escalation Report June 14 Page 2

• confirming that the Executive Team has the authority to approve business cases, with delegated authority up to £50,000.

• the Finance & Performance Committee having delegated authority to approve business cases from £50,001 to £150,000, with larger cases being endorsed although subject to ratification by the Board.

2.1.4 Advisory Reports - Project Allerton It was agreed that the Finance & Performance Committee will receive a tracker on all external and internal advisory reports providing an update on actions and any issues identified. At present this would relate to Project Allerton and the tracker for this would link to the tracker in place supporting the turnaround plan.

Francis Patton Chair, Finance & Performance Committee July 2014


REF: 14/07/P-14

SUBJECT: 2014/15 BUDGET REPORT

DATE: JULY 2014

PURPOSE:

Tick as applicable

Tick as applicable

For decision/approval √ Assurance For review Governance For information Strategy

PREPARED BY: Stuart Diggles, Interim Director of Finance

SPONSORED BY: Stuart Diggles, Interim Director of Finance

PRESENTED BY: Stuart Diggles, Interim Director of Finance


The 2014/15 budget sets the financial plan for the Trust. It details the budgeted performance for the year and gives the expected funding requirements of the Trust. It is a key element of the Trust’s governance process. The 2014/15 budget is fully incorporated within the two year Turnaround Plan as the first year of the financial plan. The Turnaround Plan has been submitted to Monitor.


What is the Trust’s budget for 2014/15? What is the Trust’s funding requirement through 2014/15?


The Trust’s financial position remains challenging, the budget shows how the Trust’s financial position will develop over the financial year and the cash support required. It is recommended that the Board of Directors approve the 2014/15 Budget.

REFERENCE/CHECKLIST


This forms the financial element of the business plan.


Patients

BCCG

Other

Staff

BMBC

Please state:

Governors

Monitor







Yes

Not applicable

To be developed


CGC

NCGRC

Audit Committee

Finance Commitee

ET


The baseline position is not currently understood by many stakeholders, this may give rise to questions based on the level of information given so far. A communications plan is essential


Finance:

Other:




Subject: 2014/15 PROPOSED BUDGET REF: 14/07/P-14

1. INTRODUCTION AND OVERVIEW 1.1 This report details the proposed budget for 2014/15. It has been put together with the

involvement of all key stakeholders and has been subject to a number of high level reviews. The budget has been put together against the backdrop of the Trust’s current financial position, the ongoing reviews and preparation of the Trust’s two year Turnaround Plan.

1.2 The issues highlighted by the reviews completed to date around the processes and

assumptions used in preparing prior year budgets have been addressed as far as can be in the setting of this budget. However, as with any budget setting or planning process there is an element of forecasting and estimation that is integral to the process.

1.3 In preparing the budget the underlying baseline/run rates of activity, income and cost

for 2013/14 have been fully considered and are summarised within this report.

2. 2013/14 BASELINE

2.1 The table below summarises the 2013/14 baseline. It clearly shows the underlying prior year performance of the Trust compared to the actual result for the financial year.

Income and Expenditure

£’million2013/14

Baseline/Run Rate

Income

Clinical income 147.2 143.5

Other income 22.5 15.7

Total income 169.7 159.2

Operating Expenses

Pay cost (115.8) (116.2)Non pay cost (52.8) (50.9)Total operating expenses (168.6) (167.1)

EBITDA 1.1 (7.9)Depreciation and amortisation (6.3) (6.7)

Restructuring costs (0.2) -

Interest (0.1) (0.1)

PDC Dividend (1.9) (1.9)

ITDA (8.5) (8.7)

Total operating expenses (177.1) (175.8)

Net deficit pre-impairment (7.4) (16.6)

Impairment (2.5) -

Net deficit post-impairment (9.9) (16.6)

2.2 In Q4 2013/14, the Trust operated at an underlying Run Rate deficit of £16.6 million. The main factors impacting the Run Rate as compared to the 2013/14 actual position are:

• non-recurrent clinical income of £3.7 million, other non-recurrent income £1.4

million and the release of deferred income of £5.4 million; • pay cost increases at Q4 run rate of £1.6 million are partially offset by £1.2 million

of pay costs in relation to non-recurring income and projects; • non-pay costs reduce to baseline by £1.6 million in relation to non-recurring

income. Other one off non-pay costs are set off by cost pressures giving an overall movement to baseline of £1.7 million (including movements to ITDA); and

• the 2013/14 actual was impacted by a fixed asset impairment charge of £2.5 million which does not impact to the baseline.

2.3 The impacts of the above can been seen more clearly in the chart below:

(9.9)

(16.6)

1.72.5

(3.7)

(6.8)

(0.4)

(25.0)

(20.0)

(15.0)

(10.0)

(5.0)

2013/14 actual Clinical income Other income Pay costs Non-pay costs& ITDA

Impairment Baseline

£’m

illio

n

2013/14 actual to baseline

Although the baseline for 2013/14 shows a deficit of £16.6 million it must be noted that the Trust is immediately impacted in 2014/15 by £2.1 million of income reduction due to tariff and £2.0 million of pay cost increases. This effectively gives an opening run rate deficit of £20.7 million for the Trust.

3. BUDGETED STATEMENT OF COMPREHENSIVE INCOME

3.1 The table below summarises the FY2013/14 budget for income and expenditure. This is shown alongside the FY2013/14 result and baseline for comparison. This shows a total budgeted income of £165.0 million and a deficit of £11.9 million for the year.

Income and Expenditure

£‘million2013/14

Actual

Baseline/

Run Rate

Budget2014/15

Income

Income from activities 147.2 143.5 149.3

Other income 22.5 15.7 15.7

Total income 169.7 159.2 165.0

Operating Expenses

Pay cost (115.8) (116.2) (117.8)

Non pay cost (52.8) (50.9) (51.1)

Total operating expenses (168.6) (167.1) (168.9)

EBITDA 1.1 (7.9) (3.9)

Depreciation and amortisation (6.3) (6.7) (5.8)

Restructuring costs (0.2) - (0.3)

Interest (0.1) (0.1) -

PDC Dividend (1.9) (1.9) (1.9)

ITDA (8.5) (8.7) (8.0)

Total operating expenses (177.1) (175.8) (176.9)

Net deficit (7.4) (16.6) (11.9)

Impairment (2.5) - -

Net deficit Post-impairment (9.9) (16.6) (11.9)

3.2 The main movements from the baseline to the budget for 2014/15 are:

• Contract based income increases to baseline by £1.1 million incorporating the effects of activity and tariff. Other income including non-recurrent income increases by £4.4 million to baseline.

• Pay costs increase to support the non-recurring income and due to cost increases under AfC. Planned savings on agency usage reduce the total movement to baseline to £6.6 million.

• Non-pay costs increase to baseline based on activity and inflationary pressures by £1.2 million. ITDA reduces by £0.7 million.

• CIPs are assumed to deliver in year a £6.0 million (4.3%) improvement to baseline with a further £0.3 million improvement due to VAT savings on agency costs. The CIP full year effect is £8.7 million (6.2%).

• The forecast deficit for the year is £11.9 million. Accounting for the full year effect of CIPs and the Q4 Run Rate, the underlying closing Run Rate is a deficit of £8.0 million.

Note: CIP percentage savings are calculated on contracted activity based income.

3.3 These movements to baseline can be seen more clearly in the chart below:

(16.6)

(11.9)

3.2

4.46.3

(2.1)

(6.6)(0.5)

(20.0)

(18.0)

(16.0)

(14.0)

(12.0)

(10.0)

(8.0)

(6.0)

(4.0)

(2.0)

Ba

selin

e

Inco

me-

tarif

fre

duct

ion

at 1

.5%

Inco

me-

activ

itych

ang

e

Inco

me-

othe

r

Pa

y

Non

pay

& IT

DA

CIP

2014

/15

pla

n

£mill

ion

2014/15

A detailed income and expenditure statement, phased by month is shown in Appendix 1 along with the detailed assumptions that underpin the in year figures.

4. BUDGETED STATEMENT OF CASHFLOWS

4.1 The table below summarises the 2013/14 budgeted cashfow. This is shown alongside

the FY2013/14 actual for comparison. This shows a cash outflow in year of £21.4 million giving a closing cash position that is overdrawn by (requires funding of) £18.9 million.

Cash flow

£'millionActual

2013/14 Budget 2014/15

Operating loss (7.4) (11.9)Non-cash income and expenses 11.9 (4.0)Net cash flow from operating activities 4.5 (15.9)Cash flows from investing activitiesPurchase of property, plant and equipment (16.7) (3.5)

Net cash outflow from investing activities (16.7) (3.5)

Cash flows from financing activitiesPDC received 0.7 -Capital element of private finance (0.2) (0.1)PDC dividend paid (2.5) (1.9)

Net cash outflow from financing activities (2.0) (2.0)

Decrease in cash and cash equivalents (14.2) (21.4)Cash and cash equivalents at 1 April 16.7 2.5Cash and cash equivalents at 31 March 2.5 (18.9)

4.2 The main movements and assumptions within the budgeted cashflow are:

• key monthly cash assumptions included within the cashflow on average are: o contract based income £11.8 million o payroll and agency payments £9.9 million o purchase payments of £4.6 million o Creditor backlog (incl. capital expenditure) payments £11.6 million.

• The Trust received £10.0 million of PDC funding through April and May 2014 to facilitate its short-term funding requirement.

• The PDC loan is currently due to be repaid in August 2014, which together with the other monthly payments, leads to a forecast cash position of £13.8 million overdrawn at the end of August 2014.

4.3 The graph below shows the cash profile, from June 2014 to January 2015 monthly

expenditure exceeds monthly income, increasing the funding requirement to its peak end of month position of £20.2 million at the end of January 2015.

-25.0

-20.0

-15.0

-10.0

-5.0

0.0

5.0

10.0

15.0

Ma

r-1

4

Apr

-14

Ma

y-1

4

Jun-

14

Jul-1

4

Aug

-14

Sep

-14

Oct

-14

No

v-14

De

c-14

Jan-

15

Feb

-15

Ma

r-1

5

£ m

illio

n

Cash Position

A detailed cashflow statement, phased by month is shown in Appendix 2 along with the detailed assumptions that underpin the cash movements.

5. BUDGETED CAPITAL PROGRAMME

5.1 The budgeted capital programme for 2014/15 is currently set at £3.5 million. The table below summarises the schemes by area and whether they are in year schemes or schemes deferred from prior years.

Capital Programme

£'million

Budget 2014/15

Deferred Schemes

Estates 1.0

IM&T and Other 0.1

Total Schemes Deferred From Prior Years 1.1

Current Schemes

Estates 0.7

IM&T 0.5

Strategic 0.8

Contingency 0.4

Total Current Year Schemes 2.4

Total Schemes 3.5

A detailed schedule of the capital projects is shown in Appendix 3.

6. STATEMENT OF FINANCIAL POSITION

The table below shows the budgeted financial position at end of 2014/15 with the actual position at the end of 2013/14 for comparison. The various assets and liabilities shown result from the assumptions made on income and expenditure and cashflow. Statement of Position

Actual Budget£ million 2013/14 2014/15

NON CURRENT ASSETS 72.4 70.1

CURRENT ASSETSInventories 1.4 1.4NHS Trade Receivables Current 3.7 2.5Other Receivables Current 1.7 2.4Prepayments Current 0.8 0.8Cash 2.5 (18.9)

Assets Current Total 10.2 (11.8)

CURRENT LIABILITIES (< One Year)Trade Payables Current (5.0) (5.5)Other Payables Current (12.4) (3.6)PFI (0.2) (0.2)Social Security Creditors Current (3.5) (3.6)Accruals Current (4.5) (0.4)Provisions Current (0.7) (0.7)Deferred Income Current (0.5) (0.3)

Total Current Liabilities (26.8) (14.3)

NET CURRENT ASSESTS (LIABILITIES) 37.0 2.4

Other Receivables Non Current 0.7 0.3PFI NC (0.5) (0.3)Deferred Income Non Current 0.0 0.0Other Non Current (0.3) (0.3)

Total Non Current (0.1) (0.3)

TOTAL ASSETS EMPLOYED 55.6 43.7

TAXPAYERS' AND OTHERS' EQUITYPublic Dividend Capital 46.6 46.6Retained Earnings 4.8 (7.2)Revaluation Reserve 4.3 4.3

TAXPAYERS EQUITY TOTAL 55.6 43.7 A detailed statement of position, phased by month is shown in Appendix 4.

7. APPENDICES

Appendix 1 – Detailed Budgeted Statement of Income and Expenditure and assumptions

Appendix 2 – Detailed Budgeted Cashflow and assumptions

Appendix 3 – Detailed Budgeted Capital Programme

Appendix 4 – Detailed Budgeted Statement of Position

Appendix 1

Area Assumption

Clinical income

£149.3 million

• Clinical income is primarily based on the contract value which factors in changes to activity levels based on expected demand and achieving required targets (£3.2 million increase) and tariff reductions and inflation (£2.1 million reduction). Although contract values have largely been agreed with the CCGs, they have not yet been signed. As at June 2014 the draft contract values stand at total of £140.0 million (excluding CQUINs).

• The Trust has assumed a further £4.5 million of non-recurrent income from Barnsley CCG. Of this £1.5 million has so far been agreed and the remaining amount is based on business cases submitted to the CCG but for which final agreement is awaited. Of the amounts not yet agreed, £2.2 million relates to 7 Day Working, approval of which is expected in Mid July 2014 at the meeting of the CCG’s governing body.

• CQUIN income included within the draft contracts total £3.2 million. The Trust has assumed approximately £3 million of this will be achieved.

• There are other clinical incomes which total £1.8 million which mainly derives from RTA.

Other income

£15.7 million

• Other income includes all other non-patient related income including, non-patient related projects, car park income, rental income, L&D related income, R&D income and any other non-clinical income.

• The Trust has assumed a net £0.8 million will be received in relation to EPR implementation related costs incurred in 2013/14. All EPR related costs incurred in 2014/15 are assumed to be offset with additional income and has not been included in the 2014/15 plan.

Pay costs

£117.8 million

• Pay costs are based on the established organisation which factors in the new CBU structures and other organisational changes. 2014/15 Agenda for Change pay related increases have also been included. Agency premium costs of £3.5 million (a 20% reduction on 2013/14) have been included to account for the additional costs of using of agency and bank staff to cover vacant positions.

• Pay costs are also included to deliver the services planned to be funded by the non-recurrent monies to be received from Barnsley CCG. If the non-recurrent funding is ultimately not received then the costs will not be incurred.

• Planned CIPs will deliver £5.0 million of savings in year on pay costs.

• Agency VAT savings of £0.3 million are also assumed to be realised by changing the way in which agency staff are hired.

Non-pay costs

£51.1 million

• Non-pay costs are based on the closing Run Rates from 2014/15 and account for inflationary pressures, activity levels and revised contractual and supplier agreements as appropriate. Within non-pay costs are £1.1 million of costs associated with the on-going investigations and project work in relation to the Trust’s financial position and Turnaround Planning. CNST costs are included at £6.5 million, an increase of £1.3 million on 2014/15.

• Planned CIPs will deliver £1.0 million of savings in year on non-pay costs.

ITDA

£8.0 million

• Restructuring and redundancy costs of £0.4 million have been assumed.

• PDC dividend PFI interest costs have been estimated to be £1.9 million based on forecast net asset and cash positions.

• Depreciation has been estimated at £5.8 million having taken account of the opening FA position, the planned capital expenditure programme of £3.5 million and a review of existing asset UEL (as per PwC management letter following the 2013/14 audit).

Appendix 2

Annual£'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000sBudget Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15

Cash Flows from Operating Activities

Operating Surplus / (Loss) (11,945) (1,836) (1,799) (1,657) (855) (1,551) (1,021) (252) (1,067) (510) (623) (486) (288)

Non-cash Income and ExpensesDepreciaition and Amortisation 5,771 454 454 454 485 485 485 491 491 491 495 495 495

Fixed Asset of Impairments 0 0 0 0 0 0 0 0 0 0 0 0 0

(Gain) / Loss on Disposal 0 0 0 0 0 0 0 0 0 0 0 0 0

PDC Dividend 1,884 157 157 157 157 157 157 157 157 157 157 157 157

Interest Received (20) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2)

Amortisation of PFI Credit 0

Decrease / (Increase) in Trade and Other Receivables 548 1,048 339 527 (1,509) (252) 410 (955) (131) (576) (526) (3) 2,176

(Increase) / Decrease in Inventories (0) 0 0 0 0 0 0 0 0 0 0 0 (0)

(Decrease) / Increase in Trade and Other Payables (8,312) 1,238 (1,023) (1,939) (2,929) (1,934) (2,982) 428 408 395 414 399 (787)

(Decrease) / Increase in Other Liab ilities (4,038) (234) (369) (388) (433) (432) (361) (388) (284) (360) (166) (318) (305)

Deferred Income (218) (18) (18) (18) (18) (18) (18) (18) (18) (18) (18) (18) (18)

Decrease / (Increase) in Provisions 0 0 0 0 0 0 0 0 0 0 0 0 0

Other Movements 424 35 35 35 35 35 35 35 35 35 35 35 35

NET CASH INFLOW FROM OPERATING ACTIVITIES (15,904) 842 (2,226) (2,830) (5,069) (3,511) (3,297) (503) (410) (387) (233) 260 1,462

Cash Flows from Investing ActivitiesInterest received 20 2 2 2 2 2 2 2 2 2 2 2 2

Purchase of intangib le assets 0

Purchase of Property, Plant and Equipment (3,476) (220) (320) (669) (722) (708) (56) (135) (320) (55) (195) (45) (30)

Net Cash Outflow from Investing Activities (3,456) (218) (318) (668) (720) (707) (54) (133) (318) (53) (193) (43) (28)

Cash flows from financing activitiesPDC Received 0 3,260 6,695 0 0 (9,955) 0 0 0 0 0 0 0

Capital Element of Private Finance Inititive Obligations (180) (15) (15) (15) (15) (15) (15) (15) (15) (15) (15) (15) (15)

Interest Element of Private Finance Initiative Obligations 0 0 0 0 0 0 0 0 0 0 0 0 0

PDC Dividend Paid (1,884) (157) (157) (157) (157) (157) (157) (157) (157) (157) (157) (157) (157)

Cash Flows from other financing Activities 0

Net Cash Outflow From Financing Activities (2,064) 3,088 6,523 (172) (172) (10,127) (172) (172) (172) (172) (172) (172) (172)

Increase / (decrease) in cash and cash equivalents (21,424) 3,711 3,979 (3,670) (5,961) (14,345) (3,524) (809) (901) (613) (598) 45 1,262Cash and Cash Equivalents at 1 April 2,527 2,527 6,239 10,217 6,547 586 (13,759) (17,283) (18,092) (18,992) (19,605) (20,203) (20,159)

Cash and Cash Equivalents at 31 March (18,897) 6,239 10,217 6,547 586 (13,759) (17,283) (18,092) (18,992) (19,605) (20,203) (20,159) (18,897)

(21,424) 3,711 3,979 (3,670) (5,961) (14,345) (3,524) (809) (901) (613) (598) 45 1,262

Appendix 3

Appendix 4

Annual£'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000sBudget Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15

NON CURRENT ASSETS 70,093 72,389 72,155 72,022 72,238 72,475 72,699 72,270 71,914 71,743 71,307 71,008 70,558 70,093

CURRENT ASSETSInventories 1,379 1,379 1,379 1,379 1,379 1,379 1,379 1,379 1,379 1,379 1,379 1,379 1,379 1,379

NHS Trade Receivables Current 2,520 3,729 2,535 2,049 1,367 2,565 2,671 2,106 2,900 2,884 3,305 3,692 3,400 2,520

Other Receivables Current 2,390 1,728 1,766 1,804 1,851 2,053 2,091 2,137 2,191 2,229 2,275 2,305 3,143 2,390

Prepayments Current 792 792 900 1,009 1,117 1,226 1,334 1,443 1,551 1,660 1,768 1,877 1,334 792

Cash (18,897) 2,527 6,239 10,217 6,547 586 (13,759) (17,283) (18,092) (18,992) (19,605) (20,203) (20,159) (18,897)

Assets Current Total (11,816) 10,156 12,819 16,459 12,262 7,810 (6,283) (10,217) (10,070) (10,840) (10,877) (10,950) (10,902) (11,816)

CURRENT LIABILITIES (< One Year)Trade Payables Current (5,536) (5,048) (5,571) (5,572) (5,571) (5,557) (5,552) (5,550) (5,552) (5,550) (5,541) (5,549) (5,544) (5,536)

Other Payables Current (3,564) (12,362) (13,078) (12,054) (10,116) (7,201) (5,272) (2,291) (2,718) (3,128) (3,532) (3,938) (4,343) (3,564)

PFI (181) (181) (181) (181) (181) (181) (181) (181) (181) (181) (181) (181) (181) (181)

Social Security Creditors Current (3,606) (3,475) (3,633) (3,642) (3,644) (3,711) (3,674) (3,660) (3,540) (3,545) (3,546) (3,548) (3,552) (3,606)

Accruals Current (363) (4,531) (4,140) (3,762) (3,371) (2,871) (2,476) (2,130) (1,861) (1,573) (1,211) (1,044) (722) (363)

Provisions Current (683) (683) (683) (683) (683) (683) (683) (683) (683) (683) (683) (683) (683) (683)

Deferred Income Current (328) (545) (527) (509) (491) (473) (455) (436) (418) (400) (382) (364) (346) (328)

Total Current Liabilities (14,260) (26,827) (27,812) (26,402) (24,057) (20,677) (18,293) (14,931) (14,954) (15,059) (15,076) (15,307) (15,370) (14,260)

NET CURRENT ASSESTS (LIABILITIES) 2,443 36,982 40,632 42,861 36,319 28,487 12,010 4,714 4,883 4,219 4,199 4,357 4,468 2,443

Other Receivables Non Current 306 730 695 659 624 589 553 518 483 447 412 376 341 306

PFI NC (349) (529) (514) (499) (484) (469) (454) (439) (424) (409) (394) (379) (364) (349)

Deferred Income Non Current 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Other Non Current (282) (282) (282) (282) (282) (282) (282) (282) (282) (282) (282) (282) (282) (282)

Total Non Current (325) (81) (102) (122) (142) (163) (183) (203) (224) (244) (264) (285) (305) (325)

TOTAL ASSETS EMPLOYED 43,692 55,637 57,060 61,957 60,300 59,445 47,940 46,919 46,666 45,600 45,090 44,466 43,980 43,692

TAXPAYERS' AND OTHERS' EQUITYPublic Dividend Capital 46,603 46,603 49,863 56,558 56,558 56,558 46,603 46,603 46,603 46,603 46,603 46,603 46,603 46,603

Retained Earnings (7,181) 4,763 2,927 1,129 (528) (1,383) (2,934) (3,955) (4,207) (5,274) (5,784) (6,407) (6,893) (7,181)

Revaluation Reserve 4,271 4,271 4,271 4,271 4,271 4,271 4,271 4,271 4,271 4,271 4,271 4,271 4,271 4,271

TAXPAYERS EQUITY TOTAL 43,692 55,637 57,060 61,957 60,300 59,445 47,940 46,919 46,666 45,600 45,090 44,466 43,980 43,692

SUBJECT: MONTHLY INTEGRATED TRUST BOARD REPORT – REPORT PERIOD MONTH 2

DATE: JULY 2014

PURPOSE:

Tick as applicable

Tick as applicable


PREPARED BY:

SPONSORED BY:

Stuart Diggles, Interim Director of Finance Karen Kelly, Director of Operations Heather Mcnair, Director of Nursing & Quality Hilary Brearley, Director of Human Resources & Organisational Development

PRESENTED BY:

Stuart Diggles, Interim Director of Finance Heather Mcnair, Director of Nursing & Quality Karen Kelly, Director of Operations Hilary Brearley, Director of Human Resources & Organisational Development


To provide an overview of the Trust’s performance in terms of quality, activity, workforce and finance for June 2014.

To provide positive assurance against the following Trust business plan.


How has the Trust performed in month 2 and year to date? Are sufficient actions in place to address any areas of concern?

CONCLUSION AND RECOMMENDATION(S) The report shows that the Trust has achieved the A&E 95% target for the first three months. Other areas of performance are clearly set out in the report. Where exceptions have been identified, mitigating actions are in place.

The Board of Directors is asked to receive and consider the contents of the report.

1

REFERENCE/CHECKLIST


The report is intended to show progress against delivery of the Trust’s business plan and highlight any issues of concern.


Patients

BCCG

Other

Staff

BMBC

Please state:

Governors

Monitor







Yes

Not applicable

To be developed


CGC

NCGRC

Audit Committee

Finance Commitee

ET


Inherent within the report.


Finance:

Other:




2

Monitor DashboardLatest Months DataMay-2014

Indicator

Code

Indicator Name Target Mar-14 Apr-14 May-14 2014/15

Q1

To Date

FYTD This month,Last

month↑ = Got Better

↓ = Got Worse

12 Month

Trend

M102 All Cancer 2 Week Wait 93.0% 93.9% 94.2% 93.1% 93.7% 93.7% ↓

M103 Breast Symptomatic 93.0% 89.0% 92.1% 98.7% 94.5% 94.5% ↑

M104 31 Day Diagnosis To Treatment 96.0% 100.0% 98.6% 100.0% 99.3% 99.3% ↑

M105 31 Day Subsequent Treatment (Surgery) 94.0% 100.0% 100.0% 100.0% 100.0% 100.0% ↔

M106 31 Day Subsequent Treatment (Drugs) 98.0% 100.0% 100.0% 100.0% 100.0% 100.0% ↔

M107 62 Day Urgent GP Referral to Treatment 85.0% 92.0% 89.6% 85.3% 87.6% 87.6% ↓

M108 62 Day Screening Programme 90.0% 100.0% 92.0% 100.0% 96.1% 96.1% ↑

M109 62 Day Consultant Upgrades 80.0% 100.0% 100.0% 100.0% 100.0% 100.0% ↔

M110 RTT -Admitted - % treated within RTT 90.0% 94.3% 94.7% 95.2% 94.9% 94.9% ↑

M113 RTT - Non-Admitted - % treated within RTT 95.0% 98.0% 97.5% 98.1% 97.8% 97.8% ↑

M117 RTT - Incomplete Pathways % still waiting 92.0% 97.0% 97.5% 96.8% x x ↓

M127 ED - Total Time in ED - 4 hours or less 95.0% 95.0% 95.0% 98.6% 96.8% 96.8% ↑

M148 MRSA 0 0 0 0 0 0 ↔

M149 Cdiff 20 1 0 0 0 0 ↔

Management Information Services [email protected]

Performance DashboardLatest Months DataMay-2014

Indicator

Code


Q1

To Date



↓ = Got Worse

12 Month

Trend

M111 RTT - Admitted - 95th Percentile 23.0 19.1 18.3 19.6 x x ↓

M112 RTT - Admitted - Median Wait 11.1 10.4 10.8 5.9 x x ↑

M114 RTT - Non-Admitted - 95th Percentile 19.3 15.5 15.7 16.0 x x ↓

M115 RTT - Non-Admitted - Median Wait 6.6 5.1 5.5 6.0 x x ↓

M116 RTT - Non-Admitted - % Audiology treated within RTT 95.0% 100.0% 100.0% 100.0% 100.0% 100.0% ↔

M118 RTT - Incomplete Pathways - 95th Percentile 28.0 15.9 15.9 16.3 x x ↓

M119 RTT - Incomplete Pathways - Median Wait 7.2 4.7 5.1 5.1 x x ↓

M120Diagnostic Tests Numbers waiting over 6 weeks

(DM01)94 140 236 376 376 ↓

M122 2 Week Rapid Access Chest Pain 100.0% 98.7% 100.0% 100.0% 100.0% 100.0% ↔

M131 ED - Admitted patients - Single Longest Wait 360 655 639 618 x x ↑

M134 ED - Non-Admitted patients - Single Longest Wait 360 596 838 500 x x ↑

M137 ED - Unplanned Re-attendance Rate 5.0% 1.9% 2.4% 2.0% 2.2% 2.2% ↑

M138 ED - Left Without Being Seen 5.0% 1.9% 2.0% 1.3% 1.6% 1.6% ↑

M144 ED - Time to treament Decision - Single Longest Wait 406 431 236 x x ↑4

Performance DashboardLatest Months DataMay-2014

Indicator

Code


Q1

To Date



↓ = Got Worse

12 Month

Trend

M145 % Cancelled Operations 0.8% 0.1% 1.0% 0.3% 0.6% 0.6% ↑

M146 Cancelled Operations - Breaches of 28 day Rule 0 0 0 0 0 0 ↔

M147 Delayed Transfer of Care - % of bed occupancy 1.0% 0.2% 0.2% 0.3% 0.2% 0.2% ↓

M179 Screening to Offer of 1st Assessment <=3 weeks 90.0% 83.9% 95.7% x 95.7% 95.7% ↓

M180 Screening to 1st Assessment 90.0% 80.6% 91.5% x 91.5% 91.5% ↓

M181 Screening to issue of normal results <=2 weeks 90.0% 80.8% 90.6% x 90.6% 90.6% ↓

M199 Elective Activity (IP & Daycase) 2365 2269 2327 4596 4596 ↓

M200 Non Elective Activity 2278 2420 2471 4891 4891 ↓

M201 GP Written Referrrals - made 3677 3953 3999 7952 7952 ↓

M202 GP Written Referrrals - seen 2950 3257 3075 6332 6332 ↑

M204 First Outpatient Attendances 4056 4718 4505 9223 9223 ↑

M205 Emergency Department Attendances 6925 6743 6779 13522 13522 ↓

M210 DNA Rate - ALL (exc eg Ophthal, Neurology,) 9.0% 10.5% 10.9% 11.6% 11.3% 11.3% ↓


Performance Dashboard ExceptionsLatest Months DataMay-2014

Indicator

Code

Indicator Name Target May-14 Comment

M131ED - Admitted patients - Single

Longest Wait360 618

Clinical Exception – PT refused treatment initially then seen by CAMHS then agreed to be treat

then the patient was admitted - Leslie Hammond ED

M134ED - Non-Admitted patients -

Single Longest Wait360 500

Patient suitable for CDU but no beds available on CDU patient was awaiting social service input -

Leslie Hammond ED

M144ED - Time to treament Decision -

Single Longest Wait236

Busy in the department at the time the patient arrived high percentage of patients were near 4

hours, Patient arrived at 23:44 and had a nurse assessment at 23.45 including obs, ECG and access

for bloods - Leslie Hammond ED

M210DNA Rate - ALL (exc eg Ophthal,

Neurology,)9.0% 11.2%

Service managers are to work with clinicians to formulate action plans to reduce DNA's. Analysis

has been completed to identify high offending areas, which will be targetted.

Work is also being undertaken with IT to configure new contact centre software which will enable

an automated reminder/re-book service.

6

Performance Dashboard ExceptionsLatest Months DataMay-2014

Indicator

Code


M120Diagnostic Tests Numbers waiting

over 6 weeks (DM01)236

-18 hpw locum sonographer secured from 2nd July – requisition authorised – contract in final

stages. This is for Obs/Gyn & General Ultrasound (not MSK).

-1.0 WTE Sonographer has returned to work with effect from 1st

Week in June.#Waiting list

initiatives (voluntary) undertaken – 5 in May, 6 in June =77 additional patients.

-w/c 14th July looks to be return to non-breaching fetal anomaly position. General Gynae waiting

needs monitoring as position can change rapidly.

-Other radiologists have been approached to undertake Specialist Ultrasound (which is the range

of exams not within the skill set of a general sonographer in Barnsley) – these exams explain the

longer waits for general ultrasound that fluctuates between 5-9 weeks. The lower end of the wait

are predominantly exams performed by sonographers. No uptake at present.

-MSK – wait peaked at 13 weeks (June) – basic paper (attached) e-mailed to Karen, Nicki, Martin

Wickham outlining a couple of options, with cost impact. Only action to date are two Waiting List

sessions in June (14th/28th) by Dr Maliyakkal = 28 patients off list. Minimal impact at present. More

WLI can be done, but ad-hoc depending on Dr Maliyakkal availability.

-The MSK options propose a solution using private sector scanning at weekends – 6 week wait

recovery by September (assumed July start). If approved, given requisition and ordering

requirements, likely late July/August commencement before this starts, with subsequent delayed

recovery position in October/November (assuming delivery occurs as planned).

-Rheumatology/Orthopaedics looking at some MSK Ultrasound provided using their own kit –

longer term delivery I would suggest.#Recruitment strategy currently being looked at between

Radiology and the new HR recruitment officer.

Andy Hardy, Radiology


7

Quality DashboardLatest Months DataMay-2014

Indicator

Code


Q1

To Date



↓ = Got Worse

12 Month

Trend

M101 VTE 95.0% 95.5% 96.6% 98.7% 97.6% 97.6% ↑

M150 Handwashing (95 - 100%) 100.0% 99.9% 99.6% 99.9% 99.7% 99.7% ↑

M151 Falls 515 50 72 59 131 131 ↑

M152 Multiple Falls 128 10 17 8 25 25 ↑

M153 Multiple Falls Rate x 20.0% 23.6% 13.6% 19.1% 19.1% ↑

M154 Incidence of Medication Errors - All 400 36 38 52 90 90 ↓

M155 Incidence of Medication Errors - No adverse outcome x 31 0 46 46 46 ↓

M156 Incidence of Medication Errors - Near misses x 5 26 6 32 32 ↑

M157 Incidence of Medication Errors - Causing harm 10 0 0 0 0 0 ↔

M158 Never Events 0 0 0 0 0 0 ↔

M160 Single Sex Breaches 0 0 0 0 0 0 ↔

M163 MSSA x 0 0 1 1 1 ↓

M164 Ecoli - Total Hospital x 3 2 0 2 2 ↑

M165 Serious incidents - Adult 0 10 8 3 11 11 ↑

8

Quality DashboardLatest Months DataMay-2014

Indicator

Code


Q1

To Date



↓ = Got Worse

12 Month

Trend

M166 Serious incidents - Child 0 0 0 0 0 0 ↔

M167 Serious incidents - Not patient specific 0 1 0 0 0 0 ↔

M168 Sudden Unexplained Deaths 0 1 1 0 1 1 ↑

M169 Serious Case Reviews - Adults x 0 0 0 0 0 ↔

M170 Serious Case Reviews - Child x 0 0 0 0 0 ↔

M174 Coroners Inquest's- Number x 2 0 3 3 3 ↓

M175Prevention of Future Death Reports (previously known

as Rule 43) – Notifications Received0 0 0 0 0 0 ↔

M176 DOLS - Urgent Authorisations Awarded x x 5 9 14 14 ↓

M177DOLS - Patients Subject to DOLS Authorisation at

Month endx x 2 2 x x ↔

M178 DOLS - Standard Authorisations Awarded x x 5 8 13 13 ↓

M206 DOLS - Standard Authorisation Not Awarded x x 0 1 1 1 ↓

M209 Learning Events - Child x x 1 1 2 2 ↔

M306Prevention of Future Death Reports (previously known

as Rule 43) – Number Outstandingx x 0 x x ↔

M308 Patient Safety Incidents Total (All) 7400 x 535 510 1045 1045 ↑


Quality Dashboard ExceptionsLatest Months DataMay-2014

Indicator

Code


M165 Serious incidents - Adult 3 See Below

SI1

SI2

SI3


2014/17122 - Failed discharge contributing to unexpected death.

(SI Investigator Julian Harris/Karen Sharp/Alwyn Davies).

2014/15048 – Pressure Ulcer Grade 3 – Avoidable

(SI investigator Denise Tate, Matron)

2014/15043 – Pressure Ulcer Grade 3 – Avoidable

(SI investigator Denise Tate, Matron)

.

10

Patient Thermometer DashboardLatest Months DataMay-2014

Indicator

Code

Indicator Name Target Mar-14 Apr-14 May-14 This month,Last


↓ = Got Worse

12 Month

Trend

M211 Harm Free 92.40% 93.7% 90.6% 90.4% ↓

M212 Pressure Ulcers- All 1.95% 2.6% 4.0% 5.3% ↓

M213 Pressure Ulcers - New 0.70% 1.6% 1.0% 0.8% ↑

M214 Falls with Harm 0.35% 0.5% 0.2% 1.3% ↓

M215 Catheters & UTIs 0.15% 0.0% 0.5% 1.5% ↓

M216 Catheters &New UTIs 0.10% 0.0% 0.0% 1.0% ↓

M217 NewVTEs 1.45% 3.5% 5.2% 2.3% ↑

M218 All Harms x 6.3% 9.4% 9.6% ↓

M219 New Harms x 5.4% 6.2% 5.1% ↑

M220 Sample Size x 427 405 395

M221 No of Surveys x 23 21 22


11

Patient Thermometer Dashboard ExceptionsLatest Months DataMay-2014

Indicator

Code


M211 Harm Free 92.40% 90.4%M212 Pressure Ulcers- All 1.95% 5.3%

M213 Pressure Ulcers - New 0.70% 0.8%M214 Falls with Harm 0.35% 1.3%

M215 Catheters & UTIs 0.15% 1.5%

M216 Catheters &New UTIs 0.10% 1.0%M217 NewVTEs 1.45% 2.3%


The targets are a 50% reduction from baseline prevalences based on a median value of six

consecutive local monthly data points up to 31 March 2014. The 50% improvement is in line with

the NHS Safety Thermometer CQUIN for Pressure Ulcer prevalence - Gill Feerick

12

Key Issue RAG Trend Financial Performance Summary Appendix

Key to RAG

Rating

The RAG Rating applied to financial commentary is based the on following criteria

• Green equating to on or exceeding plan.

• Amber behind plan by up to 5%.

• Red greater than 5% behind plan.

Financial

Reporting Indices

The Trust’s continuity of service rating exclusive of working capital facility at month 2 is 1. In line with expectations, a number of indicators of forward financial risk have been triggered. Liquidity is -22 days, and the capital servicing capacity defined as revenue available for capital service over annual debt service is -7. The outturn for capital expenditure is 70% of plan.

Appendix 1

Statement of

Comprehensive Income

The consolidated overall position for month 2 is a £3.37m deficit, against a plan position of £3.64m deficit, a favourable variance of £0.27m. (A deficit of £1.78m was reported for month 1 against a plan deficit of £1.33m.) EBITDA is -£2.15m against a planned position of -£2.36m, which is favourable.

Appendix 2

Income

Contract income £0.55m behind plan at month 2, of this £0.23m is due to risks and penalties. (Month 1 £0.27m behind). The significant variance relates to CBU 1 (Emergencies, Orthopaedics and Care Services) and CBU 6 (Womens and Childrens). Other Income £0.12m ahead of plan at month 2, (£0.01m behind plan at month 1).

Appendix 2a

Cost

Improvement Programmes

Achievement at month 2 is £0.43m which is to plan, although there are variances at scheme level. The current position includes significant achievements, for example, the closure of ward 29. The Working Together target of £0.05m has been identified as a significant risk and a replacement scheme is being developed.

Appendix 3

Amber

Green

Green

Green

13

Key Issue RAG Trend Financial Performance Summary Appendix

Pay

Total pay expense is showing a favourable variance of £0.46m. Agency costs are below plan, although continue to be a pressure in some of the CBUs, with particular pressures in CBU 1 (Emergencies, Orthopaedics and Care Services) and CBU 3 (General & Specialist Medicine).

Statement of

Financial Position

The principal variances at month 2 are total debtors, which are higher than plan by £1.52m, due to the raising of an invoice to Barnsley CCG in respect of £1.50m non-recurrent monies. Total creditors including accruals are lower than plan by £1.02 million, over half of which is due to short term timing differences on payments. Overall, total assets employed are £0.19m favourable to plan.

Appendix 4

Cash

Cash is £0.5m behind plan due to a payment run being made at the end of the month. Cash flow has been micromanaged over the previous 2 months with particular attention given to the payment of creditors.

Appendix 4a

Capital

Capital expenditure is £0.38m year to date, £0.16m behind plan, being principally EPR, O Block, Kitchens AB/KL and the Theatre Chiller Plant, offset by spending on the Maternity Birthing unit, Endoscopy and Urgent Care.

Appendix 5

Amber

Green

Red

Amber

14

Appendix 1

Indicators of Forward Financial Risk - Consolidated accounts

Risk Actual

Unplanned decrease in EBITDA margin in two consecutive quarters Yes

Quarterly self-certification by trust that the continuity of service rating (COSR) may be less than 3 in the next 12 months Yes

Working capital facility used in pervious quarter No

Debtors > 90 days past due account for more than 5% of total debtor balances Yes 5.26%

Creditors > 90 days past due account for more than 5% of total creditor balances No 5.00%

Two or more changes in Finance Director in a twelve month period No

Interim Finance Director in place over more than one quarter end No

Quarter end cash balance < 10 days of operating expenses No 21

Capital expenditure < 75% of plan for the year to date Yes 70.19% Continuity of Service RatingMetric Weight Definition Rating Categories Score Rating

1 2 3 4Liquidity ratio (days) 50% Working capital balance * 360

Annual operating expenses <- -14 -14 -7 0 -22.1 1

Capital Servicing capacity (times) 50% Revenue available for capital service < 1.25 1.25 1.75 2.5 -7 1Annual debt service

Overall rating 1

15

Appendix 2

Performance against plan @ Month 2

Statement of Comprehensive Income Draft Month Month Cumulative CumulativePerformance against draft plan/budget at Month 2 FY2014/15 Budget Plan Actual Variance Plan Actual Variance

Full Year May-14 May-14 YTD YTD YTD YTD£'000 £'000 £'000 £'000 £'000 £'000 £'000

NHS Clinical IncomeElective Long Stay 10,867 857 839 -18 1,720 1,443 -277Non Elective 49,406 4,118 4,235 117 8,174 8,250 76Planned Same Day 14,310 1,130 1,170 40 2,272 2,271 -1Out-patients 25,748 2,035 1,880 -155 4,070 3,986 -84A & E 7,368 641 637 -3 1,250 1,219 -31Other 40,548 3,070 2,811 -259 6,149 5,919 -230

Total 148,247 11,850 11,572 -278 23,635 23,088 -547

Non NHS Clinical IncomePrivate patients 13 1 1 0 2 1 -1Other Non Protected Clinical Income (RTA) 1,088 91 270 179 182 353 171

Total 1,100 92 271 179 184 354 170

Other incomeResearch and development 545 45 40 -5 90 85 -5Education and Training 4,098 343 349 6 686 698 12Other income 10,709 5 149 144 1,946 1,887 -59PFI specific income 0 0 5 5 0 5 5

Total 15,351 393 543 150 2,722 2,675 -47

Total income 164,698 12,335 12,386 50 26,541 26,117 -424

CostsEmployee benefits expenses (Pay) & Agency costs -118,554 -10,232 -9,903 329 -19,900 -19,445 455Drug costs -11,710 -980 -956 24 -1,952 -1,990 -38Clinical supplies and services -17,548 -1,490 -703 786 -2,924 -2,001 923Misc other operating expenses (excl Dep'n) -20,846 -1,677 -2,368 -691 -4,123 -4,835 -712

Total costs -168,657 -14,379 -13,930 449 -28,900 -28,271 629

EBITDA -3,959 -2,044 -1,544 500 -2,359 -2,154 205

Depreciation & Amortisation - owned assets -5,723 -446 -449 -3 -900 -903 -3Depreciation & Amortisation - PFI assets -48 -8 -8 0 -8 -8 0Interest Income 20 2 4 2 4 6 2Restructuring Costs -350 -29 0 29 -58 0 58PFI Interest Expense 0 15 7 -8 0 -8 -8PFI Specific Costs 0 0 -22 -22 0 -22 -22PDC Dividend expense -1,884 -172 -137 35 -314 -279 35

Net Surplus/(Deficit) -11,945 -2,682 -2,149 533 -3,635 -3,368 267

Consolidated Statement of Comprehensive Income

16

Appendix 2a

Activity £'000 Activity £'000Plan Actual Variance Plan Actual Variance Plan Actual Variance Plan Actual Variance

01 - Elective Inpatients 352 348 -4 849 827 -21 708 624 -84 1,704 1,423 -281 02 - Elective Daycases 1,818 1,844 26 1,130 1,139 9 3,648 3,688 40 2,272 2,271 -0 03 - Non Elective 2,819 2,887 68 3,809 3,913 103 5,586 5,714 128 7,564 7,765 20103 - Non Elective (CDU) 254 225 -29 138 123 -16 495 443 -52 270 241 -28 04a - Excess Beddays (Non Elective) 758 527 -231 171 119 -52 1,509 1,188 -321 341 253 -88 04b - Excess Beddays (Elective) 35 55 20 8 12 4 70 88 18 16 20 405 - Outpatients New Att. 5,398 5,292 -106 831 775 -56 10,795 10,822 27 1,661 1,593 -68 06 - Outpatients F/up Att 17,356 15,468 -1,888 1,204 1,207 3 34,723 32,621 -2,102 2,409 2,479 7008 - A&E Attendances 6,979 6,778 -201 641 618 -23 13,619 13,521 -98 1,250 1,219 -31 09 - Critical Care 662 824 162 494 593 99 1,303 1,473 170 973 1,079 10710 - Maternity Pathway Tariff 518 367 -151 484 316 -168 1,019 876 -143 953 809 -144 11 - Direct Access Tests 209,665 217,890 8,225 333 337 4 419,337 427,845 8,508 667 674 712 - High cost drugs revenue 0 0 0 613 560 -53 0 0 0 1,226 1,151 -75 12a - Unbundled Radiology 1,391 1,393 2 140 144 4 2,782 2,929 147 280 298 1813 - Other non-tariff revenue 4,141 3,048 -1,093 327 319 -8 8,283 6,738 -1,545 694 697 314 - Schedule of Service Fee Items 0 0 0 16 16 0 0 0 0 31 31 015 - Community Paediatrics 0 0 0 88 88 0 0 0 0 175 175 016 - Business Cases 0 0 0 169 169 0 0 0 0 338 338 017 - Therapy Services 2,633 2,491 -142 94 92 -2 5,267 4,783 -484 189 183 -6 18 - Specialist Nursing 907 937 30 44 42 -2 1,813 1,917 104 88 82 -6 TOTAL 11,583 11,408 -174 23,100 22,782 -318

Activity £'000 Activity £'000Plan Actual Variance Plan Actual Variance Plan Actual Variance Plan Actual Variance

CBU 1 - Emergencies, Orthopaedics & Care Services 2,304 2,241 -62 4,582 4,207 -375 CBU 2 - Theatres, Anaesthetics & Critical Care 327 329 3 643 667 24CBU 3 - General & Specialist Medicine 4,087 4,036 -52 8,176 8,254 78CBU 4 - General & Specialist Surgery 1,889 1,875 -13 3,773 3,781 7CBU 5 - Diagnostics & Clinical Support Services 527 537 10 1,079 1,108 30CBU 6 - Women, Children's & GUM 2,295 2,213 -82 4,543 4,417 -126 CBU 7 - Corporate 154 177 22 303 348 45TOTAL 11,583 11,408 -174 23,100 22,782 -318

CQUINs (1/12 of total) 267 267 0 535 535 0

Risks & Penalties Current Month Year To DateContract Risks & Adjustments (e.g N:F Ratios) 0 -46 -46 0 -98 -98 Quality Schedule (RTT, Diagnostics & D1) 0 -40 -40 0 -97 -97 2014/15 CQUINs (Dementia - 1/12 of declared risk) 0 -17 -17 0 -33 -33 TOTAL 0 -103 -103 0 -228 -228

Risk Adjusted Total 11,850 11,572 -277 23,635 23,088 -547

CBU Analysis

Current Month - May-14

Current Month - May-14

Year To Date - May-14

May-14Year To Date -

POD Analysis

17

Appendix 3 Income, Pay, Non-Pay summary Full Year Month 2 Month 2 Month 2

Target Target Actual Variance£1000's £1000's £1000's £1000's

Income 310 23 30 7Pay 5,038 330 334 4Drugs 100 0 0 0Clinical Supplies 513 66 66 0Non-Clinical Supplies 0 0 0 0Miscellaneous Other Expenses 355 11 0 (11)Total 6,316 430 430 0

Scheme summary Full Year Month 2 Month 2 Month 2Target Target Actual Variance

£1000's £1000's £1000's £1000'sCI001 - Endoscopy Consumable Budget Reduction 15 0 0 0CI002 - 5% Reduction on Printing Budgets 22 4 0 (4)CI003 - 5% Reduction on Travel Budgets 12 2 0 (2)CI004 - Savings on Prosthetics 30 0 0 0CI005 - Savings on PACS System Costs 78 0 0 0CI006 - Reduce Computer Maintenance Budgets 162 0 0 0CI007 - Savings Projects Continuing From 13/14 144 32 32 0CI008 - Renewal of Contracts Ending in Year 18 0 0 0CI009 - New Saving Initiatives 150 8 8 0CI010 - Buying Team Transactional Savings 156 26 26 0CI011 - Income Generation 32 0 0 0CI012 - EPR System Benefits 140 0 0 0CI013 - Reduce Interpreter Budgets 15 3 0 (3)CI014 - Removal of Budget for Counselling Services for the Hospice 16 3 0 (3)CI015 - Medicine Management Savings 100 0 0 0CI016 - Working Together 50 0 0 0CI017 - Closure of Ward 29 600 100 100 0CI018 - Closure of 2 Further Wards 702 0 0 0CI019 - 1% Vacancy Factor on all Pay Budgets 1,000 167 180 14CI020 - Reduction in 2nd On Call Budgets 25 0 0 0CI021 - Reduction of hours for A&C Staff (37.5 to 35) 58 10 0 (10)CI022 - Reduction of SPAs to 1.5 per Consultant 250 0 0 0CI023 - Capping Maximum number of PAs to 12 250 0 0 0CI024 - Radiology Skill Mix Review 135 17 17 0CI025 - Cardio Respiratory Skill Mix Review 15 3 3 0CI026 - Restructure Bed Management Team 50 0 0 0CI027 - 2.5% Reduction of Back Office Functions 952 0 0 0CI028 - Pathology Partnership Savings 202 34 34 0CI029 - Increase Salary Sacrifice Income 50 8 11 2CI030 - Increase Patient Car Parking Charges 10 2 2 0CI031 - Increase Staff Car Parking Charges 38 6 18 11CI032 - Increase SLA for Telecommunications Services to SWYPT 40 7 0 (7)CI034 - CBU 1 CIP Target £200K Full Year but not to start until August 133 0 0 0CI035 - CBU 2 CIP Target £200K Full Year but not to start until August 133 0 0 0CI036 - CBU 3 CIP Target £200K Full Year but not to start until August 133 0 0 0CI037 - CBU 4 CIP Target £200K Full Year but not to start until August 133 0 0 0CI038 - CBU 5 CIP Target £200K Full Year but not to start until August 133 0 0 0CI039 - CBU 6 CIP Target £200K Full Year but not to start until August 133 0 0 0

6,316 430 430 0

18

Appendix 4

2013/14 2013/14Plan Actual VarianceMay May£'000 £'000 £'000

NON CURRENT ASSETS 71,654 71,493 -161

CURRENT ASSETSInventories 1,379 1,185 -194NHS Trade Receivables Current 2,417 4,181 1,764Non NHS Receivables Current 550 530 -20Other Receivables Current 1,254 1,030 -224Prepayments Current 1,009 854 -155Cash 10,200 9,726 -474Assets Current Total 16,810 17,506 696

CURRENT LIABILITIES (< one year)Trade Payables Current -5,571 -6,259 -688Other Payables Current -12,054 -7,627 4,427PFI Leases Current -181 -185 -4Social Security Creditors Current -3,639 -3,625 14Accruals Current -3,749 -6,476 -2,727Provisions current -683 -699 -16Deferred Income Current -508 -1,875 -1,367Total Current Liabilities -26,385 -26,746 -361

NET CURRENT ASSETS (LIABILITIES) -9,576 -9,240 336

Other Receivables Non current 659 666 7 PFI Leases Non Current -499 -491 8

Other non current -282 -282 0Total Non Current -121 -107 14

TOTAL ASSETS EMPLOYED 61,957 62,146 189

TAXPAYERS' AND OTHERS' EQUITYPublic dividend capital 56,558 56,558 1Retained earnings 1,129 1,317 189Revaluation reserve 4,271 4,271 1

TAXPAYERS EQUITY TOTAL 61,957 62,146 190

Consolidated Statement of Position

19

Appendix 4a

DRAFT DRAFT DRAFTBudget Budget Actual Variance Budget Actual Variance£'000s £'000s £'000s £'000s £'000s £'000s £'000s

Annual May-14 May-14 May-14 YTD YTD YTDCashflows from Operating Activities

Operating Surplus/(Loss) -11,945 -2,309 -1,592 717 -3,635 -3,368 267

Non-cash Income & Expenses/ movements in Working CapitalDepreciation & Amortisation 5,771 454 457 3 908 911 3PDC Dividend 1,884 172 137 -35 314 279 -35PFI Interest 0 -15 -7 8 0 8 8Interest Received -20 -2 -4 -2 -4 -6 -2Decrease/(Increase) in Trade & Other Receivables 579 1,255 -547 -1,802 1,755 137 -1,618Decrease/(Increase) in Inventories 0 0 383 383 0 383 383(Decrease)/Increase in Trade & Other Payables -8,325 -1,122 -3,149 -2,027 213 -2,132 -2,345(Decrease)/Increase in Other Liabilities -4,140 -530 0 530 -619 619(Decrease)/Increase in Deferred Income -218 -18 1,330 1,348 -36 1,330 1,366(Decrease)/Increase in Provisions 0 0 16 16 0 16 16Other Movements 424 -279 69 348 -244 -19 225NET CASH INFLOW FROM OPERATING ACTIVITIES -15,988 -2,394 -2,907 -513 -1,348 -2,461 -1,113

Cash Flows from Investing Activities

Interest received 20 2 4 2 4 6 2 Purchase of Property Plant & Equipment -3,476 -320 -284 36 -908 -354 554

Net Cash Outflow from Investing Activities -3,456 -318 -280 38 -904 -348 556

Cash flows from Financing ActivitiesPDC Received 0 6,695 6,695 0 9,955 9,955 0Capital Element of Private Finance Initiative Obligations -180 -15 -23 -8 -30 -38 -8Interest Element of Private Finance Initiative Obligations 0 15 19 4 0 4 4

PDC Dividend Paid -1,884 0 0 0 0 0 0Net Cash Outflow from Financing Activities -2,064 6,695 6,691 -4 9,925 9,921 -4

Increase/(Decrease) in Cash and Cash Equivalents -21,508 3,983 3,504 -479 7,673 7,112 -561

Cash and Cash Equivalents at 1 April 2,527 6,217 6,222 5 2,527 2,614 87Cash and Cash Equivalents at 31 May -18,981 10,200 9,726 -474 10,200 9,726 -474

-21,508 3,983 3,504 -479 7,673 7,112 -561

Consolidated Statement of Cashflows

20

Appendix 5

Capital Programme 2014/15 Annual Budget Actual VarianceBudget to date to date£'000s £'000s £'000s £'000s

2013-14 Deferred SchemesElectrical Testing 9 9 0 -9 Maternity Birthing Unit 266 260 274 14Kitchens AB/KL 35 35 0 -35 O Block 613 60 16 -44 Pharmacy Robot - Inpatients 18 18 15 -2 OT Kitchen Refurbishment 5 5 4 -1 Urgent Care 7 7 26 20Hospital Contact Centre 7 7 4 -3 Replace Theatre Chiller Plant 40 40 13 -27 Ceiling Tracking Hoist 2 2 0 -2 Estates Deferred 2013-14 1,002 443 353 -90 Digital Dictation 6 0 0 0Intelligent Drug Cabinets 6 0 0 0Intelligent Drug Cabinets (AMU) 48 0 0 0IM&T Deferred 2013-14 60 0 0 0Ceiling Tracking Hoist 17 17 0 -17 Winpath POCT Interface Blood Gas Analyser 1 1 0 -1 M&S Equipment Deferred 2012-13 19 19 0 -19 Total Deferred 2013-14 1,081 462 353 -109 Electrical Infrastructure 360 0 0 0Escape Lighting 50 0 0 0Security 20 18 0 -18 Air Tube Upgrade 50 0 0 0H&S Barriers 35 0 0 0HV Switchgear (Sub 3) 40 0 0 0Asbestos Enabling 30 0 0 0Day Case Chiller 50 0 0 0KL Condensate Tanks 45 0 0 0FRA Upgrades 50 0 0 0ESTATES Backlog Maintenance 2014/15 730 18 0 -18 VDI 445 0 0 0Replace Wireless AP's 5 0 0 0Colposcopy Database 40 0 0 0IM&T 2014/15 490 0 0 0Medical & Surgical Equipment 0 0 0 0M&S Equipment 2014/15 0 0 0 0EPR 605 60 0 -60 O Block - Neonatal Unit 100 0 0 0Endoscopy Suite 4th Room 0 0 14 14Pathology Autoclave 70 0 0 0STRATEGIC SCHEMES 2014/15 775 60 14 -46 Contingency 400 0 12 12TOTAL CAPITAL PROGRAMME 3,476 540 379 -162

21

Workforce

Green

= on target

Improvement in performance

Amber

= under performance (within 5% of target)

Deterioration in performance

Red

= fail (>5% target) No change in

performance

22

Workforce Exceptions

23

Green

= on target Improvement in performance

Amber

= under performance (within 5% of target)

Deterioration in performance

Red

= fail (>5% target) No change in performance

24

Sickness Absence

4.46% for the 12 months cumulative to 31st May 2014, the same as the April figure 4.46%. The 12 months cumulative target is 3.5% by March 2015.

The monthly figure for May is 4.01%, showing a decrease since last month which was 4.16%.

Diagnostics and Clinical Support Services CBU

Sickness for this CBU is 6.04% showing an increase from 5.57%

Sickness absence has risen in Pathology from 6.58% to 7.62% though the amount of sickness related to stress has fallen as plans to resolve the issues raised have been put in place. Levels of sickness in Phlebotomy have also risen from 15.6% to 17.94%. Long term sickness cases are issues here and are being dealt with in procedure. Pharmacy sickness absence has fallen from 4.78%% to 4.38%. Radiology sickness absence has risen due to four new long term episodes from 2.50% to 4.53%.

General and Specialist Surgery CBU

Sickness in General and Specialist Surgery CBU has risen from 3.12% to 3.43%.

There are high levels of sickness on Ward 31 at 10.91%. This is due to four staff off with long term sickness. Ward 32 continues to have long term sickness issues rising from 7.67% to 8.28% and all cases are being dealt with within procedure.

Theatres, Anaesthetics and Critical Care Services

Sickness absence in Theatres, Anaesthetics and Critical Care is down from 4.93% to 4.82%

Theatres sickness has decreased from 6.59% to 5.66% with 14 episodes of short term sickness in May and continues the decline over the last two months of the level of short term sickness being taken. Recovery has also seen a continuing improvement in sickness absence falling from 11.33% to 5.51% and is due to long term sickness cases returning.

Sterile Services sickness has fallen from over 9% to 8.08% with long term cases returning.

Emergencies, Orthopaedics and Care Services CBU

Sickness in Emergencies, Orthopaedics and Care Services CBU has risen from 3.73% to 4.77%

Care of the Elderly sickness rates have risen from 2.03% to 5.90% due to an increase in short term absence on Ward 19 for May. No underlying health cause to this rise has been identified Trauma and Orthopaedics rose from 2.93% to 4.54%. This is largely down to long term sickness increases on Wards 33/34. Therapy Services absence fell from 4.45% to 2.15%.

Generalist and Specialist Medicine CBU

The sickness absence rate for General and Specialist Medicine CBU has decreased form 5.22% to 4.57%

Sickness absence in AMU is at 4.59% from 6.12%% in April.

25

BoD: XX Reference - July 2014

REFERENCE SECTION

BoD: XX Reference - July 2014

BoD:XX Reference - July 2014

SCHEDULE OF ACRONYMS

Additional acronyms may be added as appropriate/on request

A A&E Accident and Emergency A4C / AfC Agenda for Change

ACCEA Awards Committee for Clinical Excellence Awards

ACE Acute Care of the Eldery ACS Additional Clinical Services AEC Ambulatory Emergency Care AHP Allied Health Professions AHSN Academic Health Science Network AMU Acute Medical Unit ANP Advance Nurse Practitioner AOA Annual Organisational Audit AQuA Advancing Quality Alliance

ARCP Annual Review of Competence Progression

AUP Acceptable Use Policy B

BAEM British Association of Emergency Medicines

BBE Bare below the elbows BCCG Barnsley Clinical Commissioning Group

BHNFT Barnsley Hospital NHS Foundation Trust

BMA British Medical Association BMBC Barnsley Metropolitan Borough Council BMJ British Medical Journal BoD Board of Directors BWCC Barnsley Women and Children’s Centre C CAP Community Acquired Pneumonia CASU Controls Assurance Support Unit CAUTI Catheter-Associated Urinary Tract

Infection CBU Clinical Business Unit CCG Clinical Commissioning Group CCU Coronary Care Unit C. diff Clostridium Difficile CDU Clinical Decision Unit CE / CEO Chief Executive / Chief Executive Officer

CEMACH Confidential Enquiry into Maternal and Child Health

CHAI Commission for Health Audit and Improvement

CHD Coronary Heart Disease CHI Commission for Health Improvement

CHKS CHKS – name of company providing statistical/benchmarking data

CIP Cost Improvement Programme (also known as efficiency programme)

CLAHRC Collaboration for Leadership in Applied Health Research and Care

CLAUDE Clinical Audit Data Base CMO Chief Medical Officer CMT Clinical Management Team CNST Clinical Negligence Scheme for Trusts COG Council of Governors COO Chief Operating Officer COPD Chronic Obstructive Pulmonary Disease

COSHH Control of Substances Hazardous to Health

CPA Clinical Pathology Accreditation CPE Clinical Performance & Effectiveness

CPEC Clinical Performance & Effectiveness Committee

CPMS Central Portfolio Management System CPT Capital Planning Team CQC Care Quality Commission

CQUIN Commissioning for Quality and Innovation

CRS Commissioner Requested Services CSSD Central Sterile Services Department CSU Clinical Service Units D DB Designated Body DDA Disability Discrimination Act Do ICT Director of ICT DoH Department of Health

DoHR&OD Director of Human Resourses and Organisational Development

Do N&Q Director of Nursing and Quality DHSC Directorate of Health & Social Care DH / DoH Department of Health

DIPC Director of Infection Prevention & Control

DMD Divisional Medical Director DNA Did Not Attend DNAR Do Not Attempt Resusitation DPM Department of Psychological Medicine DNR Do Not Resusitate DSEU Day Surgery & Endoscopy Unit E

EBITDA Earnings before interest, taxes, depreciation and amortisation

ECIST Emergency Care Intensive Support Team

ECN Emergency Care Network ED Emergency Department EDD Estimated Date of Discharge EDS2 Equality Delivery System ENT Ear, Nose & Throat EPAP Emergency Pathway Action Plan EPR Electronic Patient Records EqIA Equality Impact Assessment ET Executive Team EWS Early Warning Score EWTR European Working Time Regulation F

FABULOS Fluids, Antibiotics, Blood Cultures, Urine, Lactate, Oxygen, Sepsis Six

FBC Full Business Case FCE/FCSE Finished Consultant Episode FFCE First Finished Consultant Episode FFT Friends and Family Testing FT Foundation Trust FTN Foundation Trust Network G GMC General Medical Council

Bod: XX Reference - July 2014

GP General Practitioner GUM / GU Med

Genito-Urinary Medicine

H

HAPPY Harmonised Approval Process Pan Yorkshire

HCA Health Care Assistant HES Hospital Episode Statistics HSE Health & Safety Executive H&S Health & Safety HDU High Dependency Unit HR Human Resources HRG Health Resource Group (finance) HSC Health Service Circular HSMR Hospital Standardised Mortality Ratio I I&E Income and Expenditure ICU Intensive Care Unit (also known as ITU)

IFRS International Financial Reporting Standards

IIP Investors in People IHP Improving Hospital Partnerships IPC Infection Prevention & Contr IR1 Incident Reporting form

IRMER Ionising Radiation - Medical Exposure Regulations

ISS ISS Mediclean – cleaning contractors at the Trust

IT Information Technology

ITU Intensive Therapy Unit (also known as ICU)

IV Intravenous IWL Improving Working Lives J

JNCC Joint Negotiating and Consultation Committee

JTUC Joint Trade Union Committee KL KPI Key Performance Indicator LA Local Authority LCRN Local Clinical Research Network LAC Local Awards Committee LDP Local Development Plan LHC Local Health Community LIFT Local Improvement Finance Trust LINks Local Involvement Networks LOS Length of Stay LPMS Local Portfolio Management System LRC Learning and Resource Centre LTC Long Term Conditions M M&S Medical & Surgical MAG Model Appraisal Guide MDA Medical Devices Agency MDT Multi-Disciplinary Team ME Management Executive

MHRA Medicines &Medical Healthcare Regulatory Agency

MINAP Myocardial Infarction National Audit Programme

MRI Magnetic Resonance Imaging MTAS Medical Training Application Service

N

NCEPOD National Confidential Enquiry into Perioperative Deaths

NED Non Executive Director NEWS National Early Warning Score NHS National Health Service NHSE National Health Service England NHSE National Health & Safety Executive

NHSLA National Health Service Litigation Authority

NORCOM North Derbyshire, South Yorkshire and Bassetlaw Commissioning Consortium

NCISH National Confidential Inquiry into Suicide and Homicide

NICE National Institute for Clinical Excellence NIMG NICE Initiation and Monitoring Group NIHR National Institute for Health Research NPAT National Patients Access Team NPSA National Patient Safety Agency NRLS National Reporting & Learning System NSF National Service Framework O OBC Outline Business Case OH Occupational Health

OJEC Official Journal of the European Communities

OPERA Older Persons Early Rehabilitation Assessment

OPT Operational Performance Team OT Occupatinal Therapy PQ PA Professional Activities (4 hours)

PACS Picture Archiving & Communications Systems

PALS Patient Advice & Liaison Services PAS Patient Administration System PBR / PbR Payment by results (tariff system) PCT Primary Care Trust PEAT Patient Environment Action Team PGME Post Graduate Medical Education PIU Planned Investigation Unit

PLACE Patient Led Assessment of the Care Environment

PMG Performance Management Group PPG Patient Participation Group PPI Public & Patient Involvement PR Public Relations PROMS Patient Reported Outcome Measures PSM Patient Services Manager PTS Patient transport services QA Quality Assurance

QIPP Quality Innovation Prevention & Productivity

QSIEB Quality and Safety Improvement & Effectiveness Board

R R&D Research and Development RAF Risk Assessment Framework

RATS Remuneration and Terms of Service

RCPCH Royal College of Paediatrics and Child Health

RCP Royal College of Physicians

Bod: XX Reference - July 2014

RFT Rotherham Hospital NHS Foundation Trust

ROCA Register of Controls Assurance RPST Risk Pooling Assessment for Trusts RST Revalidation Support Team RTT Referral to Treatment S SABS Safety Alert Broadcast System SALT Speech and Language Therapy SAS Staff and Associate Specialist SAU Surgical Administration Unit

SCH Sheffield Children’s Hospital NHS Foundation Trust

SDA Surgical Decision Area SHA Strategic Health Authority SHMI Standardise Hospital Mortality Indicators SHO Senior House Officer SI Serious Incident SIFT Service Increment for Training SLA / SLAM

Service Level Agreements / Service Level Agreement Monitoring

SOA Strategic Options Analysis SUI Serious Untoward Incident SoS Secretary of State

SPC Statistical Process Control SpR Specialist Registrar SSD Sterile Services Department

STH Sheffield Teaching Hospitals NHS Foundation Trust

STEIS Strategic Health Authority Executive Information System

SYSHA South Yorkshire Strategic Health Authority

SWYPFT South West Yorkshire Partnership Foundation Trust

TUV

TIGER The Information Governance Education Recognition Award

TWWMIB Together We Will Make It Better VDI Virtual Desktop Infrastructure VTE VenousThrombo-Embolism WXYZ WCA Wider Controls Assurance WLI Waiting List Initiative Wte whole time equivalent Y&H Yorkshire & the Humber YTD Year to Date

A MEETING OF THE BOARD OF DIRECTORS WILL TAKE PLACE … · • Best Value • Accountability...

Documents

Transcript of A MEETING OF THE BOARD OF DIRECTORS WILL TAKE PLACE … · • Best Value • Accountability...