agenda - dchs home · 2015. 1. 28. · electronic cigarettes are designed to provide inhaled doses...

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Derbyshire�Community�Health�Services

Board

Board�Meeting�-�Public�Session�-�January�2015

29�January�2015�-�09:00

Committee�Room,�Walton�Hospital,�Whitecotes�Lane,�Chesterfield,�S40�3HW

AGENDA

1 PART�1�–�Public�Session

2 INTRODUCTORY�ITEMS

3 Introductions�and�WelcomeOwner:�Chairman

Verbal

4 Apologies�for�AbsenceOwner:�Chairman

Kirsteen�Farrar

5 Declarations�of�InterestOwner:�Chairman

Verbal

6 Questions�from�the�PublicOwner:�Chairman

Verbal�

6.1 Questions�from�the�Public:�Matter�arisingOwner:�Chairman

Paper�for�Information

6.1�Response�re�DCHS�FT�Policy�on�e�cigarettes 7

http://www.eshareuk.com

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7 Carer’s�StoryOwner:�Carolyn�White


7�Carers�Story 13

8 Draft�Minutes�of�the�meeting�held�on�18�December�2014Owner:�Chairman

Paper�for�Decision

8�Minutes�-�December�2014 17

9 Matters�ArisingOwner:�Chairman

Verbal

10 Actions�MatrixOwner:�Chairman


10�Actions�Matrix�-�public�session 28

11 Chairman’s�ReportOwner:�Chairman

Verbal

12 QUALITY�AND�GOVERNANCE

13 Audit�and�Assurance�Committee�Summary�ReportOwner:�Nigel�Smith

Paper�for�Assurance

13�AAC�Summary�Report�Jan�2015 30

14 Quality�Service�Committee�Summary�ReportOwner:�Chris�Bentley


14�QSC�Summary�Report�Jan�2015 35

15 Quality�People�Committee�Summary�ReportOwner:�Barbara-Anne�Walker


15�QPC�Summary�Report�Dec�2014 42


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16 Charitable�Funds�Committee�Summary�ReportOwner:�Tony�Okotie


16�CFC�Summary�Report�Dec�2014 48

17 Quality�ReportOwner:�Carolyn�White

Paper�for�Assurance�and�Information�

17�Quality�Report 50

18 Monitor�Quality�Governance�Assurance�Framework�–�Self�AssessmentUpdateOwner:�Carolyn�White

Paper�for�Assurance�and�Decision

18�Monitor�QGAF�Self�Assessment�Update 8619 Fit�and�Proper�Persons

Owner:�Amanda�Rawlings

Paper�for�Information�and�Assurance

19�Fit�and�Proper�Persons 99

20 Board�Assurance�Framework�Quarter�3�ReportOwner:�Melanie�Curd

Paper�for�Assurance�and�Decision

20�Board�Assurance�Framework�Q3 107

21 STRATEGY

22 Chief�Executive’s�ReportOwner:�Tracy�Allen

Paper�for�Information�

22�Chief�Executive�Report 175

23 PERFORMANCE

24 Quality�Business�Committee�Summary�ReportOwner:�Tony�Okotie


24�QBC�Summary�Report�Jan�2015 182


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25 Performance�Framework�ReviewOwner:�Chris�Sands


25�Performance�Framework�Review 187

26 Performance�ReportOwner:�Chris�Sands/�Amanda�Rawlings/�Carolyn�White/�William�Jones


26�Performance�Report�Jan�2015 197

27 Financial�Performance�ReportOwner:�Chris�Sands


27�Financial�Performance�Report 243

28 Monitor�Self-Certification�–�Q3Owner:�Melanie�Curd


28�Monitor�Self-Certification�Q3 256

29 CONCLUDING�ITEMS

30 Any�Other�Urgent�BusinessOwner:�Chairman

Verbal

31 Review�of�the�Meeting�and�OutcomesOwner:�Chairman

Verbal

32 Date�of�Next�Meeting�–Owner:�Chairman

Thursday�26�February�2015�in�Committee�Room,�Walton�Hospital,�Whitecoates�Lane,Chesterfield,�S40�3HW.��The�Public�Session�will�commence�at�9.00am�and�following�completion�ofbusiness�on�the�public�agenda�the�Board�will�move�to�a�Private�Session


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33 Coffee�Break,�during�which�the�Chair,�Chief�Executive�and�Trust�Secretarywill�answer�any�questions�regarding�issues�discussed�during�the�meetingOwner:�Chairman

Verbal

AttendeesPrem�Singh�(PS) UnconfirmedChairmanTracy�Allen�(TA) UnconfirmedChief�ExecutiveProf�Chris�Bentley�(CB)� UnconfirmedNon-Executive�Director�Tim�Broadley�(TB) UnconfirmedActing�Director�of�StrategyKirsteen�Farrar�(KF)� UnconfirmedTrust�SecretaryWilliam�Jones�(WJ)� UnconfirmedDirector�of�OperationsRick�Meredith�(RM)� UnconfirmedActing�Medical�Director�Tony�Okotie�(TO)� UnconfirmedNon-Executive�DirectorAmanda�Rawlings�(AR) UnconfirmedDirector�of�People�&�Organisational�Effectiveness�Chris�Sands�(CS) UnconfirmedDirector�of�Finance,�Performance�&�Information�Nigel�Smith�(NS) UnconfirmedNon-Executive�DirectorBarbara-Anne�Walker�(BAW) UnconfirmedNon-Executive�Director�Carolyn�White�(CW)� UnconfirmedDirector�of�Quality�and�Chief�NurseIn�Attendance Unconfirmed.Melanie�Curd�(MC)� UnconfirmedDeputy�Trust�Secretary�Lynn�Booth�(LB) UnconfirmedPartnership/Locality�LeadNicky�Owen�(NO) UnconfirmedHead�of�Staff�Partnership


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Index6.1�Response�re�DCHS�FT�Policy�on�e�cigarettes.pdf..............................................................7

7�Carers�Story.docx................................................................................................................ 13

8�Minutes�-�December�2014.docx...........................................................................................17

10�Actions�Matrix�-�public�session.docx..................................................................................28

13�AAC�Summary�Report�Jan�2015.docx...............................................................................30

14�QSC�Summary�Report�Jan�2015.docx...............................................................................35

15�QPC�Summary�Report�Dec�2014.docx..............................................................................42

16�CFC�Summary�Report�Dec�2014.docx.............................................................................. 48

17�Quality�Report.docx........................................................................................................... 50

18�Monitor�QGAF�Self�Assessment�Update.docx...................................................................86

19�Fit�and�Proper�Persons.pdf................................................................................................99

20�Board�Assurance�Framework�Q3.pdf...............................................................................107

22�Chief�Executive�Report.pdf.............................................................................................. 175

24�QBC�Summary�Report�Jan�2015.docx.............................................................................182

25�Performance�Framework�Review.docx............................................................................187

26�Performance�Report�Jan�2015.pdf...................................................................................197

27�Financial�Performance�Report.pdf................................................................................... 243

28�Monitor�Self-Certification�Q3.docx................................................................................... 256


TRUST BOARD Document Title: Response to Question regarding Derbyshire Community

Health Services Foundation Trust Policy on E Cigarette Use

Presenter/Title:

Contents of Paper were previously discussed by:

Question raised at DCHSFT Board Meeting on 18 December 2014

Author/Title: Jayne Needham, Assistant Director Health Wellbeing and Inclusion Tina Jones, Tobacco Control Programme Manager

Contact Email and Telephone Number: [email protected]

Date of Meeting: 29 January 2015 Agenda Item No: 6/15

No of pages inc. this one: 6

Document is for: (indicate with an “x” – you can populate more than one box)

Information X Decision Assurance

Purpose of Paper

The purpose of the paper is to inform Board members of the response to the query from the member of the public at the December 2014 meeting regarding the DCHSFT policy on E Cigarettes.

Recommendations

The contents of the report be noted

Board Assurance Framework Risk Reference

N/A

Financial Impact

None

Further Information and Appendices

The following question was asked at the December 2014 DCHSFT Board meeting: “The banning of cigarette smoking in confined public areas has been surprisingly accepted & dramatically successful. This success is risked by the increasing use of e-cigarettes that are (mainly) nicotine containing & often look like cigarettes. Do NHS bodies intend to adopt a policy towards them?”

6.1�Response�re�DCHS�FT�Policy

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Overall�Page�7�of�264Page�1�of�6

mailto:[email protected]


The response to this query is attached as Appendix A

Monitoring Information Brief Summary and References

Are there Governor Involvement implications?

Are there Equality and Diversity implications?

Are there Patient, Public and Stakeholder Involvement implications?

Risk Register

Is the issue on the current Risk Register? Yes No N/A X

Risk Number on Register

Does this update recommend a change in the current risk score? (If so, please provide your rationale below) Yes No N/A


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Chief Executive Tracy Allen Chair Prem Singh

Babington Hospital Derby Road

Belper Derbyshire DE56 1WH

Tel: 01773 599474 Fax: 01773 525115

www.dchs.nhs.uk

8 January 2015 Dear Sir Re: Question to Derbyshire Community Health Services FT board re use of e-cigarettes I am writing in response to the written question which was discussed at the DCHSFT Board meeting on 18 December 2014: “The banning of cigarette smoking in confined public areas has been surprisingly accepted & dramatically successful. This success is risked by the increasing use of e-cigarettes that are (mainly) nicotine containing & often look like cigarettes. Do NHS bodies intend to adopt a policy towards them?” The current position is that the DCHSFT Smoking Policy already covers the use of Electronic cigarettes (electronic nicotine delivery systems, ENDS) on DCHSFT premises and asks that staff, patients, visitors and others do not use them in either the buildings or grounds. There are currently no plans to change the policy to allow the use of e cigarettes on DCHSFT premises, however, if they become a licensed smoking cessation aid supported by Public Health and Medicines Management to be included in the Derbyshire Formulary and used by the Live Life Better Derbyshire Stop Smoking Service, then the policy can be adjusted to reflect this. Background and National View: Electronic cigarettes are designed to provide inhaled doses of vaporised nicotine. They use heat to vaporise a liquid-based solution usually containing nicotine, into an aerosol mist referred to as vapour. These devices are subject to minimal regulation, and are not licensed as a medicine or currently recommended as an aid to smoking cessation. They are of concern from a tobacco control and regulation stance for three main reasonsi:

• Concerns about the relationship between smoking and the use of electronic cigarettes • Regulatory control over advertising and promotion of e cigarettes • Involvement of the tobacco industry

APPENDIX A


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The concern is that ENDS may be a “gateway” to smoking and could promote the uptake of smoking and nicotine addiction, particularly in young people. Data around these claims is inconclusive and often contradictory. A recent survey found that 6% of 10-11 year olds in Wales claimed to have tried an ENDS, as opposed to only 2% who had tried a conventional tobacco cigarette. The report stated that children who tried an ENDS are up to seven times more likely to start to smoke cigarettes within 2 yearsii. However, a briefing by ASH on ENDSiii suggests that they do not act as a gateway to cigarette smoking and that current use is confined almost entirely to those who have already tried smokingiv. Further concern is that as ENDS can resemble cigarette smoking, they may renormalize smoking in public places where it is banned and undermine the efforts and excellent compliance with the legislation around smoking in public placesv. Considerable concern exists over their advertising and promotion. A code of practice for the advertising of ENDS has recently been published and several complaints have already been received and investigated under these new rules. ENDS were originally developed and marketed independently from the Tobacco Industry, however all four large tobacco companies currently own at least one ENDS product, or have competitor products in development. Given the ethical record of the tobacco industry in the promotion and defence of smoked tobacco products, there is a key argument for regulation to prevent abuse of the ENDS market. It is important to consider the known health risks regarding smoking; traditional cigarettes deliver nicotine in conjunction with a wide range of carcinogens and other toxins. In contrast, ENDS do not burn tobacco. Their main component other than nicotine is propylene glycol, which is not known to have adverse effects on the lungvi. Some manufacturers claim that ENDS are harmless, however, there is evidence that they contain toxic substances including small amounts of formaldehyde and acetaldehyde, which are carcinogenic to humans and that in some cases vapour contains small traces of toxic metals such a cadmium, nickel and leadvii . Although levels of these substances are much lower than those in conventional cigarettes, regular exposure over many years is likely to present some degree of a health hazard and despite the levels being lower they are still of concern to some non-smokers. It is important to note that because ENDS are a very new product there have not been any tests that replicate the repeated inhalation, to determine what harm if any, sustained use over many years may cause. The view of Public Health England is “Millions of smokers alive today will die prematurely from their smoking unless they quit. Preventing this death and disability requires measures that help as many of today’s smokers to quit as possible. The option of switching to an ENDS as an alternative and much safer source of nicotine, as a personal lifestyle choice rather than medical service, has enormous potential to reach smokers currently unwilling to try existing approaches. The emergence of ENDS and the likely arrival of more effective nicotine-containing devices currently in development provides a radical alternative to tobacco, and evidence to date suggests that smokers are willing to use these products in substantial numbers. ENDS, and other nicotine devices, therefore offer vast potential


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health benefits, but maximising those benefits while minimising harms and risks to society requires appropriate regulation, careful monitoring, and risk management. However the opportunity to harness this potential into public health policy, complementing existing comprehensive tobacco control policies, should not be missed.” i The Derbyshire position The Derbyshire Tobacco Control Alliance has identified the development of a Derbyshire wide stance on ENDS and their use, as a priority action in its Tobacco Control Action Plan. This will be discussed at February 2015 meeting of the Alliance. Within the DCHSFT Integrated Wellbeing service, the Live Life Better Derbyshire Stop Smoking Service does support a very small number of clients to stop smoking who are already using an ENDS and who do not wish to use a licensed Nicotine Replacement Product. The Service adheres to NICE Guidance on Harm Reductionviii and a very clear protocol is adhered to by all Advisers when supporting clients who are using ENDS. This includes the requirement that in order to be supported a client must have smoked tobacco within 48 hours of their quit date, are motivated to stop using nicotine completely (including the use of the ENDS) and will attend behavioural support sessions weekly. In summary, there is still considerable debate around the use of ENDS and new evidence both for and against their use is emerging on a frequent basis. It is clear that a number of recognised health professionals agree that the use of ENDS may be an effective harm reduction intervention, and some promote them as a useful aid for quitting the use of nicotine completely. The current research indicates that they are likely to be a safer alternative to traditional cigarettes for those who wish to continue to use nicotine long term, however there is still a need for further research before these products can be considered safe and recommended by the NHS as an alternative to tobacco use. In the meantime, as stated earlier, DCHSFT have adopted a precautionary approach, pending stronger evidence based advice. Yours sincerely Jayne Needham Assistant Director; Health, Wellbeing and Inclusion Derbyshire Community Health Services NHS Foundation Trust Email: [email protected] Tel: 01773 599474 i Public Health England May 2014 ;Electronic cigarettes: A report commissioned by Public Health England: Professor John Britten and Dr Ilze Bodanovica. ii CHETS Wales (2014) Exposure to secondhand smoke in cars and homes, and e-cigarette use among 10-11 year old children in Wales: (Graham Moore, Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), Cardiff University) iii ASH (2014) Electronic Cigarettes (also known as vaporisers). iv Dockrell M et al ( 2013) E-cigarettes: Prevalence and attitudes in Great Britain: Nicotine and Tobacco Research DOI 10. 1093/ntr/ntt057


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v Fairchild, A.L et al (2013) The Renormalisation of smoking? E cigarettes and the tobacco “Endgame”. N Engl J Med vi United States Environmental Protection Agency.( 2006) Registration eligibility decision for propylene glycol and dipropylene glycol. vii Goniewicz, ML et al (2013) Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control. viii NICE (2013) Guidance on Harm Reduction Approaches to Smoking PH 45


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TRUST BOARD

Document Title: Carer’s Story

Presenter/Title: Mrs Pamela Wood, Main Carer for Jason Wood Peter Happe, Patient Safety Facilitator


Author/Title: Lee Allen, Public and Patient Involvement Officer

Contact Email and Telephone Number:

01773 525119




Information X Decision Assurance X

Purpose of Paper

To share the experience of being a full-time carer for a gentleman who has a learning difficulty and is registered blind (partially sighted). Family carers of people with learning disabilities are often unique amongst carers. It can also mean that family carers may have decades of experience: Carer’s Trust 2012. To highlight the experience of Mrs Pamela Wood and Mr Jason Wood during Jason’s admission to Rowsley Ward, Newholme Hospital in February 2013. To highlight the experience of Mrs Pamela Wood and Mr Jason Wood in relation to the Complaints process.

Recommendations

It is recommended that the Board note the following;

The challenges faced by family carers.

The experience of making a complaint in Derbyshire Community Health Services Foundation Trust.

That lessons have been learned from the direct experience of Mr Wood and Mrs Wood, and that a range of improvements have been made to ensure we routinely consider the additional needs of our patients, and their carers.


1.3.1 Key Quality priorities: getting the basics right, placing the patient at the centre of everything we do.

7�Carers�Story.docx

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Financial Impact

None identified


What has been the experience of being the main carer for your son (Jason) through the years into adulthood? “Being a carer for Jason has had a huge effect on my life. A carer is not the career I would have chosen, it’s the career that’s been chosen for me. My main focus and attention has to be on Jason all the time. My life has never been my own. You have to consider him first before planning anything. Jason and I are part of the same package. As well as being a full time carer, I am a wife, a mother to two more sons, born as twins when Jason was 5 years old, a mother-in-law and more recently I have become a grandmother. My whole family does not get my full attention as I would wish to give them sometimes when they are in need of help or support. I can’t just drop everything to go to be with them, I always have to consider Jason’s needs first, before I can do anything. I have to be with him to support him with his daily living activities”. Following recent cuts to Jason’s personal welfare care budget, Mrs Wood has been forced to give up her part-time job in a local Dental Practice to become Jason’s fulltime carer. Mrs Wood has recently turned 65 years young; she should be really looking forward and planning her retirement with her husband. Mrs Wood describes how she misses the loss of the social interaction, the connection, the nice people - the reward and overall well-being she got from her working role is truly felt. Mrs Wood has a lifetime of experience and knowledge in caring for Jason, she knows him like no other. She knows when he’s not well. On this occasion she instinctively knew something was wrong with Jason. She believed that the health care staff would look after him and provide the right type of care for him to meet his additional needs. The whole family wanted Jason to be well again following an accident and the resulting need for surgery. What are the reasons felt the need to make a complaint? “Lots of reasons too many things that were just not right! The standard of care for Jason on Rowsley Ward in my view was very poor right from the very beginning! Jason first transferred from Chesterfield Royal Hospital to Newholme Hospital for rehabilitation care following surgery to his hip in February 2013. “When we visited Jason it was clearly visible there was something not right. One of the other visitors to the ward stated “he’s not a well man” ” Mrs Wood raised her concerns for Jason with a staff member; their response was “he’s not settled on the ward, we may be looking to discharge him tomorrow”. Again during the visit she went to the nurse’s station to raise her concerns; and again when Mr and Mrs Wood left the ward to return home they raised their further concerns stating something was wrong, their son was not well, he was not himself! “Our anxiety levels were so high we could not relax that evening. At 9.45pm we rang the ward to check on Jason. This time we spoke to a Nurse Practitioner who carried out observations on


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Jason. She reported Jason had a high temperature and a racing heartbeat. She stated that she didn’t know whether to ring 999 or not, she asked for Mr Wood’s advice.” 999 was called and Jason was admitted to the Emergency Department at Chesterfield Royal. Jason was then diagnosed with a water infection and commenced treatment for this. This would later explain why Jason had been hallucinating, being irrational, contacting family in Australia on his mobile on numerous occasions, saying that people were watching him, ringing the police, shouting out things - whilst on the ward at Newholme and when Jason was admit ed to the Chesterfield Royal. His conduct and behaviour were totally out of character for Jason. This is what Mrs Wood was trying to relay to the various ward staff at Newholme. She felt the water infection should have been detected from tests made on Jason during his admission. Jason began to recover and returned to Rowsley Ward a second time as an inpatient for rehabilitation. In her complaint, Mrs Wood raised concerns about the lack of physiotherapy before he was discharged home. Mrs Wood describes the other concerns that formed part of her complaint relating to Jason’s second inpatient stay. These include the identification of pressure sores, the bed he was given and the attitude of one particular staff member. One night Jason told a staff member he was feeling cold; the staff member pushed his bed close to a radiator but the draft from the window above the radiator made Jason feel even colder. Another instance when Jason asked to be taken to the toilet, he was given a bottle to urinate in; Jason felt very undignified doing this on the ward in front of other patients. Mrs Wood had to request a shower; Jason had not been washed for days and was beginning to smell. On Jason’s discharge his warfarin medication amount was not clear. Mrs Wood had to contact the ward and ask for advice. The staff member responded in a condescending manner, this left Mrs Wood feeling more concerned by the lack of caring empathy portrayed to her. Jason’s accident and resulting injury has left him with one leg shorter that his other. He cannot fully rotate his left ankle and suffers with a severe limp as a result. Jason progressed on to his outpatient physiotherapy treatment at Stanton Day Unit. Jason was told to keep putting his heel down to the floor and practice walking upstairs. He could not achieve either of these two tasks without the support of his mother. Jason was given a walking stick and discharged by the service. Mrs Wood felt this was very premature and there was a lack of communication with her as the carer for Jason. This is a summary of Mrs Wood’s complaint in respect of the poor level of care and attention provided to Jason. Mrs Wood felt that the staff on the ward were not fully equipped or trained to deal with Jason’s needs. He was a person with an underlying learning disability with an acute deterioration in his condition. What was your experience of making the complaint? Originally Mrs Wood contacted Rowsley Ward by telephone to make her complaint. She raised her concerns this way as she did not fully understand, or know the correct procedure; in terms of who and where to send it took for the appropriate action to be taken. The member of staff informed her that they had taken note of her concerns and they would look into them. They later


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responded in writing stating their investigations found that Jason had been given the appropriate care, and there was nothing to answer to. Mrs Wood feels this was very unprofessional, she felt she was invading their time and they just couldn’t be bothered to look into her concerns. Mrs Wood then sent a copy of complaint to Mr Derek Bray, Area Team Director for NHS England Derbyshire / Nottinghamshire. This was then forwarded on to the Patient Experience Team at Derbyshire Community Health Services. An investigation was carried out on receipt of the complaint. At this point both Mrs Wood and Jason were also invited to a meeting to understand more about their experiences. This provided more information on which a range of improvements, led by Tina Sullivan and James Thompson, were based. A further meeting with Mary Heritage, Assistant Director of Quality, Tina Sulllivan, Matron, and James Thompson, Integrated Community Team Leader, and some further discussions with David Brewin, Head of Patient and Family Centred Care provided the final resolution of all the issues raised during 2014. Upon Mrs Wood’s complaint reaching the Patient Experience Team, she described the experience of making her complaint as ‘very professional’. She feels her concerns have been taken on board in a non-judgmental way. They have been listened to and fully acknowledged; things could and should have been done better. She and Jason have both attended a meeting where they were able to voice and share their thoughts and feelings surrounding the complaint. Actions have been taken to avoid any future negative experiences for similar patients. Lessons have been learned.



N/A


Jason has learning disabilities as well as physical and sensory disabilities.


Listening to the experiences of patients and involving them in identifying improvements is an important tool in quality improvement.

Risk Register

Is the issue on the current Risk Register? No


Does this update recommend a change in the current risk score? (If so, please provide your rationale below)

No


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Minutes of the DCHS Board Meeting held on 18th December 2014 Farnah Room – Babington Hospital

Present Name Initials Job Title

Prem Singh PS Chairman

Tracy Allen TA Chief Executive

Prof Chris Bentley CB Non-Executive Director

Tim Broadley TB Acting Director of Strategy

Kirsteen Farrar KF Trust Secretary

William Jones WJ Director of Operations

Rick Meredith RM Medical Director

Tony Okotie TO Non-Executive Director

Amanda Rawlings AR Director of People & Organisational Effectiveness

Chris Sands CS Director of Finance, Performance & Information

Nigel Smith NS Non-Executive Director

Barbara-Anne Walker BAW Non-Executive Director

Carolyn White CW Director of Quality and Chief Nurse

Apologies Barry Steans BS Non-Executive Director

In Attendance David Boddy DB Corporate Governance Manager

Lynn Booth LB Head of Staff Partnership

Mary Heritage MH Assistant Director of Quality (left after agenda item 347/14)

Nicky Owen NO Partnership/ Locality Lead

Andrew Slater

AS Patient (left after agenda item 347/14)

Eleanor Stout ES Speech and Language Therapist (left after agenda item 347/14)

Item Description Action

341/14 PART 1 – Public Session

342/14 INTRODUCTORY ITEMS

343/14 Introductions and Welcome PS opened the meeting and welcomed all the observers.

344/14 Apologies for Absence Apologies were noted as above.

8�Minutes�-�December�2014.docx

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345/14 Declarations of Interest WJ declared an interest as a non-paid surveyor for a QFI Trent Accredited organisation for a group of doctors from Sheffield University.

346/14 Questions from the Public PS advised that a question had been received from John Morrissey, a member of the public, regarding DCHS’s intentions for a policy regarding e-cigarettes. PS confirmed that the organisation would provide a reply to Mr Morrissey and also make the response available at the next Public Board meeting. KF will co-ordinate the response.

KF

347/14 Service User’s Story Andrew, supported by MH and ES, talked about the progress he has made through the help and support from the adult Speech and Language therapy (SLT) service, and ES in particular. The service is commissioned for adults with acquired conditions affecting communication and swallowing. Andrew talked about the positive impact of SLT on his ability to participate in social, family and working activities. Flexible access to the SLT service enabled him to access a diagnosis, physiotherapy and access to potentially beneficial pharmaceutical intervention. SLTs and Young People’s Physiotherapy teams in Erewash have provided some targeted interventions aimed at improving Andrew’s intelligibility and core strength. He talked about how much it had improved his self-confidence. The Board thanked Andrew for telling his story. To aid him, AR offered the support of her staff with interview technique coaching to help him achieve his ambition to get a job.

AR

348/14 Draft Minutes of the meeting held on 27th November The minutes were agreed with the exception of:

319/14 – Chairman’s Report – amend wording in third paragraph from “how we may be able to work” to “how we are able to work”

334/14 – Performance Report - reference to Delayed Transfers of Care. The words after “Monitor compliance target” to be deleted

DB

349/14 Matters Arising

325/14 – Quality Report - reference to provision of Phlebotomy at Buxton to be discussed at the Quality Assurance Group. CW confirmed that this item has now been resolved following secured agreement for investment

AR updated the Board that 62% of staff had completed their staff surveys. This was the best performance by a Community Trust in the country


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350/14 Actions Matrix The following updates were noted: 334/14 – communication to staff that have not had their flu jab. A letter has now been sent out to 2,000 staff. AR updated the Board that 1,930 staff have received their jabs which is 45% of the staff (compared to the national figure of 36.8% and DCHS’s own 2013 achievement of 36%). Efforts continue with the vaccination programme.

351/14 Chairman’s Report PS talked about the DCHS strategic theme of promoting equitable and inclusive services. In June 2014 the Board approved our Equality, Diversity and Inclusion strategy. The Public Board meeting today heard Andrew’s story and at lunchtime, the BSL Charter, demonstrating our commitment to meeting the needs of deaf people would be signed. PS reported on the very positive recent South Derbyshire Leadership Group meeting. This focussed on stepping up our leadership roles to deliver substantial and significant transformational change in delivering services and integrated organisational models. A longer, time out session in the new year will reflect more deeply on the barriers and opportunities that need to be addressed collectively. The next Operational Plan is being developed and there have been several Board discussions to reflect and plan for our journey ahead, now that we are an FT. A full day Board time out session is being planned in the new year. PS chaired the full Council of Governors (CoG) meeting as well as the Nominations Committee where they discussed the process for recruitment of our Non-Executive Director vacancy left by Barry Steans. Barry Steans was unable to attend the Board meeting and had sent his apologies. On behalf of the board PS thanked Barry for his contributions to DCHS over the last 3 years. PS was invited by the Foundation Trust Network to lead a session on sharing the experiences of our FT journey to provide a platform for learning and reflection. This reinforced the enormous work we have undertaken. .


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PS reflected on the many DCHS achievements in 2014 including:

The very strong ethos and value set with excellent staff engagement and an embedded DCHS Way

Delivery of high quality services – we have augmented our quality assurance approach to be more coherent, comprehensive and inclusive, involving our Governors and Board colleagues

Delivery on most of the CQC report actions in a sustainable way

A strong track record of Financial performance, with a continued challenging focus on Cost Improvement Programme delivery, Staffing for Quality and securing income (having won all of our Health and Wellbeing tenders thus far)

Engaging fully with our CoG, developing the Board, supporting the Executive team and re-engaging successfully with Monitor

Engaging with our communities, along with our Clinical Commissioning Group partners in shaping services fit for the future; continuing to improve and refurbish our premises so that we can provide modern, safe care; launching Caring Always: continuing to innovate in service developments to bring care closer to/or at home and playing an active role in supporting a resilient wider system

PS reflected on external endorsements such as:

The CQC commented that our staff are caring and compassionate, as reported by patients. They observed that the DCHS way is established and embedded and that we have a culture of openness and continuous improvement. They found DCHS a well led organisation with a senior team that is visible and proactive and an informed Board, aware of the challenges and dealing with them

PS said that following a revisit, the CQC had just announced that we are now fully compliant

Our Monitor authorisation underpins that we are not only delivering high quality services but are legally constituted, financially viable and well led – the first of only two specialist community FTs in the country.

We were shortlisted for the HSJ Provider Trust of the Year; won HR Director of the Year; HR Team of the year and also for our Leadership development programme; and included in the Top 100 organisations to work in;

We have had huge support from the Trust Development Authority (and the wider system), including a visit from David Flory, endorsing our service innovations highlighted above. We will continue to build strategic partnerships locally, regionally and nationally.

The achievements were possible because of the talents, dedication and commitment of the staff who work tirelessly to meet the needs of our patients and communities. PS thanked all our staff, the Board and Governor colleagues and wished everyone a very Merry Christmas and a Happy New Year. 2015 promises to be an even better and challenging year. PS said that our track record shows DCHS are up to it. The Board received the Chairman’s report.


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352/14 QUALITY, GOVERNANCE & SAFETY

353/14

Quality Service Committee (QSC) Summary Report CB presented the Summary Report from the meeting dated 16th December 2014. Care Quality Commission (CQC) Progress Report - QSC were briefed on the changes of the Essential Standards to the Fundamental Standards (April 2015), and the introduction of the ‘Fit and proper person’ and ‘Duty of Candour’ regulations for Directors, which came into effect November 2014. Information Governance - training is currently behind target. Work is to be undertaken to refresh the training package and make it more attractive. Clinical Effectiveness – QSC were updated on implementation work regarding NICE. The work is considering integrated care work. Work is behind schedule on the implementation of the 360 Assurance Internal Audit actions. Efforts are underway to get back on track. Equality, Diversity and Inclusion - QSC were updated regarding the progress to achieve the actions in the Equalities Action Plan and work to achieve the Healthcare For All objectives. Quality Always - the Committee were updated regarding the good progress of the Quality Always initiative in this quarter: Validation of Deprivation of Liberty Safeguards (DoLS) - QSC discussed the risk posed to DCHS by the Best Interest Decisions – the Supervisory body (Derbyshire County Council) failing to meet their timescales. CW has taken the issue to the Quality Assurance Group and has a meeting arranged with the Adult Social Care Lead at Derbyshire County Council (DCC). CB asked that consideration be given to quality assurance governance arrangements regarding supply chains and integrated care teams. CS said that the Management Executive had discussed the matter and work was ongoing to put controls in place. TB said this would be discussed as part of the work on contracts. PS acknowledged that this was a complex area and thought the Clinical Commissioning Groups (CCGs) had a duty of care regarding the quality of integrated services. The Board received the Summary Report and the assurance it provided.


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354/14

Council of Governors Summary Report PS presented the Summary Report from the meeting dated 11th December 2014. This was the first CoG meeting as a Foundation Trust. As part of Non-Executive Director (NED) accountability the CoG received presentations from BS and BAW regarding Quality Business Committee and the role of the Senior Independent Director. The key matters of the meeting included approval of:

The Nominations and Remuneration Committee formation and Terms of Reference

The appointment of the Chair and NEDs

The tenure of the Chair and NEDs

The recommended remuneration for the Chair and NEDs

The process for succession planning

An extension to the appointment of KPMG as External Auditors to complete the Foundation Trust part year accounts 2014/15

3 Governors to be nominated to work with the Audit Committee Chair and Director of Finance, Performance and Information to progress the tender for External Audit contract from 2015/16

An increase in the frequency of CoG meetings from 4 to 6 per year

To form a task and finish subgroup to work on potential improvements for the CoG meetings

The Changes in the membership of the Council over the quarter were noted. The Board received the Summary Report

355/14

Quality Report CW presented the Quality Report and reported that as part of Monitor’s governance arrangements DCHS is required to report on a range of quality metrics. Whilst the metrics reported may not reflect DCHS’s greatest clinical risks, we are required to monitor our performance against them and consistent failure to achieve the metrics may result in Monitor intervention. CW discussed exception reporting regarding:

Delayed Transfers of Care in OPMH services

Incidences of Clostridium difficile (CDiff) infection - 2 additional CDiff incidents have been added which brings the cumulative total to 9 placing the trust slightly ahead of its reduction trajectory. Indications are that the patients may have been admitted with the infection and are therefore not attributable to DCHS

CS said the Monitor targets relate principally to acute providers, not community services. CS is taking a consultation through Audit Committee in January in order to meet with Monitor to request the targets are reshaped and made more appropriate for community foundation trust activity.


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PS acknowledged that the small numbers involved can make for a distorted report. RM said that the numbers were made proportionately bigger by the patients that DCHS receives with acquired brain injuries. The Board discussed Pressure Ulcer performance:

Work is required to improve Pressure Ulcer data to support our understanding. CB said that QSC agreed this needed expert analytical support. TA said care should be taken not to lose the energy invested in supporting our frontline staff to deliver care

Discussions will be held with Medequip to supply improved equipment for patients. The CCGs have a role here in supporting the procurement of appropriate equipment.

CW updated the Board regarding feedback from the CQC that confirmed DCHS is fully compliant. CW also reported on improvement in Staffing for Quality. NHS England

have supplied a report that ranks organisations in relation to staffing levels

for the period May to September 2014. From the information provided,

DHCS is currently ranked 2nd out of 72 organisations for the “fill rate” of

Registered Nurse for Day shifts and 66th for Registered Nurses on Night

shifts. There is an upward trend for both.

The Board received the Quality Report and the assurance it provided.

356/14

Quality Always Update CW updated the Board regarding progress made and that the project is now back on target. This included work undertaken in developing a robust clinical leadership development assessment centre and progress on baseline ward inspections. QSC and TME discussed the RAG ratings applied to the performances. It was emphasised that red ratings should not cause anxiety because the thresholds are very low. TA said that the ratings should be seen in context because the Quality Always ratings are about achieving sustained excellence. The Board agreed that, in order to support colleagues, work should be done to improve the presentation of ratings PS was pleased to see the report and the efforts coming to fruition. He suggested that the Board receive analysis from the Quality visits.

The Board received the Quality Always Update and the assurance it

provided.

CW


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357/14

Mental Health Act Committee (MHAC) Summary Report BAW presented the highlights from the first MHAC report to Board including:

The Mental Capacity Act audit showed that a reasonable amount of assurance can be taken that staff do understand assessment of capacity

Verbal Feedback on the CQC follow-up visit focused primarily on Melbourne and Linacre Wards. Inspectors said they were made to feel welcome on the wards and the staff were very co-operative. Patients looked incredibly well cared for. Inspectors saw that progress had been made since the last inspection.

Section 5 (2) Occurrences Audit - concluded that although the figure of Section 5(2)s on the MHA Activity for Older People’s Mental Health and Learning Disability Services reported in November may seem high, it was entirely appropriate.

The Board welcomed information regarding the Associate Mental Health Act Managers (AMHAM) visits. TA undertook a visit and found it a very informative experience. The Board further discussed the delays experienced by DCHS with the validation of DoLS by DCC. Although DCC have reported that they found our DoLs assessments were good, the Board were concerned that owing to the delays, our staff may find themselves in challenging positons. CW said that our staff were experienced and very careful not to follow unlawful processes. In the interim period, while CW is resolving the matter with DCC, PS asked that we build in an audit. The Board received the Summary Report and the assurance it

provided.

358/14 STRATEGY

359/14

Chief Executive’s Report TA presented her report and highlighted the publication of the Dalton Review and the Five Year Review. The Board will consider these in detail including the challenges they present to how we review the services we provide. A local government review of the Health and Wellbeing Board recommended a refocus on what it can achieve in order to make an impact. TA updated the Board regarding partnerships set up across the Mental Health Crisis Care Concordat for people in crisis with mental health problems. DCHS Executives are now working closely with Chesterfield Royal Hospital Executives. A benefit has been the joint tenders that we have won.


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In partnership with Royal Derby Hospital GUM department, DCHS have won a tender to provide sexual health across Derby City. High winter pressures have been experienced across Derbyshire. We are holding joint daily conference calls to manage the situation. The staff were thanked for their hard work to meet this high demand. The Board discussed the importance of getting the message across to use our Minor Injuries Units more. WJ said he would talk to our partners about how to expand the support services at DCHS, such as x-ray, to help keep our services open beyond 5pm. The Board received the Chief Executive’s Report.

360/14

Memorandum of Understanding in Relation to a Strategic Partnership with Chesterfield Royal Hospital NHS FT The Board approved the Memorandum of Understanding which will underpin the good working relationship with Chesterfield Royal Hospital. This is subject to minor amendments to sections 1.5 and 1.6.

TB

361/14 PERFORMANCE

362/14

Derbyshire Community Health Services Charitable Trust – Approval of 2013/14 Annual Report and Accounts The Board, as Trustees, were updated regarding the independent examination of the Annual Report and Accounts by KPMG LLP. NS challenged the large amount of monies held in cash at the bank not earning interest. CS will review this matter. The Board, as Trustees, agreed to adopt the 2013-14 Annual Accounts and Report for the Charity as presented along with the delegated authority for signing off the Accounts to the Chair and Director of Finance, Performance and Information, and authority for signing the Letter of Representation to the Chair.


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363/14

Performance Report CS described the new Risk Assessment Framework and the quarterly declarations against it. It was requested that the Monitor Quality Risk Assurance Framework Indicators dashboard is included in the report going forward. This will be helpful in giving sight to areas of focus such as RTT, Cdiff and Delayed Transfers of Care. The Board discussed the implications of underperformance against targets. AR reported the Quality people headlines including decreasing Attendance in November to 95.92%. The Attendance Management Group meets on a monthly basis to address these issues. WJ reported on action with respect to:

Referral to Treatment (RTT) waiting time scorecards

QSC to receive reports regarding the performance of the Breastfeeding and Chlamydia screening services

QSC will be asked to receive a “deep dive” report into the reasons for the underperformance against target for antenatal Health Visits

The Board received the Performance Report and the assurance it provided.

364/14

Financial Performance Report CS reported a surplus position of £1.26m at month 8, which represents a £0.43m adverse variance against the planned surplus of £1.69m. A year end forecast surplus of £1.6m is now expected due to delays in delivering the Cost Improvement Plan and increased pressures within the Clinical Services. The reduction in the year-end forecast surplus is a reflection of the increased financial pressures being experienced driven by overspending within Integrated Care Based Services (ICBS) and non-achievement of CIP plans. It also reflects the increased financial risk as we enter the winter period. The Trust is forecasting that it will meet all its statutory financial duties for the year. NS asked about the £0.4m overspend on transport costs. CS reported that a report will be presented to the January Quality Business Committee meeting. The Board received the Financial Performance Report and the assurance it provided.

365/14 CONCLUDING ITEMS

366/14 Any Other Urgent Business There were no items of any other urgent business.

367/14

Review of the Meeting and Outcomes The Board agreed that it had been a good meeting. It was also agreed that arrangements would be considered for future meetings where the public and speakers were waiting prior to the meeting.


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368/14

Date of Next Meeting Thursday 29 January 2015 in Committee Room, Walton Hospital, Whitecotes lane, Chesterfield, S40 3HW. The Public Session will commence at 9.00am and following completion of business on the public agenda the Board will move to a Private Session.

369/14 Coffee Break


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CURRENT Actions Matrix Page 1 of 2

P

DCHS BOARD – ACTIONS MATRIX DATE: January 2015 – Public Session

Date/Item No:

Item/subject: Decision taken and/or action required:

Progress: Responsible Person:

Deadline: Outcome:

180/14 Chairman’s Report

Carer’s story to be bought to a Board meeting in the next few months

Carolyn White January 2015 *Changed from December 2014

Agenda Item at January 2015 Board

360/14 Memorandum of Understanding in Relation to a Strategic Partnership with Chesterfield Royal Hospital NHS FT (CRHFT)

Minor amendments to sections 1.5 and 1.6

Tim Broadley January 2015 Complete - the revised version has been shared with CRHFT who will be considering it at their January Board meeting

347/14 Service User’s Story

AR offered the support of her staff with interview technique coaching to help Andrew achieve his ambition to get a job

Jen Guiver to make initial contact with Andrew and following that it will be decided who can best support him within the team

Amanda Rawlings

February 2015

356/14 Quality Always Update

Work to be done to improve the presentation of the Quality Audit ratings

Carolyn White February 2015

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CURRENT Actions Matrix Page 2 of 2

Date/Item No:

Item/subject: Decision taken and/or action required:

Progress: Responsible Person:

Deadline: Outcome:

332/14 QBC Summary Report

An overall Cost Improvement Plan for 2015/16 to be presented to QBC in January and, following that to Board

Chris Sands February 2015

334/47 Performance Report

CW and RM to write a personal letter to staff who have not yet had their flu jab and a lessons learned review to be discussed at QPC.

A letter has been sent out to 2,000 staff. 1,930 staff have received their jabs which is 45%.

Carolyn White/ Rick Meredith

February 2015 Complete

192/14 DCHS’ new Equalities Strategy, 2014 – 16

A further Board Development session is being scheduled on Equality and Diversity and AR is considering inviting an external facilitator to challenge the Board

It was agreed that AR should ask Sally Edwards and the Network Group Chairs to facilitate the session and use the Equality Diversity System (Version 2) self-assessment as the basis for the discussion

Amanda Rawlings

April 2015

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Audit and Assurance Committee Summary Report

Report To: Board

Date: 29 January 2015

Name of Reporting Committee / Group: Audit and Assurance Committee

Date of Meeting: 16 January 2015

Presenter: Nigel Smith, Non-Executive Director

Author: David Boddy, Corporate Governance Manager

Key Issues

6/15 Quality Committee presentation – Business - the Committee considered the two Red Risks which are:

3.1.3 Delivery to the IBP due to change in commissioner priorities. In January QBC will consider whether to include national guidelines in this risk

3.2.3 Inability to meet financial targets The meeting reviewed the 12 Amber Risks including:

3.1.2 Competitive environment. CS updated the Committee regarding DCHS success with tenders

3.1.4 Impact of funding cuts on social services. The extent of impact of this risk is still not fully known. CS said that the risk may also need to be debated by the Quality Service Committee (QSC) as risks emerge

3.2.1 Poor estate. The score of 12 may be reviewed once the risks in this area are fully known

CS reviewed the key issues including the impact of emerging national guidance and the forthcoming General Election on healthcare delivery. DCHS will test its plans to check they are consistent with emerging issues. The Committee also discussed the issue of information sharing with regard to IT governance compliance and the potential risk around delivery of care. CW said that there is further work across internal teams. JC thought that patients considered data sharing to be with the organisation and not just with the individual clinician in the organisation. CS will ask Alvaro Pancisi to seek guidance to get clarity. The meeting considered the risk scores in the QBC Board Assurance Framework in comparison to Quality People Committee and QSC. KF said that the Executives routinely challenge the risk across the committees to ensure consistent scoring. JC thought that the scoring was appropriate. The Committee took assurance from the presentation. 7/15 Board Assurance Framework Quarterly Review - the Committee discussed the risks and:

Agreed that the Mental Health risks should be moved to the Quality Governance section

Two risks regarding the Foundation Trust application are no long relevant and are

13�AAC�Summary�Report�Jan�2015

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removed

A helpful meeting between KF, CS and SG has generated some changes to Key Performance Indicators that will be discussed by the Executives

Work will be undertaken to map the operational risk register to the strategic risks and vice versa

The Committee took assurance from the report. 8/15 Data Quality Update - CS updated the Committee regarding the current status of data quality for DCHS. 360 Assurance have been invited to review the development of a new control system to collect Key Performance Information. CS said the big issues for DCHS regarding data quality were:

Where services do not currently have electronic systems

Once all services are on electronic systems then we will have a control system in place An example was given regarding TPP not yet fully rolled out in the north of the county for Community Nursing. SG asked that a coverage measure be considered for the data quality section of the BAF. The Committee took limited assurance from the update. The Committee acknowledged that this is a large project which will take a period of time to be completed. SG said that DCHS should take some assurance from the importance it places on improving data quality. 9/15 Clinical Priority Audit Update including CEG Proposals - SB and LB presented on work to strengthen quality through renewed focus on Clinical Effectiveness. The audit work will be in partnership with clinicians with focus on their preferred outcomes for patients. It would move away from an administrative process towards a more meaningful cycle of improvement. NS thought the positioning of the approach was good because it was not just ticking boxes. However, the new approach is still at the process stage and does not yet demonstrate outcomes. SB acknowledged that the initial work has been to agree the direction of the programme. The Committee noted that the top priority audits have all been linked to Quality Service risks and will provide assurance for the BAF. NS acknowledged the quality of work completed so far to agree the “direction of travel” and noted the work that is now to be undertaken. 10/15 Care Quality Commission (CQC) Licence - The Committee were assured that the trust is licenced in accordance with CQC regulations. 11/15 Safeguarding Group Update - CW updated the Committee about the actions taken to strengthen the focus and function of the Safeguarding Governance Group and the assurance that this group provides across the safeguarding agenda. The Committee noted the steps taken to date. CW considered that the work would be completed


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in a further 3 months. KF discussed further areas where the group could improve its work. KF has suggested to the group how they should strengthen their ties with the Safeguarding Board. The Committee took limited assurance from the report. 12/15 Review of Audit Committee Handbook - the Committee reviewed the Trust’s position against the NHS Audit Committee Handbook Self-Assessment Checklist. JC commented that the review was a fair assessment of the Committee. The Committee took assurance from the report. 14/15 Part Year NHS trust Accounts - CB provided an update regarding the draft Accounts that have been prepared covering the Trust’s final period as an NHS Trust i.e. 1st April 2014 to 31st October 2014. The draft Accounts were submitted to KPMG at the end of December 2014 and will be subject to a full audit review during January 2015. Due to the nature of some of the disclosures required in the Annual Accounts, it is not possible to provide this information part way through the financial year. These issues were discussed with KPMG at an early stage. The accounts will not be fully signed off and submitted to the Department of Health and the Trust Development Agency until the end of the financial year and in line with the national timescales. The Committee noted the draft Accounts position for the first seven months of the financial year. The Committee took assurance from the report and thanked the staff involved for the extra work that they have undertaken. 15/15 Annual Financial Accounts Progress Report (Including Changes to Accounting Policies) - due to the Trust’s authorisation as an NHS Foundation Trust with effect from 1st November 2014, there is a requirement for two sets of Accounts to be produced this financial year. The first covering the final period as an NHS Trust and the second set to cover the first period as an NHS Foundation Trust. CB discussed the key differences regarding disclosure requirements; the timeframes and timetable to deliver by the deadline and the accounting policies. The Committee took assurance from progress made and noted the expectation of a change in the meeting date of Audit Committee to sign off the accounts in May. 16/15 Planning for Year End Statutory Submissions - CB provided an update regarding progress to date and planning that is in place to ensure that the Trust is able to meet the deadlines set by Monitor in respect of the Annual Report, the Quality Account and the Annual Accounts. The Committee took assurance from the progress that has been made and the detailed plans in place to meet the national deadlines for the submissions. 17/15 Quality Account Update - the Committee discussed the importance of achieving the twin goals of accuracy and timeliness for delivering the Quality Account.


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The Committee noted the lack of clarity regarding Monitor’s requirements for a Community Foundation Trust to provide a Quality Account. It was agreed that we will proceed to produce one. The Committee also agreed to ask the Council of Governors to nominate 2 governors to join the editorial board to be involved in the production process. The Committee took assurance from the progress with regard to production the 2014/15 Quality Account. 18/15 Compliance with Governance Arrangements - KF reported internal assurance that the Trust is complying with its governance requirements and arrangements. KF confirmed that the Whistleblowing Policy is not yet approved. A meeting is arranged with “staff side” to agree issues. An annual report will also be produced and will be positioned to be staff facing. The Committee took assurance from the report. 20/15 Internal Audit Progress Report - significant assurance was found in the audits of Working Capital Management, Equality and Diversity Review, Complaints, Health Care Records Management, Expenses Review, Patient Experience The Committee discussed the limited assurance reports:

Mobile Working Benefits Realisation – CS said that AP is to provide a report to QBC

Disciplinary, Grievances and Dignity at Work Case Review – SG said that AR will be taking the report to QPC

The Committee took assurance with respect to delivery of the plan. The Committee also agreed that the process to develop the Audit Plan for 2015/16 should follow the same process as previous years. 23/15 Audit Progress Report - JC updated the Committee that:

Following Audit Commission advice received this week the fee for the first part of the year’s accounts will be £42,000. A draft audit plan will be circulated to members following the meeting

JC will discuss the audit for the second part of the year with CS

The audit of the Charitable Funds account has been completed. No issues were found. The audit will be reported to the Board

The Committee took assurance from the report. 26/15 Self-Certification – Governance - KF updated the Committee on the monthly self-certification position approved by the Board during Quarter 3 and the future reporting requirements now we are a Foundation Trust. The Committee considered the detail of information that is reported to Board and concluded there were no significant gaps. The Committee took assurance from the paper.


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Items of Limited/Negative Assurance

32/15 Board Assurance Framework, Risk and Self-Certification Issues - the meeting discussed and recorded assurance taken with respect to each appropriate paper as well as an evaluation of all risks discussed. Papers with limited or no assurance were: 8/15 Data Quality Update 11/15 Safeguarding Group Update

Indicate any new risks identified during meeting

None

Decisions Made (including policies approved)

25/15 Draft Response to Consultation on Risk Assessment Framework - the Committee discussed and approved the Trust’s draft response to the Monitor consultation on updates to the Risk Assessment Framework Recommendations. 27/15 Self-Certification – Finance - the meeting reviewed and approved the finance declaration under the Provider License.

Items/issues referred to another Committee

None.

In Attendance

Nigel Smith NS Non-Executive Director (Chair)

Tony Okotie TO Non-Executive Director

Barbara-Anne Walker BAW Non-Executive Director

Sarah Banks SB Head of Quality Governance

Lisa Barrett LB Clinical Effectiveness and Audit Lead

Cath Benfield CB Head of Finance

David Boddy DB Corporate Governance Manager (minute taker)

John Cornett JC Director, KPMG


Simon Gascoigne SG Associate Director, 360 Assurance



Carolyn White CW Chief Nurse/Director of Quality

Lynne Backhouse LBa Administration Officer (observer)


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Quality Service Committee Summary Report to Board

Report To: Trust Board


Name of Reporting Committee / Group: Quality Service Committee


Presenter: Chris Bentley, Chair


Key Issues

4/15 Patient Story - AS presented a story showing the work done by the Health Visitor in delivering the healthy child core programme to a family, and how information shared regarding infant brain development and parental investment in a child’s development was taken on board by the parents, and led to a home video being taken, viewed by the committee, evidencing the value of parental interaction with a child. TA said that the Patient Story was a great reminder of the difference made to families by AS and her colleagues. The Committee thanked AS for her presentation.

8/15 Care Quality Commission (CQC) Progress Report - the Committee were updated regarding the current position of the CQC action plan, proposals for on-going management of the assurance framework and the findings of the draft CQC unannounced inspection report. SB also updated the Committee that the CQC had completed a Mental Health service inspectionthe previous day. The Committee took assurance from the update.

10/15 Quality Report - the Committee reviewed the report. Highlights included:

The proportion of patients with ‘No New Harms’ for December was 98.56%, the best score since this indicator was introduced to the Safety Thermometer in December 2013

The Community Nursing Harm Free Care (HFC) score (94.64%) was above the National District Nursing benchmark of 93.87%

There was a decrease in the prevalence of Pressure Ulcers reported in December’s survey (5.5% down from 6.08% in November)

The Medication PGDs are now up to date

The Committee discussed:

The stepped improvement through 2014 of the DCHS and the DCHS District Nursing HFC scores

The introduction of red wrist bands as a tool to help in the initiative of working with vulnerable patients who might fall

There will be some timing differences in the Monitor Risk Assurance Framework data received by QSC and the Board when the Board receives the quarterly report

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Quality Visits – CW will meet with the Non-Executive Directors to discuss regarding the goals and the arrangements of the visits and the role of the NEDs in the activity. Feedback will also be presented to the Council of Governors regarding the impact of making a late cancellation

Pressure Ulcers MO reviewed the Pressure Ulcer performance in December and highlighted the main trends: where a number of teams are involved in shared care; delays in pain management leading to reduced mobility; and the volume of incidents and prioritizing the STEIS reportable incidents to ensure compliance with Commissioner deadlines. The Committee discussed the challenges to producing meaningful and relevant data such as by number of contacts or patients on caseloads. The Committee took limited assurance from the Pressure Ulcer performance.

11/15 Risk Management Report - JH reported that there were no new high or medium risks and there had been a reduction in the number of overdue risks. The Committee discussed the new risks in detail including:

Risk 2820 reduction in the allocation of funding for training – this risk relates to some challenging central funding arrangements and not within DCHS

Risk 2824 – the Committee encouraged JH to challenge individual risks which would be better placed in relevant broader risks

The Committee took assurance from the report.

12/15 Clinical Safety Group Summary Report - some of the papers that the group had taken assurance from were:

Pressure Area Care data analysis

Safe Care Priority Group Medicines (MOST) - the safe management of medication incidents

IP&C Committee Summary Report regarding: improvements to the Synergy Contract

Bariatric Bed Audit Report The group had also taken limited assurance from:

Legionella management at the Community Dental Sites in Leicestershire - limited evidence of the monitoring processes. Estates are working on the issue to provide effective assurance going forwards. A risk assessment is taking place. This issue may require further escalation.

The Committee took limited assurance from the Legionella management issue.

13/15 Safeguarding Safeguarding Governance Group Summary Report - highlights from the report included:

Safeguarding Training Update provided limited assurance although it was acknowledged that actions are in place

Counter Terrorism Strategy – was discussed by the group

A paper outlining the national mandatory reporting framework for Female Genital Mutilation. The group took limited assurance but it was acknowledged that additional bespoke training would be made available for MIU and sexual health staff


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Safeguarding Service Update Report - JH updated the Committee regarding the DCHS Safeguarding Service activity from July to December 2014:

DCHS Safeguarding Adult Assessment Framework follow up visit November 2014. DCHS received a positive inspection report from Derbyshire Clinical Commissioning Group Safeguarding Leads in November 2014

Completion of the CQC Inspection of Safeguarding and Children in Care Services (August 2013) Action Plan

Safeguarding Adult and Children Training 2015

The Committee took assurance from the report. Feedback from Children and Young People - the Committee reviewed the approach to capturing feedback from children and young people. The Committee asked if a Patient Story might be available from the school nursing service. The Committee took assurance from the reports. 15/15 Clinical Effectiveness Clinical Effectiveness Group (CEG) Summary Report SB updated the Committee regarding assurance taken from the dissemination and integration of NICE publications. Although it was acknowledged that work is still required, less but more pertinent information is now being disseminated. The group discussed Clinical Records Audit (CRA) developments, but took limited assurance from the IT constraint. QSC noted the progress in the Quality Always update. SB will take a request to the Steering Group for a change in how performance is coded (currently RAG, potentially gold, silver and bronze).

360 Tracker QSC were updated regarding the allocation of accountable leads for all actions on the 360 Tracker. The Committee discussed the “double reds” in respect of completion of actions – CB asked for a mitigation plan that included new completion dates as well as the names of owners of the actions. How Personal is DCHS Care SB presented the results from a review of current processes where personalised care is currently captured. A review of the existing Root Cause Analysis (RCA), Clinical Records Audit and newly introduced Clinical Assessment and Accreditation System (CAAS) has been undertaken. The Committee considered the report very interesting and said that Quality Always provided a good platform of information. TA said SB should feedback information to frontline colleagues so they can see the benefit of review work. The Committee took assurance from the reports.


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16/15 Wheelchair Update - RM updated the Committee regarding the waiting time performance of the Wheelchair service along with the clinical risk for wheelchair waiting times and the work on service development and commissioner specification development. The Committee reviewed the current performance including the increased levels of referrals and the number of complaints relating to access and waiting times, a number of which have been escalated. There is continued pressure on the service and the service demand has shifted to include meeting more complex patient needs in a timelier manner and to meet both health and social care needs. CW said that some patient needs are very complicated. The service has established an internal service development project group. DCHS have also agreed to undertake with the commissioners a service specification review. This will be discussed with the Contract Commissioning Group. The review will be led by Gareth Harry (Chief Commissioning Officer for Hardwick CCG).

The Committee were advised that although the risk had reduced, the capacity of the service will not change until the CCG led review. TA commented that there was variation in performance between the north and the south of the county. QSC took limited assurance from the report but noted the progress to date. The Committee were informed of the constraints of the data presented in the report. TA recommended that Board discuss how to influence the availability of IT capacity to support work. 17/15 Dissemination Learning - MH considered the challenges of how we share information effectively across such a large and diverse organisation. The Committee noted the sequence involved in learning from events and making sustainable improvements across the organisation in response to that learning. QSC noted that the Learning the Lessons Group is well placed to overcome some of the barriers. KF was invited to attend one of the meetings of the group to support their governance processes. The Group will review their Terms of Reference to include dissemination activity. The paper was taken for information.

19/15 Patient Experience Patient Experience and Engagement Group (PEEG) Summary Report Highlights from the Summary Report included:

Community Nursing Complaints – PEEG has requested that a detailed breakdown be presented to the group.

Patient Experience Team performance indicators – MH is to review performance of the team

Friends and Family Test score for the month increased to 89.5. When converted to the new scoring this was 98% (recommending DCHS services) which was the highest score this year

Review of 2014 Development Plan (Patient Experience and Involvement Strategy: 2013-16) Complaints Project The Committee were updated regarding progress with improving complaints handling.


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The Complaints Project Task and Finish Group that oversees developments in relation to complaints handling in the Trust has been meeting on a monthly basis and has a new project lead in place. Following the December meeting, DCHS received feedback and an action plan from the Patients Association following Review Panels held with North Derbyshire CCG and Chesterfield Royal Hospital. The report is encouraging, highlighting our strengths and how we can be even better. The report states: “It is exceptional that Derbyshire Community Services NHS Trust demonstrated satisfactory practice or above for all six complaints”. A further Review Panel is planned for February to increase the number of cases reviewed. The Committee took assurance from the report. 20/15 Healthcare for All - Compliance Update - the Committee considered the proposed “DCHS Healthcare for All Assurance Framework” and the ‘key lines of enquiry’ within and the level of assurance presented. The Committee agreed to confirm to the Board that Healthcare for All is compliant with the Monitor Risk Assessment Framework. AR and CW reflected on the recent independent checks such as by the CQC who have reported positive assurance about DCHS. However, the Committee agreed that there is more to be achieved for Healthcare for All by DCHS’s own high standards. It was acknowledged that the Equality Strategy and the Carers Strategy are key initiatives linked to the Healthcare for All work. The Committee agreed the four green RAG rated criteria and the two amber criteria and requested that :

Amber RAG rated criteria - DM and MH to provide an action plan that includes individual actions, names for those responsible for the actions and deadlines

Information available in “easy read” –. DM to test if it is in our core service leaflets

QSC will be updated regarding progress to complete actions. Work will also be reported to QSC in the Summary Reports from the Equality, Diversity and Inclusion Forum, Quality Always and PEEG

An appendix to be added with detailed distinctive characteristics for people with Learning Disabilities

The Committee took limited assurance regarding the progress of the work within the Quality Schedule 2014/15. 21/15 Legal Issues Report - MC updated the Committee of the effective arrangements in place for managing Claims and Coroner’s inquests/investigations during Quarter 3 2014. The Committee also considered details of any Court of Protection cases. The Committee reviewed the 16 clinical and 9 non-clinical claims being handled within DCHS. In addition there are 40 potential clinical claims at the disclosure of records stage or where an extension


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to the limitation period has been granted. Three new requests for information have been received from the Coroner this quarter although one has already been closed. The Committee discussed the ongoing cases. The Committee also reviewed the trends across each quarter. The Committee took assurance that these areas are being managed appropriately.

27/15 Matters Referred from Other Committees - the Committee had received two referrals from the Board:

Healthcare for All – QSC was to consider and make a recommendation to the Board regarding compliance. This was discussed in agenda item 20/15.

Antenatal Visit performance - this is scheduled to be discussed at the February QSC meeting.


32/15 Board Assurance Framework, Risk and Self-Certification Issues The meeting discussed and recorded assurance taken with respect to each appropriate paper as well as an evaluation of all risks discussed. Papers with elements of limited assurance were: 10/15 Clinical Quality Report – Pressure Ulcers 12/15 Clinical Safety Group Summary Report - Legionella management at the Community Dental Sites in Leicestershire 16/15 Wheelchair Update 20/15 Healthcare for All - Compliance Update


The Committee asked for consideration to be given to again raising the risk regarding Legionella in Leicester Dental services.


19/15 Complaints – Financial remedy QSC were asked to provide direction for the approval of the Financial Remedy paper which explained the duty to provide financial remedy to complainants and for a new process for DCHS.

The Committee agreed the principles of when to consider financial remedy, the process for agreeing to make a payment and how much will be paid and monitoring and audit arrangements. 23/15 Claims Handling Policy - the Committee approved the policy.


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28/15 Issues Arising from Meeting for Board Briefing - the Committee requested that the Board discuss how to influence the availability of IT capacity to support work that features in several reports to QSC. 29/15 Issues for Governor Briefing - Quality Visits – CW will provide feedback to the Council of Governors regarding the impact of making late cancellations.

In Attendance

Tracy Allen TA Chief Executive

Jim Austin JA Salford Royal NHS FT (observer)

Chris Bentley CB Non-Executive Director (Chair)

Sarah Banks SB Head of Quality Governance

Lisa Barrett LB Clinical Effectiveness & Audit Lead


Mary Heritage MH Associate Director of Quality and Professional Lead for Therapies

Jo Hunter JH Deputy Chief Nurse

Rick Meredith RM Acting Medical Director

David Muir DM Head of Pathway and Outcome Development

Bola Owolabi BO General Practitioner in Quality

Michelle O’Connor MO Senior Matron Clinical Quality & Professional standards

Amanda Rawlings AR Director of People and Organisational Effectiveness (POE)

Gary Roe GR Compliance Manager

Alexandra Sullivan AS Health Visitor

Carolyn White CW Chief Nurse and Director of Quality



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Quality People Committee Summary Report to Board



Name of Reporting Committee / Group: Quality People Committee

Date of Meeting: 22 December 2014

Presenter: Barbara-Anne Walker, Chair


Key Issues

Owing to an unavoidable work requirement WJ left the meeting following discussion of 195/14 to 209/14 and 215/14 and 220/14. The meeting was not quorate from 210/14. 200/14 Actions Matrix - 129/14 Response to Jimmy Savile Inquiry – QPC agreed that DCHS should be proactive regarding our response, and not wait for the NHS Employers Report. 201/14 Staff Story – Impact of the Making Every Contact Count (MECC) Training - JJ and CJ showcased the impact of training our staff in Making Every Contact Counts (MECC) by:

Presenting a patient story showing how MECC is embedded in practice resulting in a positive outcome for a client.

Presenting a summary of the work of our Workplace Health Champions who are key to implementing Making Every Staff Contact Count

The programme has trained 3,405 staff and there are 80 workplace health champions in place. The Committee heard about one champion, Hazel Lea, and the positive impact she has had in her workplace to support staff to lose weight and do more exercise. CB said healthy staff project a positive image to patients. JG talked about the work to improve the Health and Wellbeing offer to staff - a strategy will be presented to QPC in 2015. The DCHS website and The Voice will used as communication channels to influence our staff. Our Making Every Staff Contact Count programme was recently shortlisted for a Nursing Times Award in the category of ‘Excellence in Staff Health and Wellbeing’. The Committee took assurance from the success of the MECC programme and the impact it has on patients and staff alike. QPC supported the continuation of the MECC training programme so that all staff are trained to ‘make every contact count’ with patients, clients, carers, families, friends and colleagues. 203/14 Board Assurance Framework (BAF) Quarterly Review - The BAF was presented one month early to allow QPC to review it prior to being discussed at the January Audit Committee. The Committee considered the level of risk assigned to each of the 8 strategic risks and considered if there were any further gaps in assurance or control.

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During the quarter KF met with Simon Gascoigne of 360 Assurance to see how the BAF may be enhanced. Ideas will be discussed by the Executives in January. WJ asked the Committee to consider whether there should be a new risk for where a member of staff might by their own actions cause disruption and risk the reputation of DCHS. KF will respond to WJ. The Committee took assurance from the report. 204/14 Strategic Workforce Report - JG updated the Committee regarding:

Industrial Action – further action is planned for January 29 (12 hour walkout), January 30 to February 24 (work to rule) and 25 February (24 hour walkout). Planning is underway to manage services through this period.

Pension Changes – sessions to support staff affected by the Pension Choice 2 changes have been very successful.

National Staff Survey and Friends and Family Test – the final completion rate for DCHS was 62.1% which was the best performing Community Health Service trust in the country. The Committee was very pleased with the result and considered what could be done to support our part time staff when they have little time available to complete the survey. Detailed results of the survey will be available in the New Year.

DCHS Flu Campaign – 1,930 staff and 45% of frontline staff have received their jab (compared to 36% in 2013). Work continues to maintain the momentum

DCHS Extra Mile Awards – 300 nominations have been received compared to 226 in 2013. An event has been organised in March and a good deal of sponsorship has been raised for the event.

The Committee took assurance from the report. 205/14 Recruitment and Attraction Strategy - the proposed strategy document stimulated good debate and was well received. The Committee requested that the document include reference to equality beyond disability. An improved paper will be presented to the February QPC. 207/14 Quality People Performance Report and Priority Areas of Focus - highlights included::

Attendance had decreased slightly but the trend has remained stable. It was noted that DCHS is performing well against national and regional benchmarking. The paper set out the work undertaken by the Attendance Management Group to impact on the performance. This included the involvement of Occupational Health with absent staff. The Committee looked forward to continuing improvement

A deep dive report into overpayments was discussed. The Committee looked at the process, the reasons for them happening and the work underway to recover them. QPC will receive regular progress updates in the Performance Report

Core Essential Learning – the trend is improving. QPC discussed action undertaken to further improve the performance

Appraisal Completion remains at a level of 82%. Some appraisals have been completed but not fully uploaded to the ESR system. Letters have been sent to managers. The Committee discussed how managers should be held to account for the completion of staff appraisals

Safeguarding training – a deep dive report will be presented to the February QPC meeting. Staff may be targeted to prioritise their training


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The assurance taken by the Committee was limited by the current position over outstanding overpayments, Essential Learning and Appraisal Completions. It was noted that the limited assurance did not diminish how hard our staff are working. 208/14 People Services and Employee Relations Report - the Committee discussed the Bank and Agency spending in detail and the impact on the DCHS financial position. The Committee noted the reduction in agency spending October 2013 to October 2014. The committee were surprised by the reduction of staff currently affected by organisational change as at 30th November 2014 as they expected this to be higher given the tender work which is ongoing. JG agreed to check the detail reported in the Redeployment paragraph with respect to planned change programmes to ensure this was accurate. The Committee took assurance from the report. 209/14 Staffing for Quality Report - KS reported that NHS England ranked DCHS 2nd out of 72 organisations for fill rate of Registered Nurse for day shifts and 66th for Registered Nurses on night shift. This was an improving rate. The Committee were updated regarding improvement in staffing night shifts in particular locations such as St Oswald’s. Work to include Community Nursing is underway. It is expected that Community Nursing will be included in 18 months. The Committee also discussed the amount of time required of front line staff to complete documentation because this reduces the amount of time with their patients. The importance of systems, software and clerical staff was noted. The Committee took assurance from the data. 210/14 Staff Partnership Committee (SPC) Summary Report - highlights from the November and December meetings included:

Support was given for the Recruitment and Attraction Policy

The Long Service Awards Policy will be brought forward

Assurance was taken by SPC regarding the People Performance Report and the People Services and Employee Relations Report

A Credit Union scheme will be launched in February 2015

Quality Always – work is undertaken to find an appropriate grading system The Committee noted the work SPC have undertaken. 211/14 Staff Health Wellbeing & Safety Group Summary Report - the Committee reviewed the Summary Report and noted the work undertaken. 212/14 Equality, Diversity and Inclusion Leadership Forum (EDILF) Summary Report

The Committee noted that EDILF took limited assurance from the outstanding red RAG rated actions in the 2014/15 Equalities Action Plan

Assurance was taken that DCHS is in a strong position to implement the requirements of the EDS2

Healthcare for All - the assurance process for HC4A is changing now that DCHS had become a Foundation Trust. Further information will be provided to the Forum in due course.

British Sign Language Charter – DCHS signed the British Deaf Association’s (BDA’s) BSL


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(British Sign Language) Charter in December. 360 Assurance Audit Report – QPC noted the work being undertaken to progress the equalities agenda within the organisation and DCHS is fulfilling its legal duties under equalities legislation and the requirements of EDS2. There are some outstanding actions to be undertaken. There followed a broader discussion of 360 Assurance reports and actions. CB told the Committee that QSC had found “double red” actions in a 360 Assurance review Actions of Clinical Quality and Effectiveness DCHS 14-15 where the actions had become out of time. JG asked that any “People” related actions be referred to her for action. The Committee noted the Workforce Equality Data and Analysis Report. A deeper dive report will be provided to the February QPC meeting. 213/14 Workforce Planning and Development (WFPD) Subgroup Summary Report - the Committee discussed the areas of the report where the group had taken little or no assurance:

Appraisals - there are areas in in Health Wellbeing and Inclusion (HWBI) where managers, due to management of change, have not pursued their staff to have their appraisal. QPC discussed whether these staff groups in HWBI should be excluded from the compliance report and the baseline adjusted accordingly. It was agreed that the targets should not be amended and instead commentary should be provided in a text box in association with the performances

Fundamentals in Care for Bank Staff – the Committee were informed that the cost of paying bank staff to become accredited was being looked at. QPC will be updated in February.

The Committee received the information provided by the report. 214/14 Workforce Planning 360 Audit - QPC were updated on the actions implemented following the audit by 360 Assurance and the outstanding areas where action is ongoing. Significant progress has been made. Two actions are outstanding and these are being worked on. The Committee received the information provided by the update. 216/14 Recent Employment Tribunal: Lessons Learnt - the Committee discussed the learning points following a recent Employment Tribunal which considered a claim by an ex-employee for unfair dismissal. A new Disciplinary Policy will be drafted for agreement as a result of some of these learning points. This will come through the normal Policy route so QPC will receive it. It was discussed that the Executive Team raised concerns over the line management time given to staff who only work nights. It was agreed that QPC would like to receive a further report from Jo Furley in February regarding manager interaction with night only staff, to include how interaction is planned, maintained, and how night only staff ensure they are up to date with current practice. The Committee noted the lessons learnt. 217/14 Annual Review of all QPC Sub-Committees including Terms of Reference - the Committee received presentations on performance, including the main achievements, of Equality, Diversity and Inclusion Leadership Forum, Staff Partnership Committee, Workforce Planning and Development and Staff Health Wellbeing and Safety Groups over the past year. The Committee noted the annual review of each QPC subgroup. QPC asked that KF review the Terms of Reference and confirm to BAW whether she supports them.


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218/14 Health and Safety Update - JG provided further information relating to the Staff Health and Safety Annual Report regarding the reduction in injuries taking into account the loss of the Leicestershire services. The total number of work related injuries was not thought to be significant this year. The Committee received the paper for information and asked that a paper be provided to the February QPC with up to date figures because it was not sure whether the data in the current paper was correct. The Health and Safety risk has been reviewed to ensure it is appropriately worded. 227/14 Committee Meeting Self-assessment - the Committee agreed that there had been a number of important topics discussed. The quoracy of the meeting had been affected by an unusual number of apologies owing to illness and other commitments.


228/14 Board Assurance Framework, Risk and Self Certification issues – QPC took limited assurance from: 207/14 Quality People Performance Report and Priority Areas of Focus


No new risks were identified.


215/14 Update Report on Clinical Essential Training, to include Safeguarding Training Update - CWi updated QPC regarding the progress of:

Current training review

Safeguarding Training compliance for DCHS and

An associated action plan for the provision of Safeguarding training. Following a workshop in January, the Committee will be updated on progress in February. The Committee took assurance from the paper and supported the re- classification of Statutory and Mandatory training. 220/14 Addendum to Family Leave Policy to include shared statutory parental leave - QPC approved the addendum and took assurance that policy development and creation is occurring across DCHS for HR related polices.


None.

In Attendance

Barbara-Anne Walker BAW (Chair)

Chris Bentley CB Non-Executive Director

Lynn Booth LB Head of Staff Partnership

Jennifer Guiver JG Deputy Director of People and Organisational Effectiveness



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Christine Wint CWi Head of Workforce Development and Education

Sally Edwards SE Head of Equality, Diversity and Inclusion

Catherine Johnson CJ Workforce Health and Wellbeing Co-ordinator

Jennifer Jones JJ Integrated Community Team Leader

Karen Scott KS Lead for Workforce Planning



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Charitable Funds Committee Summary Report



Name of Reporting Committee:

Charitable Funds Committee

Date of Meeting: 11 December 2014

Presenter: Tony Okotie: Non-Executive Director

Author: Cath Benfield: Head of Finance David Russell: Patients’ Monies and Charitable Funds Manager

Key Issues

The Charitable Funds Committee held a specially convened telephone conference on 11 December 2014 to specifically discuss the following two issues:- Finance and Governance Matters Annual Report and Accounts 2013/14 The Committee were informed that the Annual Report and Accounts had been examined by KPMG LLP. After discussion the Committee resolved to recommend the Annual Report and Accounts to the Trustee for formal adoption prior to lodgment with the Charity Commission. Rhoslan, Lime Avenue, Ripley – Business Case The Committee discussed the draft letter to the Charity Commission received as amended by the solicitors, Browne Jacobson LLP, in respect of the disposal of the above property. After discussion it was agreed that the subject should be placed on the agenda of the DCHS Planning and Capital meeting in order to ascertain some level of commitment regarding the level of financial contribution from the Trust in the event of any shortfall in proceeds from the sale of the property alone compared to its combined value to the Charity.


None


None

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The Committee approved the 2013/14 Annual Report and Accounts and agreed to recommend them to the Trust Board for formal adoption prior to submission to the Charity Commission. The Committee agreed to recommend to the Trustees that the authority for signing off the Accounts is delegated to the Chair and Director of Finance, Performance and Information, and furthermore the authority for signing the Letter of Representation is delegated to the Chair.


None

Present

Name Job Title

Tony Okotie Non-Executive Director, DCHS – Chair

Barry Steans Non Executive Director, DCHS

William Jones Director of Operations, DCHS

Cath Benfield Head of Finance, DCHS

David Russell Charitable Funds and Patient Monies Manager, DCHS

Tika Khan Deputy Chief Finance Officer, Southern Derbyshire CCG

Emma McFee Senior Financial Accountant, Southern Derbyshire CCG

Stacey Forbes Financial Controller, Derbyshire Healthcare Foundation Trust

Kirsteen Farrar Trust Secretary, DCHS

By Invitation Ian Murray Capital and Estates Programme Manager

Minutes David Russell Charitable Funds and Patient Monies Manager, DCHS

16�CFC�Summary�Report�Dec�2014

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TRUST BOARD

Document Title: Quality Report

Presenter/Title: Carolyn White, Director of Quality / Chief Nurse


The core contents of this paper are updated on a monthly basis and are a summary of Quality Group Reports

Author/Title:

Jo Hunter, Deputy Chief Nurse Michelle O’Connor, Senior Matron Clinical Quality & Professional Standards Contributions from Subject Specialists form the body of the report


Jo Hunter – 0797 067 0726 [email protected] Michelle O’Connor – 07887530317michelle.o’[email protected]


No of pages Inc. this one: 36


Information x Decision Assurance X

Purpose of Paper

The paper is presented to Directors to provide an assurance report against a range of quality indicators and work streams in place across DCHS. The report is presented using the five domains by the Care Quality Commission (CQC) as part of its revised health inspections regime. (These sections continue to represent the Trusts focus on quality i.e. patient safety, clinical effectiveness and patient experience):

1. Safe Care 2. Effective Care 3. Responsive 4. Well led 5. Caring 6. Staffing for Quality

Recommendations

The Board is asked to receive and discuss the report and agree the levels of assurance provided across the areas of the Quality agenda covered by this report.


1.1.1 - There is a risk to patients due to exposure to unsafe care resulting in harm (Risk Reg ID - 2357) 1.2.1 - There is a risk to patients due to failure to provide services that are clinically effective and

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of high quality resulting in patient harm or resulting in no benefit (Risk Reg ID – 1996) 1.2.2 - There is a risk that patients do not get optimal care due to the Priority Clinical Audit Programme for the Trust not being appropriately focused and effective at driving service improvements in priority clinical areas and the effect to delivery of good patient outcomes and organisational learning. 1.2.4 - There is a risk to the organisation due to implementation of changes to our Quality Assurance processes resulting in ineffective reporting and assurance on quality 1.3.1 - There is a risk to patients due to the failure to learn lessons from patients feedback and experiences resulting in negative effect on patient care (Risk Reg ID - 2361) 1.3.2 - There is a risk to the organisation due to patient and public non-engagement and involvement in service improvements resulting in reputational harm (Risk Reg ID - 2362)

Financial Impact

There are no direct financial implications to this report, although some Serious Incidents may result in a claim being made with increased litigation and financial sanctions for not managing patient care and other key functions appropriately

Further Information and Appendices:

Key Messages The proportion of patients with ‘No New Harms’ for December is 98.56% which is an

improvement from 97.27% in November. This is the best score since this indicator was introduced to the Safety Thermometer in December 2013

For the second time in this financial year the Community Nursing Harm Free Care (HFC) score (94.64%) is above the National District Nursing benchmark of 93.87% (Dec 2014)

There has been a decrease in the prevalence of Pressure Ulcer’s reported on December’s survey (5.5% down from 6.08% in November)

1. Safe Care 1.1 Safety Thermometer The NHS Safety Thermometer is a national tool designed to be used locally for measuring, monitoring and analysing patient harms and ‘harm free’ care. Prevalence data is collected once monthly on a set day to provide the data into the national system. The tool measure 4 aspects of care Falls, Venous Thromboembolism (VTE). Catheter Acquired Urinary Tract Infections (CAUTI) and Pressure Ulceration. Patient safety is a top priority for DCHS and the results from this toolkit continue to be used to improve practice across the organisation. The graph below illustrates DCHS’s position compared with the National District Nursing HFC benchmark and demonstrates that in December DCHS was marginally above the internal HFC target for 2014/15 - 93%. The DCHS score 93.78% in December (Nov 92.37%, Oct 93.2%, Sept 91.59%, Aug 93.25%, July 90.96%) was above this target of 93%. There has been a decrease in the prevalence of Pressure Ulcer’s reported on December’s survey (5.5% down from 6.08% in November). It should be noted that for the second time in this financial year the Community Nursing HFC score (94.64%) is above the National District Nursing benchmark of 93.87%


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Rehab Wards December HFC – 85.54% down from 90.18% in November (December breakdown-22 PUs of which 6 were new, 0 fall, 2 CAUTI, 0 new VTE) – Sample - 166 OPMH December HFC – 94.0% up from 93.75% in November (December breakdown - 1 Old PU, 1 fall, 0 CAUTI, 1 new VTE) – Sample - 50 DN Teams December HFC – 94.64% up from 92.45% in November (December breakdown-69 PUs of which 8 were new, 7 falls, 1 CAUTI, 0 new VTE) – Sample - 1436 LDS Teams December HFC – 100% remains at 100%

New Harm Rate The proportion of patients with ‘No New Harms’ for December is 98.56% which is an improvement from 97.27% in November. This is the best score since this indicator was introduced to the Safety thermometer in December 2013. 1.2 Falls The Safety Thermometer data (prevalence data) re falls with harm rate for December was 0.48% compared withNovember’s performance of 1.43%. The incident data however demonstrates an increase in reported falls in December (Incident data taken from DATIX aligned with bed occupancy data from PAS).

Consideration of the incident data held on DATIX has shown two wards as outliers:

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Melbourne ward reported 16 falls in total (including no harm) in the month, 5 repeat fallers accounted for 13 of these. Of the 9 injurious falls 8 recorded minor or no injury and there was 1 which caused significant harm (fractured Neck of Femur). This patient had 3 falls in the month and the incident is currently subject to a RCA.

Fenton ward reported 11 falls in total, with 1 patient accounting for 5 of these. Of the 4 injurious falls, 2 of these were the same patient, but all 4 were reported as causing minor harm.

The Patient Safety and Safe Care team are working with these wards to understand the factors behind the falls. The Quality Directorate are currently recruiting a falls prevention facilitator to work with ward teams when they have patients who have multiple falls to ensure that effective prevention plans are in place. 1.3 Pressure Ulcers The prevalence for this key KPI for December was 5.5% demonstrating an improvement against Novembers performance. (November was 6.08%). ‘New PU’ prevalence for December is 0.84% (November was 1.3%). The data for December demonstrates a small increase in the total number of pressure ulcers reported, and continues to demonstrate early recognition of this damage. The incidence of Grade 3 damage remains relatively static since May 2014 across all pressure ulcer incidents ranging from 31-41 incidents per month (average 35). The data for December relating to pressure damage developing or deteriorating within DCHS services demonstrates a 7% increase in the number of incidents, from 113 in November to 122 in December. The data however, supports the earlier observation that staff are recognising pressure damage earlier with 93 patients i.e. 76% of the incidents relating to Grade 2 damage. It should also be noted that activity was considerably higher in month.

Chesterfield community locality has consistently been reported as one of the outlying teams in terms of poor performance but in month data for this locality demonstrates a significant reduction

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(33%) in their incidence rate, equivalent to 9 fewer patients reported as acquiring pressure damage from this locality for December. Bolsover & North East has shown a slight increase but generally the data shows an increase in incidence throughout all localities. Amber valley was found to have increased by 41% (12 patients) and there was a 50% (5 patients) increase in High Peak as well as inpatient areas. It should also be noted that in December Amber Valley Community teams saw 341 more patients than in the previous month and High Peak teams 317 whilst other teams saw a stable number of patients. It is thought that this increase in incidence may be attributed to the bad weather spell as well as increased episodes of flu and chest infections within the general population. It is recognised that such conditions can adversely impact on the patient’s mobility, nutrition, hydration, motivation and mood, and consequently affects the skin condition. The Tissue Viability team will continue to monitor the impact of winter pressures on the incidence of pressure ulcers. The data relating to the Tissue Viability team activity continues to be monitored and demonstrates an ongoing increase in equipment authorisation evidencing that staff are actively assessing patient needs and putting in place prevention plans. The revised pressure relieving equipment guide has been ratified by Safe Care Priority Group and Clinical Safety Group and Medequip has agreed to source the new additions as requested in readiness for January/ February 2015. The trends within the inherited data outlined in Appendix 2 remain the same. Although there has been a decrease in the percentage of inherited incidents since August (51% to 41%), the actual number of incidents has remained within a constant (range 140 - 150). 1.3.2 Avoidable pressure damage The graph below provides the total number of avoidable pressure ulcers verified during December.

It should be noted that this data relates to the month the avoidability was verified and not the month the incident was reported.

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Trends from RCA investigations indicate that poor management in relation to pain control resulted in reduced mobility, low mood and motivation to follow pressure ulcer interventions. There were delays in escalation of pain management and appropriate referral to specialists The second RCA investigation involved a number of disciplines providing shared care. There was a lack of regular documented assessments and timely reviews of the patient. It was apparent from the investigation that no individual agency/ discipline took the lead in ensuring that all aspects of care were coordinated, planned and delivered as required to meet this patient’s needs. 1.3.3 Themes identified in December 2014 The main themes within the 12 RCA reports completed during December relate to:

Patients following repositioning advice. 1 patient was visiting friend and did not take the pressure relieving equipment with them, 1 related to the family who were the main care providers lack of acceptance of how unwell the patient was, 1 related to the patient declining to follow advice and 1 related to the patient being unable to tolerate laying on side due to a chest infection and difficulty with breathing when in this position.

5 incidents related to a deterioration in the patients general condition either an acute episode (urine or chest infection) or an expected deterioration in an underlying medical condition (cancer, multiple sclerosis)

There was evidence that staff did not always identify when a patient’s general condition was deteriorating so did not meet the changing needs of the patient e.g. by increasing visits

Lack of joined up working where more than one service or agency is involved is an increasing trend with the complex patients in the community setting

Lack of effective pain management affecting the patient’s ability to follow pressure ulcer prevention advice or affecting the patient’s mobility is also an increasing trend.

These issues have been addressed with the services involved with the relevant patient care and will continue to be monitored via the Safe Care Priority Group. The summaries of these RCA reports are shared at this group to enable lessons to be learnt across the organisation. 1.4 Catheter Acquired Infections (CAUTI) The CAUTI rate has improved in December to 0.18% from 0.37% in November.

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Safety Thermometer Overall DCHS

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It remains positive that from the Safety Express and Datix data collection that CAUTI rates are low overall and within agreed parameters. The numbers of patients with a catheter is also remaining stable. Analysis of the incident data on DATIX shows slightly increased levels of CAUTI were reported in December with 4 from the North and 2 were from the South of the County. The level of reporting on DATIX has increased following work by the continence team across ICBS. All incident reports for CAUTI were verified as unavoidable as all correct measures were in place. Constructive feedback is provided from the Continence Service for every incident reviewed to ensure that best practice is promoted.

In order to help to reduce CAUTI and improve catheter care and communication the Continence Team have devised a ‘catheter passport’ which is distributed to patients with an indwelling catheter. The catheter passports provide lots of useful advice and information for patients and their relatives / carers and they also help with communication from one area of care to another. 1.5 Venous Thromboembolism (VTE) The New VTE rate has deteriorated in December to 0.06% from 0% in November. There was a single VTE reported on Spencer ward, the symptoms were quickly identified and the patient received appropriate medical treatment. This incident was not reported on DATIX, an omission which has now been rectified and an RCA has commenced. The incident has been reported late onto STEIS due to the initial failure to report onto DATIX. The Matron has ensured that the ward team are reminded of the need to report VTE onto DATIX as well as the Safety Thermometer so that an RCA can be undertaken to understand the factors behind the development. 1.6 Infection Prevention & Control Clostridium difficile infections A review has been undertaken during January 2015 of the data to ensure that it reflects the national reporting requirements. All Clostridium difficile positive stool sample results are reported on the National HCAI Database. To date there have been 12 positive results reported for DCHS. Provider Organisations are then expected to complete a Root Cause Analysis (RCA) to identify any lapses in care. The criteria for lapses in care have been agreed with the lead commissioners and the provider organisation and include the following:

1. Evidence of cross infection 2. Antibiotic prescribing pre C difficile diagnosis not in line with formulary 3. Delay in isolation of patient and relevant actions not taken 4. No evidence of increased cleaning 5. Lack of appropriate and prompt referral of patient to IP&C team 6. Delay in prescribing C difficile treatment


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7. Lack of medication review 8. Patient reviews not in line with policy

Completed RCAs are sent to the CCG quality team who independently assess lapses in care. Clostridium difficile is one of the key performance indicators used by Monitor to assess performance, however, only cases which are deemed as lapses in care are required to be reported. To date, only one of the 12 positive Clostridium difficle cases has been assessed as a lapse in care. The table below provides a breakdown of the Clostridium difficile positive cases taking into account the above. The table also identifies whether the diagnosis occurred within 72 hours of the patient being admitted to DCHS services. If a positive Clostridium difficile result is obtained within 72 hours of the patient’s admission to DCHS care, it is unlikely that the cause of the infection is the result of the care provided by DCHS. This would be confirmed/challenged within the RCA process.

Month National HACI Database

Pre-72 hour diagnosis

Post-72 hour diagnosis

Lapses in Care agreed with Commissioners

April 2014 2 1 1 0

May 2014 1 0 1 0

June 2014 3 3 0 1 (*2 RCAs in progress)

July 2014 2 0 2 (relapse) (*1 RCA in progress)

August 2014 0 0 0 0

September 2014

1 1 0 0

October 2014 0 0 0 0

November 2014

0 0 0 0

December 2014

3 1 2 (*3 RCAs in progress)

January 2015

February 2015

March 2015

Total 12 6 6 1 (*6 RCAs in progress)

*N.B RCAs in progress and awaiting validation by IP&C Committee and lead commissioner.

During the review of the data, it has become evident that DCHS requires access to the National HCAI Database to validate the Clostridium difficile samples attributed to DCHS. Currently DCHS relies on each of the CCGs to provide the data. The IP&C Matron will be approaching Public Health England to identify whether DCHS is able to have administration rights to view the database. If this is not forthcoming the issue will be appropriately escalated. Lapse in Care Future Dashboard reports will include a summary of the RCAs where a lapse in care has been identified. The chief Nurse will review all RCAs were a positive specimen has been identified post 72 hours of admission. MRSA Screening The MRSA screening score for December was 100%


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1.7 Medication Safety The new system for the authorisation and sign-off of Patient Group Directions (PGDs) is now well established with the admin support to the PGD steering group having a face-to face meeting with the Medical Director, Chief Nurse and Head of Medicines Management, at which all new or reviewed PGDs that have been agreed by the PGD Steering group are discussed. As a result of these meetings, all PGDs are now up to date on SharePoint and the process is running about 3 months in advance of forthcoming PGD expiry dates. An amended version of the ‘5 Rights of Medicines Administration’ has been devised specifically for the administration of insulin injections. This has now been agreed by the Clinical Safety group and will be distributed to all appropriate clinical staff. A medication incident report that was submitted onto Datix in November with a clinical rating of having caused ‘significant harm’ to the patient was reviewed thoroughly. As a result of this, the clinical significance was downgraded to having caused ‘minor injury’ to the patient, due to the patient’s pre-existing medical condition. 1.8 STEIS reportable incidents There was 1 STEIS reportable incident reported in December which falls outside the Harm Free Care Agenda (Falls, Pressure ulcers, VTE, CAUTI and for the purpose of this report Medication incidents). This is classed as a missed diagnosis but refers to data collection issues identified within the Chlamydia Screening Outreach Programme.

2.0 Clinically Effective 2.1 Priority Audit Programme- status report Planning continues to meet the commitments for the National audits. Frail Elderly – Outline plan for a care planning outcomes audit has been agreed, awaiting confirmation of the commencement of phase 2 of the pilot site before this can be finalised. Diabetes and Pressure Ulcer Management – Further discussions with the Specialist Nurses are planned to develop audit plans for 2015/16. Identification of LD Patients now has a detailed plan and is due to collect data in quarter 4. Medicines Management Treatment Cards, Medicines Management Omitted Doses – Planned reports for Q2 have not been received. Agreement with Malcolm Stuart that the reports will be completed for the CEG meeting in February. The Antipsychotic Audit Data collection to begin in January. The Sentinel Stroke National Audit is now recruiting community services. Teams will need to be informed to assist their participation in the study. The National Diabetes Foot Care Audit is still being scoped, and some locality podiatry services have already registered for this audit. In the final stages of planning. The NCEPOD Sepsis Audit – Planning in place. Not yet clear when national results will be available.


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National COPD Audit . DCHS is registered for participation, commences in 01/15. The number of services in DCHS due to participate is under review and will be finalised shortly. The National Parkinson’s Audit will be taking registrations in 01/15 but not commencing till the next financial year. Liaison with the relevant DCHS clinical specialists to participate is underway, and this year the audit will include a patient experience measure. National PROMs – Q1 results have been shared with teams. Results are being analysed and action plans developed. The National Audit of Intermediate Care - The national and local results are now available. Results to be analysed and action plan developed. Outcomes: Mental Capacity Audits (Records, DoLs, Carers and AMCAT) – Action plan and re-audit planned for the clinical record audit following completion of the baseline audit in OPMH and LD wards and residential services, and now needs rollout plan to further services. IP&C Antimicrobial – The Q2 report showed an improvement on past results. IP&C Hand Hygiene – The Q2 result is 99.2% against target of 100%, (the same as the Q1 result). A significant number of teams are not submitting returns and there is a plan for improving this, including addressing the turnover of Hand-washing Champions. IP&C Isolation – The Q2 result of 87% compliance with 2 hour target for isolation of patients with suspected infectious diarrhoea is an improvement over Q1. Clinical Records - Q2 sustains the Q1 improvement by a further 2% in overall scores to 76%. The rollout of electronic records is thought to have contributed to this sustained improvement.

3.0 Responsive 3.1 Friends and Family Test result The graph below gives a breakdown of the current FFT score by Division together with the new percentage of respondents that would recommend our services to friends and family (which is the new way of reporting data from 1 January 2015 and is identified by the black line). Both the overall Trust score (91) and the percentage recommending (97.7) are the highest this year percentage recommending (97.7) are the highest this year.


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3.2 Complaints

Complaints Level

1 Level

2 Level

3 Level

4

Enquiries & Other Activity

Total Activity

% of all concerns resolved at Level 1

Apr-14 26 3 2 0 31 62 84

May-14 13 5 3 0 21 42 62

Jun-14 28 9 6 0 24 67 65

Jul-14 10 6 3 0 31 50 53

Aug-14 10 5 4 0 25 44 53

Sep-14 16 10 4 0 18 48 53

Oct-14 14 8 3 0 27 52 56

Nov-14 14 9 8 0 14 45 45

Dec-14 16 5 2 0 27 50 70

TOTAL 2014/15 147 60 35 0 218 460 61

Level 1 Green resolved complaints that have been resolved by the end of the next working day

Level 2 Yellow low level complaints that are investigated under the NHS Complaints process

Level 3 Amber medium level complaints that are investigated under the NHS Complaints process

Level 4 Red high level complaints that are investigated under the NHS Complaints process


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Complaints in December decreased to 23 from 31 in November. Of these, 16 were quickly and informally resolved as level 1’s and 7 will be investigated fully through our complaints process. 70% of complaints were resolved by the end of the next working day (ie at Level 1) which is a significant improvement.

4.0 Well led

4.1 Board Quality Visits QSC discussed the Quality Visits and concerns raised by the Non-Executive Directors regarding the process. It was agreed that further discussion regarding the process is required and will be addressed at a future NED meeting. There were 14 Quality visits planned for the period 17th November 2014 to 17th December 2014 inclusively; out of the 14 visits that were planned 10 were completed and 4 were cancelled.

Learning from visits included the impact on ambulance waiting times for patients within MIU.

Need for MPVA training for relief staff before working within high risk areas such as OPMH

Improvements in personalised care planning

Effectiveness of team work and support in high stress environments

The value patients and carers place on DCHS services

Need to continue to reiterate the importance and options for clinical supervision

5.0 Caring

5.1 6C’s and Care Makers The Chief Nurse England is reviewing progress against the ambitions identified within her strategy document. Work is ongoing nationally to evaluate progress to date and a team has been established to reenergise the work nationally. DCHS has a number of care makers who are working with Charlotte Miller from the FLCC a key component of this work is DCHS’s adoption of #Hello My Name Is…. As part of its CQuIN objectives for 2015/16 DCHS will be asked to address a target related to patient and compassion. Patient experience and engagement team are considering how this can be managed. 5.2 Patient Feedback (see Appendix 1 for detailed results) Under new guidance from NHS England we are changing the way we report on Friends and Family Test from the ‘net promoter’ score to a percentage recommending our services. Both are provided in this month’s report. The format of the FFT cards has changed and will include demographic monitoring questions as well as an option for respondents to select and not have their comments made public. The new cards will be distributed during January and will replace the current format with immediate effect. An article for Our Voice to raise awareness of these changes is in preparation. We are now required to ensure that the FFT includes everyone using our services. An alternative version of the FFT card is being piloted for children aged 3-11 during January. We will also develop an alternative version of the test for children and adults with learning difficulties. DCHS staff should not help patients to complete the test, and this may be a way that volunteers can support patient experience data collection in future. This will be piloted within the Home from Hospital volunteer project initially. We are still actively working towards a trial of the use of iPads in various services as an alternative to the ‘comment cards’.


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We are piloting new ways to collect patient feedback. In Quarter 3 the electronic kiosk in MIU at Ilkeston provided 42 returns on the FFT. Further work is planned to understand how we can increase the number of patients choosing to provide feedback this way.

Patient opinion/ NHS choices – patient feedback provided online

There has been a small increase in feedback online so far this year, and we need to consider how

we can ensure best value from our subscription to Patient Opinion. A meeting in January with

Patient Opinion will identify what steps we can take to increase this route for patient feedback.

We would anticipate that this will be an increasingly popular option for patients and their families

in the future. Other social media (eg Twitter) are also used to provide feedback, but still in very

small numbers.

6.0 Staffing for Quality Staffing Levels by Ward December 2014

This graph by Hospital site and ward area demonstrates the percentage of actual staff on duty against that which was the planned staffing level; we have two shifts, one which covers the day

Sept Oct Nov Dec

Kiosk 54 21 17 4

FFT Cards 82 75 52 51

54

21 17

4

82 75

52 51

0

10

20

30

40

50

60

70

80

90

FFT Cards V Kiosk at Ilkeston Hospital MIU (Sept to Dec 14)


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and one which covers the night time. The planned level of staff is based upon how many beds we have on each wards. Sometimes the number of staff who are actually working will change as this is reviewed by the Matron and Ward Manager depending on the care needs of patients. This is advised by registered nursing workforce (blue bar) and non- registered nursing workforce (red bar) and also by total number of all staff (green bar.) To note that this includes all registered staff and all non-registered staff including those obtained through Bank or Agency routes. Every ward has a Ward Manager who usually works Monday to Friday 9-5pm with global management responsibilities and on occasion they provide clinical care so may be included in the actual staffing numbers.


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Ash Green

Hillside Ward

Hillside

Early Late Night

RN 2 2 1

HCA 4 3 2

111%

100%

94%

68%

61%

100%

70% 70%

98%

0%

20%

40%

60%

80%

100%

120%

Early Late Night

Hillside Ward - 1st to 31st December 2014 % staffing against agreed staffing levels

Registered Staff % Non-registered % Overall %

8

5

0

2

4

6

8

10

Hillside

Hillside Bed Occupancy December 2014 - 63%

Available Beds

Average OccupiedBeds


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Valley View Ward

Valley View

Early Late Night

RN 1 1 0

HCA 3 3 2

100% 100%

1100%

61% 54% 89% 71% 65%

105%

Early Late Night

Valley View Ward - 1st to 31st December 2014 % staffing against agreed staffing levels


5

3

0

1

2

3

4

5

6

Valley View

Valley View Bed Occupancy November 2014 - 60%

Available Beds



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Ash Green Hospital –Combined staffing

Ash Green

Early Late Night

RN 3 3 1

HCA 7 6 4

108%

100%

129%

66% 59%

94%

76% 69%

101%

Early Late Night

Ash Green Site LD - 1st to 31st December 2014 % staffing against agreed staffing levels

Registered Staff % Non-registered % Non-registered %

13

10

0

5

10

15

Ash Green

Ash Green Bed Occupancy December - 69%

Available Beds



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Babington Hospital

Baron

Early Late Night

RN 2 2 2

HCA 3 2 2

Budgetted

Early Late Night

RN 3 2 2

HCA 3 3 2

119%

102% 100%

110%

124%

100%

114% 113%

100%

0%

20%

40%

60%

80%

100%

120%

140%

Early Late Night

Baron Ward - 1st to 31st December 2014 % staffing against agreed staffing levels*


20

14

0

10

20

30

Baron

Baron Bed Occupancy December 2014 - 70%

*BI stating 15 beds

Available Beds

AverageOccupied Beds


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Bolsover Hospital

Linden Ward

Linden

Early Late Night

RN 2 2 2

HCA 3 2 1

100% 103%

97% 100%

97% 97% 100% 100%

97%

0%

20%

40%

60%

80%

100%

120%

Early Late Night

Linden Ward - 1st to 31st December 2014 % staffing against agreed staffing levels


16 14

0

5

10

15

20

Linden

Linden Bed Occupancy December 2014 - 88%

Available Beds



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Rowan Ward

Rowan

Early Late Night

RN 2 2 2

HCA 3 2 1

95% 95% 97% 100% 100% 100% 98% 98% 98%

0%

20%

40%

60%

80%

100%

120%

Early Late Night

Rowan Ward - 1st to 31st December 2014 % staffing against agreed staffing levels


16 14

0

5

10

15

20

Rowan

Rowan Bed Occupancy December 2014 - 88%

Available Beds



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Cavendish Hospital

Fenton Ward

Fenton

Early Late Night

RN 2 2 2

HCA 3 2 1

102% 102% 97% 99%

102% 106%

100% 102% 100%

0%

20%

40%

60%

80%

100%

120%

Early Late Night

Fenton Ward - 1st to 31st December 2014 % staffing against agreed staffing levels


18

15

0

5

10

15

20

Fenton

Fenton Bed Occupancy December 2014 - 83%

Available Beds



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Spencer Ward;

Registered Nurse level is at one night staff rather than the planned two (this remains within safe staffing guidance of 1 RN to 11 patients on nights due to reduced bed occupancy)

Spencer

Early Late Night

RN 2 2 1

HCA 2 2 2

Budgetted RN Early Late Night

HCA 2 2 2

2 2 1

100% 102%

116%

108% 105%

89%

104% 103% 98%

0%

20%

40%

60%

80%

100%

120%

140%

Early Late Night

Spencer Ward - 1st to 31st December 2014 % staffing against agreed staffing levels*


12 9

0

5

10

15

Spencer

Spencer Bed Occupancy December 2014 - 75%

* BI stating 10 beds

Available Beds



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Clay Cross Hospital

Alton Ward

Alton

Early Late Night

RN 2 2 2

HCA 3 2 2

100% 100% 100%

106% 102%

98% 104%

101% 99%

0%

20%

40%

60%

80%

100%

120%

Early Late Night

Alton Ward - 1st to 31st December 2014 % staffing against agreed staffing levels

Registered % Unregistered % Overall %

17

14

0

5

10

15

20

Alton

Alton Bed Occupancy December 2014 - 82%

Available Beds

Average bednumbers for month


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Ilkeston Hospital

Heanor Ward

Heanor

Early Late Night

RN 2 2 1

HCA 3 2 2

Budgetted

Early Late Night

RN 2 2 2

HCA 3 2 1

106% 103% 103%

91%

105%

113%

97% 104%

110%

0%

20%

40%

60%

80%

100%

120%

Early Late Night

Heanor Ward - 1st to 31st December 2014 % staffing against agreed staffing levels*


16 15

0

5

10

15

20

Heanor

Heanor Bed Occupancy December 2014 - 94%

Available Beds



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Hopewell Ward

Hopewell

Early Late Night

RN 2 2 2

HCA 3 2 1

Budgetted

Early Late Night

RN 3 2 2

HCA 3 2 1

129%

110%

98% 106%

135%

103%

115% 123%

100%

0%

20%

40%

60%

80%

100%

120%

140%

160%

Early Late Night

Hopewell Ward - 1st to 31st December 2014 % staffing against agreed staffing levels*


20 18

0

5

10

15

20

25

Hopewell

Hopewell Bed Occupancy December 2014 - 90%

Available Beds



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Ilkeston Hospital; Combined staffing

Ilkeston Site

Early Late Night

RN 4 4 3

HCA 6 4 3

118%

106% 100% 99%

120%

110% 106%

113%

105%

Early Late Night

Ilkeston Site - 1st to 31st December 2014 % staffing against agreed staffing levels


36 33

0

10

20

30

40

Ilkeston Site

Ilkeston Site Bed Occupancy December 2014 - 83%

Available max

Average bednumbers formonth


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Newholme Hospital

Riverside Ward: Registered Nurse level is at one night staff rather than the planned two (this remains within safe staffing guidance of 1 RN to 11 patients on nights due to reduced bed occupancy.) There is to be review of non-registered staffing on the ward to consider conversion of existing posts into non-registered nursing workforce.

Riverside

Early Late Night

RN 2 2 1

HCA 2 2 2

Budgetted

Early Late Night

RN 3 2 2

HCA 4 4 2

100% 98% 97%

61%

85%

100%

81%

92% 99%

0%

20%

40%

60%

80%

100%

120%

Early Late Night

Riverside Ward - 1st 31st December 2014 % staffing against agreed staffing levels*


18

9

0

10

20

Riverside

Riverside Bed Occupancy …

Available Beds



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Rowsley Ward;

In December staffing levels for Registered nurses and non-registered staff have fell below that which was planned as during this time building work occurred reducing bed occupancy by 50%

Rowsley

Early Late Night

RN 2 2 2

HCA 3 2 1

94%

84% 77% 75%

90%

139%

83% 87%

98%

0%

20%

40%

60%

80%

100%

120%

140%

160%

Early Late Night

Rowsley Ward - 1st to 31st December 2014 % staffing against agreed staffing levels


18

9

0

5

10

15

20

Rowsley

Rowsley Bed Occupancy December 2014 - 50%

*BI Stating 16 beds

Available Beds



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Ripley Hospital

Butterley Ward

Butterley

Early Late Night

RN 2 2 2

HCA 3 3 2

Budgetted

Early Late Night

RN 3 2 2

HCA 2 3 2

134%

108% 102%

90% 95%

102% 108%

100% 102%

0%

20%

40%

60%

80%

100%

120%

140%

160%

Early Late Night

Butterley Ward -1st to 31st December 2014 % staffing against agreed staffing levels*


20 18

0

5

10

15

20

25

Butterley

Butterley Bed Occupancy December 2014 - 90%

Available Beds



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St Oswald’s Hospital

Okeover Ward;

In December the actual staffing levels increased to that which was planned however Registered nurse levels on night shifts remain at one rather than the planned two. Recruitment to posts has occurred with staff commencing in January.

Okeover

Early Late Night

RN 3 2 2

HCA 3 3 2

118%

135%

52%

116%

92% 98%

117% 110%

75%

0%

20%

40%

60%

80%

100%

120%

140%

160%

Early Late Night

Okeover Ward - 1st to 31st December 2014 % staffing against agreed staffing levels


24

13

0

10

20

30

Okeover

Okeover Bed Occupancy December 2014 - 54%

Available Beds



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Walton Hospital

Linacre Ward, during December RN levels on nights fell thus at times there has only been two RN across the site rather than the planned three.

Linacre

Early Late Night

RN 2 2 2

HCA 4 4 3

Budgetted

Early Late Night

RN 3 2 2

HCA 5 5 4

123%

111%

68%

102% 106%

98%

109% 108%

86%

0%

20%

40%

60%

80%

100%

120%

140%

Early Late Night

Linacre Ward - 1st to 31st December 2014 % staffing against agreed staffing levels*


24 15

0

20

40

Linacre

Linacre Bed Occupancy December 2014 - 63%

* BI stating 16 beds

Available Beds



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Melbourne Ward

Melbourne

Early Late Night

RN 2 2 1

HCA 4 4 3

Budgetted

Early Late Night

RN 3 3 2

HCA 5 5 4

113% 106%

113% 108%

116%

133%

110% 113%

128%

0%

20%

40%

60%

80%

100%

120%

140%

Early Late Night

Melbourne Ward - 1st to 31st December 2014 % staffing against agreed staffing levels*


24

15

0

10

20

30

Melbourne

Melbourne Bed Occupancy December 2014 - 63%

*BI stating 16 beds

Available beds



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Walton Hospital: Combined Staffing

Walton Site

Early Late Night

RN 4 4 3

HCA 8 8 6

118%

109%

83%

105% 111%

116% 109% 110%

105%

Early Late Night

Walton Site - 1st to 31st December 2014 % staffing against agreed staffing levels


48

30

0

10

20

30

40

50

60

Walton Site

Walton Site Bed Occupancy December 2014 - 63%

Available max

Average bednumbers formonth


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Whitworth Hospital

Oker Ward

Oker

Early Late Night

RN 3 2 2

HCA 3 3 2

98%

106% 105%

97% 99% 100% 97%

102% 102%

0%

20%

40%

60%

80%

100%

120%

Early Late Night

Oker Ward - 1st to 31st December 2014 % staffing against agreed staffing levels


22 21

0

5

10

15

20

25

Oker

Oker Bed Occupancy December 2014 - 95%

Available Beds



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Appendix 1 Friends and Family Results December 2014

North South Community MIU

Trajected

ReturnsN/A 1236 815 510 x 2739

Returns 66 61 256 339 1071 753 x 2546

F&F

Score77 92 95 89 75 90 x 84

Trajected

ReturnsN/A 1368 1071 510 x 3127

Returns 72 71 212 411 500 543 x 1809

F&F

Score96 87 96 90 86 91 x 90

Trajected

ReturnsN/A 1330 550 510 x 2568

Returns 113 70 157 428 697 710 x 2175

F&F

Score94.7 91.4 94.9 93.0 82.4 91.5 x 89

Trajected

ReturnsN/A 1576 550 510 x 2814

Returns 90 50 201 585 746 619 x 2291

F&F

Score91.5 96.0 90.0 90.9 79.9 96.6 x 89

Trajected

ReturnsN/A 1406 550 510 x 2644

Returns 69 46 212 541 701 602 x 2171

F&F

Score91.3 91.3 93.3 93.1 76.0 89.4 x 87

Trajected

ReturnsN/A 1261 550 510 x 2499

Returns 60 64 216 435 331 767 x 1873

F&F

Score96.7 92.2 90.3 92.9 84.9 92.2 x 91

Trajected

ReturnsN/A 1201 550 510 x 2439

Returns 86 72 250 618 654 762 x 2442

F&F

Score91.9 100.0 88.8 91.1 84.4 84.9 x 87

Trajected

ReturnsN/A 1126 550 510 x 2364

Returns 98 38 228 305 539 621 16 1845

F&F

Score89.8 94.4 85.1 95.4 81.4 94.4 87.5 89

Trajected

ReturnsN/A 1114 550 510 x 2352

Returns 59 37 197 422 368 609 5 1697

F&F

Score94.9 75.5 91.9 94.8 87.2 90.8 80.0 91

Dec

178

Nov

178

Jun

178

May

July

178

Oct

178

Aug

178

Sept

178

Friends and

Family Test

Scores 2014/15

Overall

DCHS

returns/

F&F Score

Integrated Community Based

Service - Community

NB MIU separated out from

IBS Community in October

forward

Integrated Community Based

Services (Inpatients excluding

Learning Disabilities and

Older Peoples Mental Health)

NB Services split into North &

South in September forward

Health

Wellbeing

and Inclusion

Planned

Care

Commissioned

Services

178

Apr

178


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Risk Register

Is the issue on the current Risk Register? Yes No N/A


Falls Risk - Reg 2463 Pressure Ulcers Risk - Reg 2473 Medication Risk – Reg 2577 Nice Guidance Risk - 2718


No No N/A

A number of aspects of this report feature on the risk register, these risks will be reviewed in light of any discussions and recommendations from QSC.



Training is being provided to Governors who have indicated that they are willing to join the Quality visits

Are there Equality & Diversity implications?

This report includes issues related to patients with protected characteristics



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TRUST BOARD

Document Title: Monitor Quality Governance Assurance Framework – Self-Assessment Update

Presenter/Title: Carolyn White, Chief Nurse /Director of Quality


Trust Board - September 2014

Author/Title: Carolyn White, Chief Nurse/ Director of Quality


[email protected]




Information Decision x Assurance x

Purpose of Paper

This paper is to support the review of the Trust self-assessment against the Monitor Quality Governance Assessment Framework (QGAF). It builds upon the previous assessments and papers providing assurance presented through the governance system especially the Quality Committees and Board meetings. Due to the distributed nature of its services DCHS takes its responsibilities for assuring and improving quality extremely seriously. The evidence previously submitted to its Board sub-committees and directly to the Board of Directors has been used to support the evidence required to demonstrate compliance with Monitor’s QGAF self-assessment process and the trust’s ongoing pursuance of robust quality assurance. This paper:

- reiterates previous evidence against the standards which has been reviewed and where appropriate brought up-to-date

- states the assurance against each standard provided by KPMG in their independent review in July 2014 and follows up recommended actions

- provides updated evidence of assurance taken from Board sub committees and Board reports and external assurance where possible

- identifies areas for further improvement

The Board is asked to review the assurance provided and consider the current status of our self-assessed position. This report provides a further update to the paper presented in September 2014 at this time the Trust’s self-assessed score was 2.5 and the Board are asked to consider and agree the current score based on the information shared and against any evidence of progress.

Recommendations

The Board are asked to:

18�Monitor�QGAF�Self�Assessmen

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- Consider the evidence provided and assess whether this alters the current rating against each criteria

- Consider what other evidence could be submitted as assurance - Consider what additional actions could improve the trusts QGAF status further - Consider the frequency of future assessments


4.1.1 - There is a risk to the organisation due to not having strong corporate governance systems in place resulting in Trust vision not being delivered

Financial Impact

None


Report attached



Yes Governors will seek assurance of our governance systems


Yes Provision of robust quality services requires equality and diversity to be considered at all levels


Yes Stakeholders will seek assurance that we provide quality services

Risk Register




No


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Monitor Quality Governance Framework

This diagram describes the 10 key domains within the Quality Governance Assurance Framework How to Risk Rate and Score the QGAF Self-assessment The table below provides overarching guidance as to how the assessment of each section of the QGAF is made.

Risk Rating Scoring Definition Evidence

GREEN

0.0 Meets or exceeds expectations

Many elements of good practice and there are no major omissions

AMBER/ GREEN

0.5 Partially meets expectations but confident in management’s capacity to deliver green capacity within a reasonable timeframe

Some elements of good practice, has no major omissions and robust action plans to address perceived shortfalls with proven track record of delivery

AMBER/RED 1.0 Partially meets expectations but with some concerns on capacity to deliver within a reasonable timeframe

Some elements of good practice, has no major omissions. Action plans to address perceived shortfalls are in early stage of development with limited evidence of track record of delivery

RED 4.0 Does not meet expectations

Major omissions in Quality Governance identified. Significant volume of action plans required and concerns on management capacity to deliver


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Background

Since 2013 DCHS has worked consistently to manage and reduce its QGAF score whilst

strengthening its processes for the provision of assurance to the Board of Directors

In December 2014 DCHS was successfully licensed as a foundation trust with a Moniotr

QGAF score of 3.0

The outcome of the Trusts self-assessment at this time was a rating of 2.5 which was

subsequently verified by an independent assessment undertaken by KPMG who also rated

the trust at 2.5.

A development plan to maintain progress and provide further assurance was agreed by the

Board in November 2014.

The table below provides a summary of the ratings over the last 2 years.

1A 1B 2A 2B 3A 3B 3C 4A 4B 4C total Trust self assessment Jan 2013

0.0 0.5 0.5 0.0 0.0 0.0 0.5 0.5 0.5 0.5 3.0

Deloitte rating Dec 2012

0.0 0.5 0.5 0.0 0.0 0.5 0.5 0.5 0.5 0.5 3.5

Monitor rating April 2013

0.5 1.0 0.5 0.0 0.5 0.5 0.5 0.5 0.5 0.5 5.0

Monitor rating post Board to Board

0.0 0.5 0.5 0.0 0.0 0.5 0.5 0.5 0.5 0.5 3.5

Trust self assessment Nov 13

0.0 0.5 0.0 0.0 0.0 0.5 0.0 0.5 0.5 0.5 2.5

Trust self assessment March 2014

0.0 0.5 0.0 0.0 0.0 0.5 0.0 0.5 0.5 0.5 2.5

KPMG rating June 2014

0.0 0.5 0.0 0.0 0.0 0.5 0.0 0.5 0.5 0.5 2.5

Monitor rating September 2014

0.5 0.5 0.5 0.5 3.0

Taken from Monitor letter dated 30th September (unclear which were 2 other sections lacking assurance

January 2015 assessment

1A Does quality drive the Trust’s strategy? Evidence • DCHS has a well-established framework ‘The DCHS Way’ which describes its integrated approach to quality and quality governance ensuring that quality is seen as the golden thread that links each part of the organisation. • The DCHS Way through its annual planning process identifies organisation wide quality goals, the BIG 9 which provide a focus for quality improvement across the organisation in terms of quality services, quality people and quality business. • Service and divisional quality reports provide links to overarching quality objectives through development of Little 9 quality improvement objectives relevant to their own services. • Quality objectives are required to be SMART in their approach and link to the trust’s overarching strategic objectives and local service improvement plans.


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• Performance against improvement trajectories are reported monthly to quality committees and to the Board of Directors. • Quality BIG 3 for 2014/15 have been selected related to ongoing incidents, reports and from staff and patient feedback and include:

Patient safety- medication and prescribing errors Clinical effectiveness – Diabetes management and training Patient engagement – Volunteers strategy and engagement groups

• People and Organisational Engagement strategy which supports organisational development updated 2014 • Quality goals and outcomes as detailed within the annual quality account • Monthly QSC, QPC and QBC reports to Board • Monthly quality report to Board • Patient stories to Board and other key committees and meetings on monthly basis. • QSC annual governance review ( QSC October 2014) Assurance provided by KPMG in July 2014 The Trust has an established framework, the ‘DCHS Way’ that describes its organisational culture, vision and

values. The Trust’s vision and values are well communicated and visible throughout services. Quality goals and priorities are well monitored through Board, Committees and in performance reports. The Trust has a focus on three quality improvement areas for 2014/15. These were chosen due to performance

issues or feedback from staff and patients. A well developed sub-committee structure is in place and functions well.

Specific examples since last reporting period include:

CQC inspection and final report indicating full compliance with essential quality standards

Quarterly Board assurance framework reviews and updates

Board memorandum (Board of Directors July 2014)

Quality Always launch and roll out (monthly updates to QSC and Board of Directors)

Patient/ staff stories to Board, QSC and QPC with shared learning

Health Service Journal finalist for Trust of the Year 2014

1A Rating

Agreed Actions DCHS Progress/Evidence Further work

Green 0.0

Clinical and quality strategy to be developed as one document and dovetailed with people and organisational effectiveness strategy

Key elements of strategy presented and agreed December 2014

Key elements to be included within annual Monitor plan

Complete work on strategy and ensure alignment with POE strategy

1B Is the Board sufficiently aware of potential risks to quality? Evidence • The trust has a well-developed and maintained Board Assurance Framework (BAF) which is reviewed formally on a quarterly basis and items considered for update at all Quality Committees and Board meetings • The Board and Quality Service Committee receive a risk register report monthly this details month on month movement in risks highlighted from directorates and services areas • QSC undertakes a detailed review of the whole risk register on a quarterly basis (wef Feb 14) • All significant service changes and cost improvement proposals undergo formal quality impact assessments, equality impact assessments and risk assessments. • All quality impact assessments are reviewed and signed off by the Medical Director and Chief Nurse • Quality metrics measuring impact of quality impacts are exception reported to QSC on a monthly basis. • Monthly performance report to Board which highlights quality, staff and business risks and issues within an integrated report • Audit and Assurance report presented to Board quarterly • The trust has a defined whistle blowing policy (updated October 2014 QSC) and information for staff on ‘How to raise a concern’


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• There is NED identified as Whistle blowing champion • PULSE check helps to monitor level of staff engagement on a regualar basis • Intelligence monitoring group collates information regarding potential ‘hot spots’ • Board quality and safety visits facilitate culture of openness between frontline staff and Board Assurance provided by KPMG in July 2014 There is a well-developed and well maintained Board Assurance Framework. This accurately reflects current

priorities. The Risk Register is reviewed regularly at the relevant Quality Committee and is formally reviewed/refreshed at

Quality Services Committee. From our attendance at a Board meeting and review of the agenda and minutes of Quality Services Committee

meetings there is evidence of robust discussion and challenge regarding risks to safety and quality. There is a process for undertaking Quality Impact Assessments for cost improvement schemes and this

includes monitoring of metrics during and post implementation. The Quality Impact Assessment process may benefit from Non-Executive Director presence and challenge and

this could be incorporated into a star chamber style approach. The programme of Board Quality Visits should include an element of out-of-hours and unannounced visits

.

Specific examples of reports which highlight how significant risks have been managed include:

Clinical effectiveness group monthly reports which include improvements in management of NICE guidance, 360 assurance tracking, clinical audit priority audit reporting

System resilience report October 2014 QSC& Board

Clinical Audit update AAC October 2014

Emergency preparedness resilience and response core standards self assessment Sept 2014 QBC

Tender oversight group including quality oversight monthly QBC

A NED is now included within the QIA of all cost improvement plans as recommended by KPMG

Health and safety annual report QPC October 2104

Rapid response to Chamydia screening issue (Board Dec 2104, QSC) External Assurance

360 assurance Head of Internal Audit opinion 2014 significant assurance (July2014 AAC)

Annual report counter fraud (July 2014 AAC)

1B Rating


Green /amber 0.5

Improvement in Health and Safety practice across trust

Improved health and safety practices including risk assessment and treatment plans are now being employed across the trust

Annual health and safety report

Embedding of new health and safety practices.

The programme of Board Quality Visits should include an element of out of hours and unannounced visits

Out of hours and unannounced visits are currently conducted on an ad hoc basis by senior managers

The Board to consider how they should be engaged in out of hours and unannounced visits.

2A Does the Board have the necessary leadership skills and knowledge to ensure delivery of the quality agenda? Evidence

Both NEDs and Executive directors have cross membership of the three quality committees and Audit and Assurance committee. The chief executive attends all quality committees on a quarterly rotation.

A NED chairs the MHAC

Board members attend regular Board Development Sessions

NED chairs the Quality services committee with a further NED sitting on the committee

Board quality and safety visits help to support engagement with frontline staff and promote ‘open’ culture

The skill mix of the Board membership is broad and facilitates positive challenge and broad understanding.


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The DCHS Way and the Big 9 quality objectives help to focus the organisations attention on key quality issues

Consistent reporting against an agreed set of quality metrics helps to develop understanding of the key issues influencing performance.

BAF quarterly (AAC)

Assurance provided by KPMG in July 2014 Executives and Non-Executive Directors possess a broad range of appropriate skills. Board development sessions occur and have been positively evaluated by members. Board members are able to consistently articulate the top risks and challenges the Trust faces and the

mitigating actions in place where appropriate. Robust challenge occurs at Board and sub-committees. Board membership is stable with just one interim position, the Medical Director post, and this is soon to be

advertised. Specific examples of reports/changes include:

Appraisal and revalidation report for medical staff (QPC and Board Oct 2014)

Audit code for NHS trusts (AAC Oct 2014)

Compliance with Governance arrangements (AAC Oct 2014)

Fit and proper persons test DCHS approach report ( Board of Directors November 2014)

Appointment of substantive Executive Medical Director with extensive general practice and community experience (November 2014)

Improved arrangements for NICE review and reporting established through CEG

External Assurance

Quality account review – external audit July 2014

2A Rating


Green 0.0

Develop more robust process for NICE guidance evaluation

Clinical effectiveness group has reviewed the process for evaluation of NICE guidance during July2014

Work needs to be completed to embed new process organisation wide

Identify potential for further benchmarking

Some areas for benchmarking key clinical risks eg pressure ulceration are being explored

Further opportunities for benchmarking still need to be explored

Appoint to vacant NED post

2B Does the Board promote a quality focused culture throughout the Trust? Evidence • Board quality and safety visits • NED chair of QSC (and QPC, QBC and AAC) • NED chair of MHAC • Resources committed to:

Additional nurse staffing (Staffing for Quality) Additional Physiotherapist in OPMH Improvements in estate e.g. Bolsover, Whitworth, Melton Mowbray Improving emergency care pathway

• Emergency care pathway initiatives led by Medical Director • Staffing for Quality initiatives led by Chief Nurse • Attendance and well being effectiveness review for staff led by Director of POE • Front line Care Council • Staff partnership forum • Staff leadership forum • Staff forum • Register of whistleblowing incidents • Extra mile awards • Staff newsletter • Weekly Chief Executive email • Quality Improvement and assurance framework • Development of clinical strategy Assurance provided by KPMG in July 2014


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There is high visibility of the Board throughout the Trust’s services. There is evidence of a positive culture and the values of the organisation are embedded. There are a number of quality initiatives led by the Board e.g. Staffing for Quality; road shows etc. A peer review process has recently commenced with training to support consistency of methodology. The process of Board Quality visits is being refreshed to maximise effectiveness of these opportunities. As part

of the new format the Board should ensure outcomes from the visits programme are themed and reported to the Board regularly.

Specific reports include: Introduction of Staff stories to QPC to share learning from staffs experience Francis report update (QSC Nov 20140 Clinical Supervision report (QSC Oct 2014) Development and launch of raising concerns (Board Oct 2014)

External Assurance

360 assurance report of clinical supervision Adoption of quality improvement and assurance framework

2B Rating


Green 0.0

Revision of Board quality visits

New style quality visits are now operational with Governor engagement since June.

A review of the pilot period was undertaken during September

Reporting from visits is now being included within QSC reports

Learning from pilot phase is now being built into quality visits programme

3A Are there clear roles and accountabilities in relation to quality governance? Evidence

DCHS Way, vision and values

Job descriptions of Board members and other staff

Appraisals of Board members and other staff

Job descriptions provide clear information on line management and lines of accountability

Organisational structure charts

Committee and sub group structure charts

Quality Improvement and Assurance framework (awaiting approval)

Terms of reference of committees and sub groups

Executive Director portfolio leads on quality Chief Nurse and Medical director Quality Services. POE Director Quality people and Finance Director Quality Business

Board standing agenda items include:

Patient story

Quality report Risk report QSC briefing QPC briefing QBC briefing

Assurance provided by KPMG in July 2014 Board members are aware of their accountabilities in relation to quality. There is a clear sub-committee structure and roles and responsibilities are defined in the terms of reference. Executive led performance review meetings are conducted with Divisions where they are held to account for

the performance of their services. Divisional Quality Leads are in place and these feed into local governance processes. Appraisal rates are high but the process should be audited to assess the application and effectiveness

Specific papers/changes supporting this include:

Annual Governance review (Jan 2014 Board)

MHAC annual review and terms of reference (Jan 2014 QSC)


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AAU annual review (July 2014)

QSC annual review (QSC Oct 2014)

QBC annual review (QBC Nov 2014)

Safeguarding training action plan (QPC Oct 2014)

MHAC reporting directly to Board of Directors (Dec 2014)

Staffing for quality quarterly reports to QPC and Board

Core essential training report (QPC monthly)

Health and safety reports (QPC monthly)

Whistleblowing and raising concerns policy updated (QPC Oct 2014)

3A Rating


Green 0.0

To continue to embed quality agenda and BIG 9 quality objectives organisationally

Big 9 continue to be used to focus organisation on key quality improvement areas for quality business, people and services and are monitored and reported monthly.

To agree Big 9 for 2015/16

To continue to improve Board to patient to Board reporting

Clinical dashboard has been developed in year and is starting roll out process..

Roll out of clinical dashboard and real time data to be completed

Appraisal rates are high but the process should be audited to assess the application and effectiveness

Reviews of appraisals have been undertaken.

POEM team have this as part of their planned schedule of work

Report on progress through QPC

3B Are there clearly defined well understood processes for escalating and resolving issues and managing quality performance Evidence

Risk management strategy and policy

Top x risks process

Board Assurance Framework

Serious incident policy

Rapid response process for serious incidents

Complaints policy

Quality Improvement and assurance framework

Annual clinical audit programme

Lessons learned review group Assurance provided by KPMG in July 2014 A Risk Management Strategy and Policy are in place, and Datix Web is used to administer the risk register. The Trust is a high reporter of incidents which is indicative of a good reporting culture. ‘Deep dives’ are requested by Quality Services Committee to review areas where performance is off target and

this has been helpful to understand and improve performance in areas e.g. pressure ulcers within community services.

There is a process for dissemination of lessons learnt from serious incidents throughout the Trust’s services and although this is supported by a variety of communications, the Trust is seeking to further strengthen cross-organisational learning.

The Clinical Audit programme requires strengthening to ensure it is used to target areas that are of concern to the Trust.

Specific reports/information that support this standard include:

CQC progress report monthly (QSC)

Clinical supervision policy (QSC Dec 2014)

Quarterly report on professionals reported to professional bodies

Whistleblowing policy (QPC Oct 2014)


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Health and Safety annual report (QPC Oct 2014)

Rapid response process has been employed for: • Chlamydia reporting • Learning disability service

Tissue viability priority action plan (QSC monthly)

Patient stories shared at CCG quality assurance group and health community Star Council

External Assurance

Independent review of complaints management process (CCG Dec 2104)

CQC reference to evidence of effective safety reporting embedded within wider workforce

3B rating


Green/ amber 0.5

Increase opportunities and processes for cross organisational learning from incidents

Learning lessons group has started to include the sharing of positive learning and best practice examples

Intelligence monitoring group shares findings across organisation

Patient stories,complaints and patient feedback are now fed into lessons learned group and outside organisation

Continue to develop mechanisms for shared learning

The clinical audit programme requires strengthening to ensure it is used to target areas that are of concern to the Trust.

Clinical audit plan has been refined in year

Clinical audit plan to be linked to specific organisational challenges in 2015

3C Does the Board actively engage patients staff and other key stakeholders on quality? Evidence

Quality account published on internet and available in hard copy

Trust Board papers published on internet

Board meetings held in public

Annual General Meeting

Patient stories at Board QSC and QPC on monthly basis

Governors becoming involved in quality agenda

Board quality and safety visits

Patient experience and engagement strategy

Patient experience and engagement reports to Board and QSC

Annual staff survey

Regular staff PULSE checks

Staff leadership forum

Staff forum

Front line care council

Staff partnership forum

Quality Assurance Group with commissioners

Pathway development with GPs, secondary care led by medical director

Specific reports and engagement

Patient engagement groups part of BIG 9 quality objectives

Public consultation and public engagement meetings on major change eg Heanor hospital

Rapid response review papers QSC June 2013

Patient engagement strategy

Caring Always promises Assurance provided by KPMG in July 2014 There are good examples of patient and public engagement and patient stories are presented at each Board

meeting. The Trust collects patient feedback in a variety of ways and this has resulted in areas of service improvement.


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The Board meet with staff in quality forums and use national reports such as the Francis report to enhance engagement and promote a positive culture.

Relationships with commissioners are maturing although this is seen as a key area for ongoing development. Specific reports and evidence that support this standard include:

Patient experience and engagement report monthly to QSC and Board

Equality diversity and inclusion reports monthly (QPC & QSC)

Staff partnership summary report (QPC Oct 2014)

CCG inspection of Ashgreen LD services (QSC Aug 2014)

Joint working group with Chesterfield Royal NHS FT

Joint work across hea;th community on pressure ulcer managent

Care Makers working across trust with FLCC

#Hello My Name is initiative

Nominations for extra mile awards 2014/15

CQC report onDCHS performance against essential standards

Staff survey results (QPC Jan 2015)

Volunteer project

3C rating


Green 0.0

Improved reporting and interrogation of complaints by Board or sub committee

First phase of new complaints revew process has been undertaken

DCHS received favourable response

Refine new complaints review process with CCG and embed in normal practice

Increase number of patient engagement fora

6 groups have been established to date

To ensure plan is kept on target for year end

4A Is appropriate quality information being analysed and challenged? Evidence

Monthly performance dashboard includes national and local indicators and wide selection of metrics including safety effectiveness, patient feedback

Rapid response dashboard being rolled out with key early warning indicators including patient safety and staffing

Intelligence monitoring group

Serious incident reports monthly to QSC

Patient feedback and complaints reports monthly to QSC

Patient safety thermometer reported monthly to QSC and Board

Medicines incidents monitored and reported through MOST to QSC

Monthly risk report to QSC and Board

Monitor metrics reported to Board

Key metrics linked to trust strategy as evidenced through DCHS Way Big 9 reported monthly

Quality committee summaries to Board delivered by NEDs

Dashboard is supported by kite mark assurance schemes Assurance provided by KPMG in July 2014 Highlight reports are presented from sub-committees to the Board detailing areas for escalation and actions

taken for performance in decline. The presentation and content of Board and Committee reports has evolved and continues to strengthen. The Divisions receive more granular performance reports allowing drill down to service lines for use in

Divisional meetings and performance reviews. There are further planned developments such as Business Intelligence System that will generate Quality

Dashboards and allow greater triangulation of data. Some paper based systems are still in use, and the introduction of the Business Intelligence System will assist

in the reduction of these

Specific reports providing evidence

Data quality update (AAC Oct 2014)

Quality dashboard update (QSC Nov 2014)

Monthly Performance Report to Board has been updated as a consequence of Foundation Trust approval

External Assurance


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Quality account review external audit AAC July 2014

Head of audit opinion AAC July 2014

4A rating


Green/ Amber 0.5

Roll out of rapid response reporting system organisation wide

Clinical dashboard has been developed in year and is starting roll out process.

Roll out of clinical dashboard and real time data

There are further planned developments such as Business Intelligence system that will generate quality dashboards and allow greater triangulation of data

Some paper based systems are still in use, and the introduction of the Business Intelligence System will assist in the reduction of these

4B Is the Board assured of the robustness of the quality information? Evidence

Data kite mark assurance system

Terms of reference for all governance groups

Clinical audit priority plan agreed by AAC

Increasing number of electronic systems TPP, epay, erostering, BIS, Oracle however still some issues of gaps between systems

Annual internal and external audits of selected data sets

external audit review of quality account

Informatics report (bi monthly QBC) Assurance provided by KPMG in July 2014 The Internal Audit programme includes reviews on data quality and these have received significant assurance. Data items in the Board Performance Report is subject to a data kite mark system which assesses six

elements: completeness; process; audit; sign off; granularity; and timeliness. This is being extended to other data sets.

There is an increased number of electronic systems in use throughout the Trust's services, however some areas remain on paper based systems and this has potential to weaken data quality. This is an ongoing area of development for the Trust.

Specific report providing supporting evidence

Data quality update (AAC Oct 2014)

Review of dental RRT data (Board Nov 2104)

Information Governance summary report (QSC Dec 2014)

Data quality update (AAC Jan 2104) External Assurance

Head of audit opinion AAC July 2014

360 assurance report against plan (AAC Oct 2014)

4B rating


Green/ Amber 0.5

Further roll out of kite mark assurance system

Kite mark system has been enhanced to include more data checks in year

The kite mark system will continue to be enhanced

Development of priority audit plan 2014/15

Priority audit plan has been developed to focus on areas on clinical risk and concern

Priority audit plan has been reviewed in year

2015 plan will be more closely aligned to trust priorities


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There are an increased number of electronic systems in use throughout the Trust’s services, however some areas remain on paper based systems and this has the potential to weaken data quality. This is an ongoing area of development for the trust.

Ward based nurse staffing has now migrated fully onto ESR, with further roll out into community teams. This has enabled robust reporting of Safer Staffing reports as part of new national reporting scheme

Roll out to community teams has recommenced

Continued roll out of TPP System One and migration onto electronic systems

4C Is quality information used effectively? Evidence

Monthly quality report to Board and QSC

Benchmark information is used where available

Data is presented one month in arrears

Committee timetable has been adjusted to enhance reporting through QSC to Board

All cost improvement projects and significant change management schemes undergo a quality impact and equality assessment

Quality information is shared with commissioners monthly to assure on quality standards against contract Assurance provided by KPMG in July 2014 Quality dashboards are being developed and will allow greater triangulation of data for individual service areas

and this can assist in early warnings of an area ‘in difficulty’. The Trust has some examples of where benchmarking data has been used to drive decisions to improve

quality but this could be extended and better evidenced. Mortality reporting and review is an area recognised by the Trust for further development Specific examples include:

Quality impact assessments used to stop or revise cost improvement plans exception reports to QSC

Root cause analysis are compared and monitored to identify key patient safety themes eg tissue viability focus on patient equipment and patient compliance

Falls data influenced investment in additional physiotherapists for OPMH

Staffing data is monitored monthly and has rsulted in additional investment in community nursing

4C rating Agreed Actions DCHS Progress/Evidence Further work

Green/ Amber 0.5

Mortality reporting The process for mortality reporting is currently being reviewed by the newly appointed Medical Director

To develop a framework for review and reporting of appropriate mortality data suitable for community services

The Trust has some examples of where benchmarking data has been used to drive decisions to improve quality but this could be extended and better evidenced

This area has not been progressed Identify opportunities for further benchmarking


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TRUST BOARD

Document Title: Fit and Proper Persons Requirements

Presenter/Title: Amanda Rawlings, Director People and Organisational Effectiveness


Public Board Meeting November 2014

Author/Title: Amanda Rawlings, Director of People and Organisational Effectiveness Melanie Curd, Deputy Trust Secretary

Contact Email and Telephone Number: [email protected] 01773 525065




Information X Decision Assurance X

Purpose of Paper

This paper outlines the actions that the Trust is taking to ensure that we meet the Fit and Proper Person’s Requirement (FPPR). The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 has been updated to cover important changes to health and social care standards which are regulated by the Care Quality Commission (CQC). They represent one of the main ways in which the Government is responding to the Francis Inquiry. There are 12 fundamental standards that replace the previous essential standards and apply to all health and social care service providers, with the Duty of Candour applying only to NHS providers. The other aspect is the Fit and Proper Person Requirement for all Directors or those acting in an equivalent role within any service provider. FPPR for Directors plays a major part in ensuring the accountability of Directors of NHS bodies. The Board received a briefing on the FPPR in the Chief Executive Report to Board in November 2014 and the requirements came into force on the 27 November 2014. The guidance is being updated and will be incorporated into CQC’s guidance (to be issued on 1 April 2015) on meeting all fundamental standards. Following a new Director-level appointment, the new regulations will require the Chair to:

• confirm to the CQC that the fitness of all new directors has been assessed in line with the regulations; and

• declare to the CQC in writing that they are satisfied that they are fit and proper individuals for that role.

The CQC will cross-check notifications about new Directors against other information that they hold or have access to, to decide whether we want to look further into the individual’s fitness. They will also have regard to any other information that they hold or obtain about Directors in line with current legislation on when convictions, bankruptcies or similar matters are to be considered ‘spent’. FPPR covers not only Board members, but as described in the CQC guidance “Directors” are Executive Directors (ED) and Non-Executive Directors (NED) and any other person performing

19�Fit�and�Proper�Persons.pdf

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the functions of, or equivalent or similar functions to, a Director. It applies to Executive and Non-Executive Directors, permanent, interim and associate positions, irrespective of voting rights. There are a set of key actions that Providers are required to assure they meet the requirements:

• Identify the Directors captured in the FRRP • Establish a process for assessing Directors’ FPPR compliance at recruitment • Establish a process for monitoring and record keeping • Update your standard documents (employment contracts, appointment letters) • Track the national developments

The table attached is presented to the Board to provide assurance of the processes, policies and practices that we have in place to ensure our Directors meet the requirement of the FPPR. Over the next eight weeks we will be issuing all Directors with new employment statements and introducing an annual search of Insolvency and Bankruptcy Registers and Disqualified Directors Register. In addition, a self-declaration will be issued on an annual basis and a central register held in the Chief Executive’s Department. An update paper will be presented to the Quality People Committee (QPC) once the actions are complete.

Recommendations

The Board is asked to: • Note the FPPR requirements and to take assurance that the Trust has in place the policies

and monitoring processes to provide ongoing assurance

• Note the outstanding actions and an update paper will be presented to QPC once these are complete. This will be reported to Board via the QPC Summary Report


4.1.1 There is a risk to the organisation due to not having strong corporate governance systems in place resulting in Trust vision not being delivered (Risk Reg ID - 2383) 4.2.1 There is a risk to the organisation due to not meeting regulatory, contractual or legal obligations resulting in sanctions (Risk Reg ID - 2384)

Financial Impact

Nil


Appendix 1 – Assurance Table


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Are there Governor Involvement implications? Governors will need to be assured

Are there Equality and Diversity implications? X The FPPT will be applied to all Directors who fulfil CQCs definition.

Are there Patient, Public and Stakeholder Involvement implications? X

Risk Register



Does this update recommend a change in the current risk score? (If so, please provide your rationale below) No


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Appendix 1 – Assurance Table

Standard Assurance Evidence Providers should make every effort to ensure that all available information is sought to confirm that the individual is of good character as defined in Schedule 4, Part 2 of the regulations. (Sch.4, Part 2: Whether the person has been convicted in the United Kingdom of any offence or been convicted elsewhere of any offence which, if committed in any part of the United Kingdom, would constitute an offence. Whether the person has been erased, removed or struck-off a register of professionals maintained by a regulator of health care or social work professionals.)

Employment checks are undertaken in accordance with NHS Employers pre-employment check standards and include: • Two references, one of which must be most recent

employer • qualification and professional registration checks • right to work checks • identity checks • occupational health clearance • DBS checks (where appropriate)

In addition, we also carry out: • Declarations of fitness by candidates • Search of insolvency and bankruptcy register (*) • Search of disqualified directors register (*)

References Other pre-employment checks DBS checks where appropriate Signed declarations from applicants Register search results

*This is a new activity for the Trust *This is a new activity for the Trust

If a provider discovers information that suggests an individual is not of good character after they have been appointed to a role, the provider must take appropriate and timely action to investigate and rectify the matter.

Disciplinary policy and procedure provides for such investigations. Revised contracts allow for termination in the event of non-compliance with regulations and other requirements.

Contracts of employment (for EDs and director-equivalents) Terms and conditions of service agreements (for NEDs) Disciplinary policy and procedure


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Standard Assurance Evidence Where a provider deems the individual suitable despite not meeting the characteristics outlined in Schedule 4, Part 2 of these regulations, the reasons should be recorded and information about the decision should be made available to those that need to be aware.

This would be the subject of debate at the RATS Committee (for EDs and director-equivalents) and at the council of governors (for NEDs). The minutes would record such decisions. The Chair would take advice from internal and external advisors as appropriate.

Minutes of meetings.

Where specific qualifications are deemed by the provider as necessary for a role, the provider must make this clear and should only employ those individuals that meet the required specification, including any requirements to be registered with a professional regulator.

This requirement is included within the job description for relevant posts and is checked as part of the pre-employment checks.

Person specification Recruitment policy and procedure

The provider should have appropriate processes for assessing and checking that the individual holds the required qualifications and has the competence, skills and experience required, (which may include appropriate communication and leaderships skills and a caring and compassionate nature), to undertake the role; these should be followed in all cases and relevant records kept.

Employment checks include a candidate’s qualifications and employment references. The recruitment process also includes qualitative assessment and values-based questions.

Recruitment policy and procedure Values-based questions

The provider may consider that an individual can be appointed to a role based on their qualifications, skills and experience with the expectation that they will develop specific competence to undertake the role within a specified timeframe.

Any such decision would be discussed by the RATS Committee or council of governors and would be minuted. Actions would be subject to follow-up as part of ongoing review and appraisal.

NED appraisal framework NED Job Description and Person Specification ED appraisals


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Standard Assurance Evidence When appointing relevant individuals the provider has processes for considering a person’s physical and mental health in line with the requirements of the role.

All post-holders are subject to clearance by occupational health as part of the pre-employment process.

Occupational Health clearance

Wherever possible, reasonable adjustments are made in order that an individual can carry out the role.

This is already included in the Trust’s Equality, Diversity and Inclusion Policy

Equality, Diversity and Inclusion Policy

The provider has processes in place to assure itself that the individual has not been at any time responsible for, privy to, contributed to, or facilitated, any serious misconduct or mismanagement in the carrying on of a regulated activity; this includes investigating any allegation of such potential behaviour. Where the individual is professionally qualified, it may include fitness to practise proceedings and professional disciplinary cases. (“Responsible for, contributed to or facilitated” means that there is evidence that a person has intentionally or through neglect behaved in a manner which would be considered to be or would have led to serious misconduct or mismanagement.

“Privy to” means that there is evidence that a person was aware of serious misconduct or mismanagement but did not take the appropriate action to ensure it was addressed.

“Serious misconduct or mismanagement” means behaviour that would constitute a breach of any legislation/enactment CQC deems relevant to meeting these regulations or their component parts.”)

This has been incorporated as a specific declaration as part of the pre-employment process. It is also incorporated into a revised reference request template for all director and director-equivalent posts.

NED Recruitment Information pack Pre-employment declaration Reference Request for ED/NED


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Standard Assurance Evidence The provider must not appoint any individual who has been responsible for, privy to, contributed to, or facilitated, any serious misconduct or mismanagement (whether lawful or not) in the carrying on of a regulated activity; this includes investigating any allegation of such potential behaviour. Where the individual is professionally qualified, it may include fitness to practise proceedings and professional disciplinary cases.

This has been incorporated as a specific declaration as part of the pre-employment process. It is also incorporated into a revised reference request template for all director and director-equivalent posts.

NED Recruitment Information pack Reference Request for ED/NED

Only individuals who will be acting in a role that falls within the definition of a “regulated activity” as defined by the Safeguarding Vulnerable Groups Act 2006 will be eligible for a check by the Disclosure and Barring Service (DBS). (CQC recognises that it may not always be possible for providers to access a DBS check as an individual may not be eligible.)

DBS checks are undertaken only for those posts which fall within the definition of a “regulated activity” or which are otherwise eligible for such a check to be undertaken.

DBS policy DBS checks for eligible post-holders

As part of the recruitment/appointment process, providers should establish whether the individual is on a relevant barring list.

Eligibility for DBS checks will be assessed for each vacancy arising.

DBS policy

The fitness of directors is regularly reviewed by the provider to ensure that they remain fit for the role they are in; the provider should determine how often fitness must be reviewed based on the assessed risk to business delivery and/or the service users posed by the individual and/or role.

Post-holders undertake annual declarations of fitness to continue in post. Checks of insolvency and bankruptcy register and register of disqualified directors to be undertaken each year as part of the appraisal process. (*)

Annual declaration NED appraisal process ED appraisal process


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Standard Assurance Evidence The provider has arrangements in place to respond to concerns about a person’s fitness after they are appointed to a role, identified by itself or others, and these are adhered to.

The disciplinary policy provides these arrangements, and revised contracts (for EDs and director-equivalents) and agreements (for NEDs) incorporate maintenance of fitness as a contractual requirement.

Disciplinary policies ED contracts of employment NED agreements

The provider investigates, in a timely manner, any concerns about a person’s fitness or ability to carry out their duties, and where concerns are substantiated, proportionate, timely action is taken; the provider must demonstrate due diligence in all actions.

This will be undertaken if concerns are identified and revised contracts provide for termination if individuals fail to meet necessary standards.

Revised employment contracts for ED and NEDs

Where a person’s fitness to carry out their role is being investigated, appropriate interim measures may be required to minimise any risk to service users.

This would be reviewed when concerns are identified.

Disciplinary policy.

The provider informs others as appropriate about concerns/findings relating to a person’s fitness; for example, professional regulators, CQC and other relevant bodies, and supports any related enquiries/investigations carried out by others.

This would be completed if any concerns were identified.

Referrals made to other agencies.


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TRUST BOARD Document Title: Board Assurance Framework (BAF) 2014-15 – Quarter 3

Presenter/Title: Melanie Curd – Deputy Trust Secretary


Audit and Assurance Committee (16 January 2015), QSC (16 December 2014), QPC (22 December 2014)

Author/Title: Melanie Curd – Deputy Trust Secretary

Contact Email and Telephone Number: 01773 525065




Information Decision x Assurance x

Purpose of Paper

The Board Assurance Framework (BAF) allows the Board to be assured that the principal risks to achieving the organisations’ strategic objectives are being systematically managed. The BAF demonstrates the management (internal) and independent assurances (external) that have been considered at the Board or at one the Board Sub-Committees and any gaps in control or assurance. This paper provides the Quarter 3 position following review by the Audit and Assurance Committee on the 16 January 2015.

Recommendations

The Board is asked to approve the Board Assurance Framework.


4.2.2 - There is a risk to the organisation due to not having strong risk management controls in place resulting in failure to put effective mitigation plans in place promptly

Financial Impact

There is no financial impact linked to this BAF report.


The Audit and Assurance Committee (AAC) reviews the BAF in its entirety and each of the

20�Board�Assurance�Framework�Q

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Quality committees review their section of the BAF on a quarterly basis. The AAC took positive assurance on a presentation from the Director of Finance on the management of the Quality Business risks. In addition, AAC agreed that the Mental Health risk should be moved to the Quality Governance section as the Mental Health Act Committee now reports directly into Board. There has been one QSC Risk Meeting held during the quarter. The Risk Register was reviewed in its entirety at this meeting and it was agreed there were no risks that needed escalating for inclusion on the BAF.

There are four high risks on the BAF for the Quarter 3 report:

• 1.1.3 There is a risk to patients due to the non-implementation of pressure ulcer prevention strategies within a community setting, resulting in harm

• 2.2.1 – Not attracting, recruiting and retaining the right number of high quality, effective and compassionate employees with the appropriate level of skill and experience’ (QPC)

• 3.1.3 – delivery of the IBP due to changing commissioner priorities’ (QBC) • 3.2.3 – ability to meet financial targets, specifically CIPs’ (QBC)

The two risks regarding the Foundation Trust application which were on the Quality Governance section of the BAF are no long relevant and have been removed.

The ‘Summary View’ of the BAF (Attached word documents) allows the Board to see the various component parts that help determine the level of risk and highlights any papers that have been presented during Q3 through all “Q Committees” that received ‘limited’ or ‘negative’ assurance.

The ‘BAF Detail’ (Attached – Excel documents) maps out each item of assurance that has been presented to the “Q Committees” during the last 12 months, relevant KPI performance and links to the operational risk register.

Assurance is formally recorded on the BAF using the colour scheme below: • Green – Positive Assurance • Amber – Limited Assurance with clear action to resolve • Red – Negative assurance


Are there Governor Involvement implications? X

Are there Equality and Diversity implications? X

Are there Patient, Public and Stakeholder Involvement implications? X


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Risk Register

Is the issue on the current Risk Register? N/A



All operational risks are aligned to the BAF risks. This allows an operational profile to be established. These have been updated on the BAF as of 3 December 2014.


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Derbyshire Community Health Services

Board Assurance Framework – Quarter 3 2014-15

The 2014-15 Board Assurance Framework (BAF) is split into 4 distinct sections aligned to the DCHS Way:

• Quality Service • Quality People • Quality Business • Quality Governance

The BAF will document the assurances received by the Board and the Sub-Committees of the Board specific to the management/mitigation of the strategic risks aligned to the corporate objectives.

The Chief Executive’s Department are responsible for the collation of the Board Assurance Framework. Please direct any queries to Kirsteen Farrar or Melanie Curd on 01773 525065.


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This iteration of the BAF focuses on: QUALITY SERVICE

Objective - To deliver high quality and sustainable services that echo the values and aspirations of the communities that we serve

Lead Committee is Quality Services Committee, chaired by Chris Bentley (Non-Executive Director)

Lead Director is Carolyn White (Director of Quality/Chief Nurse)

Lead Executive Director Summary of Quality Service BAF Risks Quality improvement continues to be a significant focus across the organisation. A great deal of effort has been put into implementing the CQC action plan by both the operational and quality teams who are ensuring that changes are embedded and sustained. In quarter, there has been a CQC assessment triangulation event which evidenced some gaps in control and a significant amount of improvement across services. Quality Always clinical assessments on inpatient wards are now rolling out and highlighting areas for improvement. This initiative has been welcomed by clinical staff. Teams continue to work for DCC Dignity Awards and it is pleasing to see teams achieving silver awards. The Trust is awaiting confirmation of the CQC unannounced visit held during this quarter. Positive feedback was given at the informal verbal feedback session.


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1.1 - Safety BAF ID Risk Description Operational

risk profile Current

Risk Score Previous Quarters

Lead KPI (as agreed by Executive and Non-Executive Leads)

Month 8 Month 7

1.1.1 There is a risk to patients due to exposure to unsafe care resulting in harm (Risk Reg ID – 2357)

High – 1 Medium – 15

Low - 3

L2 x C 5 = 10

(medium)

14/15 Q2 - 10 14/15 Q1 - 10 13/14 Q4 – 10 13/14 Q3 – 10

Harm Free Care Score % 93.2% 91.59 Avoidable PUs (no.) Hospital care 1 1

Avoidable PUs (no) Community care 4 2

Medicines incidents resulting in serious harm 0 0

Falls (Major Harm/Death) 4 3 All papers presented for Assurance in Quarter 3 were received positively with the exception of: Safeguarding Governance Summary Report Clinical Quality Report CQC Action Plan Update Colposcopy Services at Buxton and Ilkeston

Identified Gaps in Control (c) /Assurance (a): Group not providing adequate assurance to parent committee (a) Pressure ulcer performance (a) Inconsistent compliance to actions across the Trust (a) Review identified actions to improve governance (a)

Action planned to address (and timescales): New Chair – review of group and terms of reference Improvement plan in place Meeting to be held with senior clinical staff Action plan in place - further paper to November QSC


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BAF ID Risk Description Operational

risk profile

Current Risk

Score

Previous Quarters


Month 8

1.1.2 There is a risk to patients due to non-implementation of pressure ulcer prevention strategies within an inpatient setting, resulting in patient harm


Low - 0

C4 x L2 = 8

(medium)

Harm Free Care Target TBC Grade 2 (actual from Datix) TBC

Grade 3 (actual from Datix)

Grade 4 (actual from Datix) 1

All papers presented for Assurance in Quarter 3 were received positively with the exception of: Clinical Quality Report

Identified Gaps in Control (c) /Assurance(a): Pressure ulcer performance (a)

Action planned to address (and timescales): Improvement Plan in place


risk profile

Current Risk

Score

Previous Quarters


Month 8

1.1.3 There is a risk to patients due to non-implementation of pressure ulcer prevention strategies within an community setting, resulting in patient harm


Low - 0

C4 x L4 = 16

(high)

Harm Free Care Target TBC Grade 2 (actual from Datix)

TBC


4






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1.2 Clinical Effectiveness


risk profile

Current Risk

Score

Previous Quarters KPI Q2 Q1

1.2.1 There is a risk to patients due to failure to provide services that are clinically effective and of high quality resulting in patient harm or resulting in no benefit (Risk Reg ID - 1996)


Low - 5

L2 x C5 =

10 (medium)

14/15 Q2 - 10 14/15 Q1 - 10 13/14 Q4 – 10 13/14 Q3 – 10

Expected Deaths 2014-15 46 75

Deaths on the End of Life (EoL) Care Pathway

This question has been removed from the audit as the EoL care pathway is no longer in use

All papers presented for Assurance in Quarter 3 were received positively with the exception of: Clinical Quality Report Wheelchair Service Update 360 Assurance Audit Tracker NICE Process

Identified Gaps in Control (c) /Assurance (a): Pressure ulcer performance (a) Waiting times within the service (a) Overdue actions from Internal Audits © No evidence changes are embedded (a)

Action planned to address (and timescales): Improvement Plan in place Further report on progress to QSC in January New process tracker in place - to return to QSC in May 2015 New process in place - leads track their progress


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Risk Score Previous Quarters KPI Month 8 Month 7

1.2.2 There is a risk that patients do not get optimal care due to the Priority Clinical Audit Programme for the Trust not being appropriately focused and effective at driving service improvements in priority clinical areas (Risk Reg ID - 2655)


Low - 0

L3 X C4 = 12

(medium)

14/15 Q2 - 12 14/15 Q1 - 12 13/14 Q4 – 12 13/14 Q3 – n/a

Development of Patient Outcomes from the Priority Clinical Audit Plan

TBC

% of patients with a preferred place of Death

TBC






Risk Score Previous Quarters KPI Qtr 2 Qtr 1

1.2.3 There is a risk to Patients due to clinical records not meeting national standards resulting in the potential of poor delivery of patient care and patient outcomes. (Risk Reg ID - 2607)


Low - 0

L4 x C3 = 12

(medium)

14/15 Q2 - 12 14/15 Q1 - 12 13/14 Q4 – 12 13/14 Q3 – n/a

Completion rate monitoring of all services on a monthly basis on the BIS system

96% 96%

Compliance rate monitoring of all services on a quarterly basis on the BIS system

76% 74%

All papers presented for Assurance in Quarter 3 were received positively with the exception of: Information Governance Summary Report Clinical Effectiveness Group Summary Report

Identified Gaps in Control (c) /Assurance (a): IG Training Performance © Overdue actions on Internal Audit Reports ©

Action planned to address (and timescales): Review of IG Training New process / central monitoring system to be developed


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risk profile

Current Risk

Score

Previous Quarters KPI Month 8 Qtr 1

1.2.4 There is a risk to the organisation during the implementation of changes to our Quality Assurance processes resulting in ineffective reporting and assurance on quality (Risk Reg ID - 2608)


Low - 0

L3 x C4 = 12

medium

14/15 Q2 - 12 14/15 Q1 - 12 13/14 Q4 – 12 13/14 Q3 – n/a

Delivery of CQUIN

Delivery of Quality Schedule (Contract)


Identified Gaps in Control (c) /Assurance (a): Pressure ulcer performance (a)



risk profile

Current Risk

Score

Previous Quarters KPI Month 8

1.2.5 There is a risk to the organisation due to non-compliance of administration of the MHA 1983 resulting in poor patient outcomes and breaches in legislation (Risk Reg ID - 2605)


Low - 0

L3 X C4

= 12 medium

14/15 Q2 - 12 14/15 Q1 - 12 13/14 Q4 – 12 13/14 Q3 – 12

Evidence of appropriate plan for discharge for patients S5(2)

Numbers of patients assessed under MHA within 72 hours of admission

All papers presented for Assurance in Quarter 3 were received positively

Identified Gaps in Control (c) /Assurance (a):

Action planned to address (and timescales):


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risk profile

Current Risk

Score

Previous Quarters KPI Month 8 Month 7

1.2.6 This was a QBC risk (Q3)

There is a risk to the organisation due to poor information governance due to poor controls resulting in breaches and non-compliance with legislation (Risk Reg ID - 2379)


Low - 3

L2 x C4 =

8 (medium)

14/15 Q2 - 8 14/15 Q1 - 8 13/14 Q4 – 8 13/14 Q3 – 8

Information Governance Toolkit Achievement - measures scoring 2 or more (score)

17 24

All papers presented for Assurance in Quarter 3 were received positively with the exception of: Information Governance Group Summary Report

Identified Gaps in Control (c) /Assurance (a): IG Training Performance ©

Action planned to address (and timescales): Review of IG Training


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1.3 Patient Experience BAF ID Risk Description Operational risk

profile

Current Risk

Score


1.3.1 There is a risk to patients due to the failure to learn lessons from patients feedback and experiences resulting in negative effect on patient care (Risk Reg ID - 2361)


Low - 0

L2 x C4 =

8 (medium)

14/15 Q2 - 8 14/15 Q1 - 8 13/14 Q4 – 8 13/14 Q3– 8

Friends & Family Test 87 91 Complaints received 11 14

All papers presented for Assurance in Quarter 3 were received positively with the exception of: Healthcare for All Clinical Quality Report EDILF Summary Report

Identified Gaps in Control (c) /Assurance (a): Not enough progress on actions (a) Pressure ulcer performance (a) Progress against actions in plan and HC4A ©

Action planned to address (and timescales): Mitigation process to be developed to ensure compliance Improvement Plan in place Further update to QSC

BAF ID Risk Description Operational risk

profile

Current Risk

Score


1.3.2 There is a risk to the organisation due to patient and public non-engagement and involvement in service improvements resulting in reputational harm (Risk Reg ID - 2362)


Low - 0

L2 x C4 =

8 (medium)

14/15 Q2 - 8 14/15 Q1 - 8 13/14 Q4 – 8 13/14 Q3 – 8

Services with a PPI lead (no.) These measures

are being developed

Service with a PPI group (no.)


Identified Gaps in Control (c) /Assurance (a): Pressure ulcer information (a)

Action planned to address (and timescales): Improvement plan in place


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Risk Description

High Med Low

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

X

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Clinical Safety Group Summary Report X X X X X i X Report to QSCX X X X

X

X i X X XNew Chair / review of group and terms of reference

X X X X

X X X X X X X X X X X XImprovements to be delivered through Improvement plan

XX X X X X X X X X X X XX X i

XX X X X X X X X X X X XX X X X X X X

X X X XMeetings to be held with senior clinical staff to understand issues

X XX X X X X Detailed report to October QSC

Security Management Annual Report XDelayed Transfers of Care Quarterly Report X X

XXX

X X X XX Quality Directorate working with NICE

XX

Colposcopy Services Ilkeston and Buxton XAction plan in place - further paper to November QSC

XColposcosy Services Ilkeston X

6. Policies and Procedures

7. Safeguarding Regulatory Framework Tissue viability, falls, risk and nutrition, fluroscopy (a)

Legal Issues Report (2)NHSLA Report (2)

Internal Assurance Provided

1 15 316n/a

40

Avoidable Pus (no) Community hospital careMedicines incidents resulting in serious harm

Medication Errors causing Serious Harm (no.)

Divisional Governance Report (8)

Adult and Child Safeguarding report (7)Safeguarding Governance Summary Report (7)

Pressure Ulcer performance (a)

Service Improvement Plan 2014/15 Pressure Ulcer Reduction

Francis Report Working Group (8)

Hardwick CCG review of Ash Green

Gaps in Control (c)/Assurance (a)

2. NHSLA Standards3. CAS Alerts4. Clinical assessment tools5. Incident Reporting System

Clinical Quality Report (8)

Group not providing assurance to parent committee

Lead KPIs

Lead Sub-Group: Clinical Safety Group (chaired by Jo Hunter)

Measure Month 8

Controls Identified External Assurance Provided

Harm Free Care Score (%)

Avoidable PUs (no.) Hospital

1.1.1 - there is a risk to patients due to exposure to unsafe care resulting in harm (Risk Reg ID - 2357)

Operational Risk Profile

93.20%

1Falls (Major Harm/Death)

Risk Score

L2 x C5 = 10

Medium

0

data quality score

n/a

1. Harm Free Care programme

164

Risk Report (9)Quality Impact Assessment for CIPs

Quality Always

Inconsistent compliance with actions across the Trust (a)

Delay in the external assessment centres (c)

Further detail required re: outcomes (a)

Francis Report UpdateQSC Annual Review

IP&C Quarterly Report

Buxton and Clay Cross Theatres Access to national guidance (c)

Spencer Ward Closure ReportEnd of Life Care Quality Report

Staffing for Quality Report Care Home Advisory Service End of Year Report

Review identified actions to improve governance (a)

Quality Governance Assessment Framework (8)

CQC Compliance UpdateCQC Action Plan Update


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Risk Description

High Med Low

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X X XImprovements to be delivered through Improvement plan


Pressure Ulcer performance (a)Clinical Quality Report

Controls Identified External Assurance Provided Gaps in Control (c)/Assurance (a)

Grade 3 (actual from datix)Lead Sub-Group: Clinical Safety Group (chaired by Jo Hunter) Grade 4 (actual from datix) 1

Risk Operational Risk Profile Lead KPIs1.1.2 - There is a risk to patients due to non-implementation of pressure ulcer prevention strategies within an inpatient setting, resulting in patient harm

C4 x L2 = 8 Medium

Measure Month 8

data quality score

Harm Free Care Target TBCGrade 2 (actual from Datix) TBC


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Risk Description

High Med Low

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X X XImprovements to be delivered through Improvement plan


Clinical Quality Report Pressure Ulcer performance (a)


Grade 3 (actual from Datix) 4Lead Sub-Group: Clinical Safety Group (chaired by Jo Hunter) Grade 4 (actual from Datix)

Risk Operational Risk Profile Lead KPIs1.1.3 - There is a risk to patients due to non-implementation of pressure ulcer prevention strategies within an community setting, resulting in patient harm

C4 x L4 = 16

Medium

Measure Month 8

data quality score

Harm Free Care Target TBCGrade 2 (actual from Datix) TBC


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Risk Description

High Med Low

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X X X i X X X X X New process / central monitoring system to be developed

X X X X

X X X X X X X X X X X XXX X

Delayed Transfers of Care Quarterly Report X XIncident Report - Missing Records

X X X X X X X X X Improvements to be delivered through Improvement PlanX

X Quality Directorate working with NICEX Audit and paper to December QSCX

End of Life Care - Review of LCP XWheelchair Service Update X Waiting times within the service (a) Further report on progress to QSC in January

X360 Assurance Audit Tracker X Overdue actions from Internal Audits © New process tracker in place - to return to QSC in May 2015NICE Process X No evidence changes are embedded (a) New process in place - leads track their progress

VTE Report

Overdue actions on Internal Audit Reports

Quarterly CQUIN report (10)

Divisional Governance Report

data quality scoren/a

9. Clinical Audit, Service Evaluation & Research Group (CASER)Clinical Records Audit (1)10. CQUIN Goals & Quality Schedule Requirements

6. Clinical Supervision Group Internal Assurance Provided7. Clinical Documentation Group

End of Life Care Quality Report

Clinical Effectiveness Group Summary Report8. End of Life Group Clinical Effectiveness Group Annual Report

5. Resuscitation Group

2. NICE Guidelines1. Clinical Audit Priority Audit Plan

3. Clinical Policy approval process4. PGD approval process


Risk Score Operational Risk Profile Lead KPIs

Lead Sub-Group: Clinical Effectiveness Group (chaired by Sarah Banks)

1 14 5

1.2.1 - There is a risk to patients due to failure to provide services that are clinically effective and of high quality resulting in patient harm or resulting in no benefit (Risk Reg ID - 1996)

L2 x C5 = 10 Medium

Measure Q2Expected Deaths (Quarter 4 2013-14) 46%

Pressure Ulcer performance (a)Service Improvement Plan 2014/15 Pressure Ulcer Reduction Further detail required re: outcomes (a)Clinical Quality Report

Not hitting the targets (a)Process for accredited NICE organisations (c)

Buxton and Clay Cross Theatres Access to national guidance (c)

IP&C Quarterly Report

Breastfeeding TeamNICE Update


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Risk Description

High Med Low

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X X 2014/15 will be Patient Outcomes identifiedX X X X X X X X X X X X Improvements will be delivered through Improvement Plan

Risk Score Operational Risk Profile

Lead KPIs1.2.2 - There is a risk that patients do not get optimal care due to the Priority Clinical Audit Programme for the Trust not being appropriately focused and effective at driving service improvements in priority clinical areas (Risk Reg ID - 2655)

L3 x C4 = 12

Medium

Measure Month 8 data quality score

0 0 0

Development of Patient Outcomes from the Priority Clinical Audit Plan

TBC% of patients with a preferred place of Death TBC

Further Patient Outcomes to be confirmed


Controls Identified External Assurance Provided Gaps in Control (c)/Assurance (a)Clinical Audit StrategyClinical Audit Policy

Internal Assurance ProvidedClinical Audit Priority Programme lack of patient focus within programme (c)Clinical Quality Report Pressure ulcer performance (a)


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Risk Description

High Med Low

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X X X i X X X X X New process / central monitoring system to be developedX X Review of IG training

Incident Report - Missing Records X timescale extended and will report back to QSC

NEW in Q4

Risk Score Operational Risk Profile Lead KPIsThere is a risk to Patients due to clinical records not meeting national standards resulting in the potential of poor delivery of patient care and patient outcomes. (Risk Reg ID - 2607)

L4 x C3 = 12 Medium

Measure Q2 data quality score

0 1 0

Completion rate monitoring of all services on a monthly basis on the BIS system 96%76%Compliance rate monitoring of all services on a quarterly basis on the BIS system

Controls Identified External Assurance Provided Gaps in Control (c)/Assurance (a)Clinical Records Standards (1)


Clinical Records Audit GroupClinical Records Policy

action plan completion (a)

Information Governance Group Summary Report IG Training Performance (c)Clinical Effectiveness & Audit Group (wef 4/14)

Internal Assurance ProvidedClinical Documentation Group

Clinical Effectiveness Group Summary Report Overdue actions on Internal Audit Reports (c)Monthly on-line reporting of clinical records audit in all services on the Business Intelligence System


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Risk Description

High Med Low Month 8

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X X X X X X X X X X X X Improvements to be delivered through Improvement PlanX X X X X X X X X X X XX X i

NEW in Q4 X XXX X X X X X Further data testing to be completedX X Update in Quarterly report to QSC

Francis Report Update X


There is a risk to the organisation during the implementation of changes to our Quality Assurance processes resulting in ineffective reporting and assurance on quality (Risk Reg ID - 2608)

L3 x C4 = 12 medium

Measuredata quality

score

0 1 0

Delivery of CQUINDelivery of Quality Schedule (Contract)


Controls Identified External Assurance Provided Gaps in Control (c)/Assurance (a)Intelligence Monitoring GroupQuality improvement and assurance framework

staff training and development


Clinical effectiveness and audit programme

Clinical Quality Report Pressure ulcer performance (a)

Quality Schedule (Contract) with


Quarterly CQUIN report Wheelchair service performance (a)

TDA Observations ReportQuality Dashboard Update

Francis Report Working GroupQuality Governance Assessment Framework

Inaccuracy of data from ESR (c)


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Risk Description

High Med Low

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X X X X X X New process to be implementedX

NEW in Q4


Lead KPIs

There is a risk to the organisation due to non-compliance of administration of the MHA 1983 resulting in poor patient outcomes and breaches in legislation (Risk Reg ID - 2605)

L3 x C4 = 12

(medium)

MeasureMonth 8

data quality score

0 1 0

Evidence of appropriate plans for discharge for patients S5(2)Numbers of patients assessed under MHA within 72 hours of admission

Lead Sub-Group: Mental Health Act Committee (chaired by Barbara-ann Walker)

Controls Identified External Assurance Provided Gaps in Control (c)/Assurance (a)1. AMHAM Audits2. MCA & DoLS Activity report3. Safeguarding reports4. Regular training updates for staff5. CQC Annual Inspections

6. Legal Issues / SI Report Internal Assurance Provided7. Risk Report MentalHealth Act Committee Summary Report (1) DoLS activity8. Policy Matrix Government priorities in improving MH9. CQC action plans


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Risk Description

High Med Low data quality score

n/a

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

IM&T Strategy Group Summary ReportIncident Report - Missing Records X

X X X X X X IG Training Performance Review of IG training X


There is a risk to the organisation due to poor information governance due to poor controls resulting in breaches and non compliance with legislation (Risk Reg ID - 2379)

L2 x C4 = 8 Medium

Measure Month 8Information Governance Toolkit Achievement - measures scoring 2 or more (score)

0 1 3

1. Reports from Information Governance Group2. Policies and Procedures

Information Governance Control System

Information Governance Group Summary ReportInformation Governance Group Annual Report

17



ead Sub-Group: Information Governance Group (chaired by Hannah Edwards


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Risk Description

High Med Low

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X i X X X X X X X X Patient groups to be set upXX

X X XX X X

X X Mitigation process to be developed to ensure complianceX X X X X X X X X X X X

EDS Leadership Group Summary Report X i i i X X X X Further update to QSCX X X X X X X X X X X X Improvements to be delivered through Improvement Plan

EDS Leadership Group Annual Review X

Lead Sub-Group: Patient Experience Group (chaired by Mary Heritage)


data quality scoren/a

Healthcare for All Not enough progress on actions (a)

Patient Experience Group Annual ReportComplaints and Compliments Annual ReportPatient Experience Quarterly Report

Patient Experience Group Summary Report Delays in engagement (a)

Legal Issues Report (5)

There is a risk to patients due to the failure to learn lessons from patients feedback and experiences resulting in negative effect on patient care (Risk Reg ID - 2361)

L2 x C4 = 8 Medium

MeasureMonth 8

Friends and Family Test Score 87Complaints received 11

0 0 0

Clinical Quality Report (8)



Lead KPIs

1. Friends and Family Test

4. Quality Account5. NHSLA Standards

2. Complaints Policy and Process3. Patient Experience Team


Progress against actions in plan and HC4A (c)Pressure ulcer performance (a)


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Risk Description

High Med Low

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X i X X X X X X X X Patient Groups to be set upX X X X X X X X X X X X Improvements to be delivered through Improvement Plan


1. Independent Scrutiny Committee - ISC

There is a risk to the organisation due to patient and public non-engagement and involvement in service improvements resulting in reputational harm (Risk Reg ID - 2362)


0 0

External Assurance Provided

L2 x C4 = 8 Medium

Measuredata

quality Services with a PPI LeadServices with a PPI Group

Month 8being

developedn/an/a

Pressure ulcer performance (a)Clinical Quality Report

0


Lead KPIs

Patient Experience Group Summary Report Delays in engagement (a)

2. Patient groups

Lead Sub-Group: Patient Experience Group (chaired by Mary Heritage)

Controls Identified


Top










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This iteration of the BAF focuses on:

QUALITY PEOPLE Objective - To build a high performance work environment that engages, involves and

supports staff to reach their full potential Lead Committee for sections 2.1, 2.2 and 2.3 is Quality People Committee, chaired by Barbara-Anne Walker (Non-Executive Director)

Lead Director for sections 2.1, 2.2 and 2.3 is Amanda Rawlings (Director of People and Organisational Effectiveness)

Lead Executive Director Summary of Quality People BAF Risks:

During the past quarter we have worked with 360 Assurance to seek independent review on our progression with the Equalities Delivery System (EDS). The review evaluated the Trust’s framework for monitoring and reviewing compliance with EDS and reviewed the effectiveness of the Trust’s EIAs framework. The Audit opinion provides significant assurance on our EIA process and progress to date and provides independent view on our risk 2.3.3 which will be reviewed in the next quarter. The recruitment of qualified nursing staff remains a red risk for the trust. We are managing this risk proactively and with positive results but it is to be noted that nationally there is an under supply of qualified nursing staff and therefore we have to continue to monitor and find innovative approaches to recruitment and retention.


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2.1 BAF ID Risk Description Operational


Risk Score

Previous BAF reports

Lead KPI (as agreed by Executive and Non-

Executive Leads) Month

8 Month 7

2.1.1 There is a risk to patients due to Staff not being appropriately trained to provide high quality care resulting in poor patient outcomes. (Risk Reg ID - 2364)


Low - 2

L2 x C 5

= 10 (medium)

14/15 Q2 - 10 14/15 Q1 - 10 13/14 Q4 – 10 13/14 Q3 – 10

Essential Learning Attendance 93% 93% Clinical Essential Learning Attendance Fire Training 88% 88% IG Training 87% 88% Staff Attending Corporate Induction 93% 95% Appraisal Completion 81% 81%

All papers presented for Assurance in Quarter 3 were received positively with the exception of: Safeguarding Training Update Quality People Performance Report

Identified Gaps in Control (c) /Assurance (a): Compliance against target (a) Overpayments to Staff (c)

Action planned to address (and timescales): Action plan in place Regular Updates to QPC

BAF ID Risk Description Operational risk profile

Current Risk

Score Previous BAF

reports Lead KPI (as agreed by

Executive and Non-Executive Leads)

Month 8 Month 7

2.1.2 There is a risk to patients due to staff performance not being monitored and improved resulting in an adverse impact on the provision of high quality care (Risk Reg ID - 2365)


Low – 0

L2 x C5 =

10 (medium)

15/15 Q2 - 10 14/15 Q1 - 10 13/14 Q4– 10 13/14 Q3– 10

Staff Attendance 95.95% 96.27% Appraisal Completion 81% 81%

All papers presented for Assurance in Quarter 3 were received positively with the exception of: Quality People Performance Report People Services and Employee Relations Report Clinical Supervision Report

Identified Gaps in Control (c) /Assurance (a): Overpayments to staff (c) Capacity issues impacting on timescales (c) Inconsistent reporting (c)

Action planned to address (and timescales): Regular updates to QPC Improvement plan Analysis of staff records and Improvement plan 20�Board�Assurance�Framework�Q

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Current Risk

Score Previous BAF

reports Lead KPI (as agreed by

Executive and Non-Executive Leads)

Month 8 Month 7

2.1.3 There is a risk of harm to staff and reputation of the trust due to both a lack of ownership and inadequate management of Health and Safety and compliance with relevant legislation. (Risk Reg ID – 2604)


Low – 7

L3 x C4 =

12 (medium)

14/15 Q2 - 12 14/15 Q1 - 12 13/14 Q4 – 12

13/14 Q3 – N/A

TBC

All papers presented for Assurance in Quarter 3 were received positively with the exception of: Health and Safety Annual Report Annual Review of QPC Sub-Groups

Identified Gaps in Control (c) /Assurance (a): No evidence of outcomes (a) Level of assurance from sub-groups (a)

Action planned to address (and timescales): Three month workplan in place Further report to QPC detailing performance against KPIs


Top





Risk Score Previous BAF

reports KPI Month 8 Month 7

2.2.1 There is a risk to the organisation in not attracting, recruiting and retaining the right number of high quality, effective and compassionate employees with the appropriate and necessary levels of skill and experience (Risk Reg ID - 2366)


Low – 0

L3 x C5 = 15 (high)

14/15 Q2 – 15 14/15 Q1 - 15 13/14 Q4 – 15 13/14 Q3 – 10

Staff Turnover 11.44% 8.83%

Health Visitor FTE 130.9 129.2

Vacancies 45 49

Bank and Agency spend (clinical) as a % of total workforce cost

3.0% 3.2%

All papers presented for Assurance in Quarter 3 were received positively with the exception: Quality People Performance Report People Services and Employee Relations Report

Identified Gaps in Control (c) /Assurance (a): Overpayments to staff (c) Capacity issues impacting on timescales (c)

Action planned to address (and timescales): Regular updates to QPC Improvement plan


Top





Risk Score

Previous BAF reports KPI

13-14 Annual Figure

2.3.1 There is a risk to organisation due to the loss of staff engagement resulting in poor patient outcomes (Risk Reg ID – 2367)


Low - 0

L2 x C5 =

10 (medium)

14/15 Q2 - 10 14/15 Q1 - 10 13/14 Q4 – 10 13/14 Q3 – 9

Improvement in Staff Survey participation rates (%) 64.2%

Improvement in Staff Survey engagement and staff satisfaction scores (no.)

3.76%

Staff Net Promoter Question Result 3.78

All papers presented for Assurance in Quarter 3 were received positively with the exception: Quality People Performance Report People Services and Employee Relations Report

Identified Gaps in Control (c) /Assurance (a): Overpayments to staff (c) Capacity issues impacting on timescales (c)

Action planned to address (and timescales): Regular updates to QPC Improvement plan


Current Risk

Score Previous BAF


2.3.2 There is a risk to organisation due to poor change management resulting in an adverse impact upon ability of Trust to implement future plans (Risk Reg ID - 2368)


Low - 0

L3 x C3 =

9 (medium)

14/15 Q2 - 9 14/15 Q1 - 9 13/14 Q4 – 9 13/14 Q3 – 9

Number of Grievances (regarding Organisation Change)

0 0

Number of Appeals against Redundancy 0 0

All papers presented for Assurance in Quarter 3 were received positively with the exception of: Staff Health and Safety Annual Report Quality People Performance Report

Identified Gaps in Control (c) /Assurance (a): No evidence of outcomes Overpayments to staff (c)

Action planned to address (and timescales): Three month workplan in place Regular updates to QPC


Top




Current Risk

Score Previous BAF


2.3.3 There is a risk to the organisation in the failure to effectively embed equalities good practice across all aspects of DCHS' business, which will result in our not meeting our legislative duties under the Equalities Act 2010 and the requirements of the NHS Equality Delivery System2 (EDS2). (Risk Reg ID - 2369)


Low - 0

L2 x C5 =

10 (medium)

14/15 Q2 - 10 14/15 Q1 - 10 13/14 Q4 – 10 13/14 Q3 – 10

EDS2 grading outcome

Developing – Amber (2)

Developing – Amber (2)

EIA completion rates 84% 83%

Equalities Action Plan (% completion rate)

3% 28% 58% 3% 28% 58%

All papers presented for Assurance in Quarter 3 were received positively with the exception of: Quality People Performance Report People Services and Employee Relations Report Annual Review of QPC Sub-Groups

Identified Gaps in Control (c) /Assurance (a): Overpayments to staff (c) Capacity issues impacting on timescales (c) Level of assurance from sub-groups (a)

Action planned to address (and timescales): Regular updates to QPC Improvement plan Further report to QPC detailing performance against KPIs


Current Risk

Score Previous BAF


2.3.4 There is a risk to the organisation in not attracting, recruiting and retaining a diverse workforce that reflects today's society and which represents the multiplicity of our service users and therefore is better able to meet their needs. (Risk Reg ID - 2657)


Low – 0

L2 x C5 =

10 (medium)

14/15 Q2 - 10 14/15 Q1 - 10 13/14 Q4 – 10 13/14 Q3 – N/A

Workforce equality profile (overall)

BME : 128 Not Stated : 77 White: 3875


Equality profile of recruits



Equality profile of leavers


BME : 3 Not Stated:2 White: 39

All papers presented for Assurance in Quarter 3 were received positively.




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Risk Description

High Med Low

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X X X X X X XX X i X iX X i X iX X i X i

Review of Effectiveness of E-Learning XFrancis, Berwick and Keogh Report XDirector of Nursing Quarterly Report X X

XX X X X

18

Action Planned

Overpayments to staff (c) Regular updates to QPC

data quality score

18

18

18

18

181


Clinical Essential Learning Attendance2

Appraisal Completion

IG Training 87%

1

Risk Score

L2 x C5 = 10

Medium

81%

6. Clinical Supervision7. Induction / Probation Process


1. Performance Reports2. NHSLA Standards3. Policies and Procedures4. Appraisal Process5. Compliance Matrix - ESR Self Service

Quality People Performance Report (1)

93%

9. Risk RegisterWorkforce Planning and Development GroupStaff Partnership Committee

Lead KPIs

Lead Sub-Group: Workforce Planning & Development Group

Measure Month 8


Essential Learning Attendance

Fire Training

There is a risk to patients due to Staff not being appropriately trained to provide high quality care resulting in poor patient outcomes. (Risk Reg ID - 2364)


93%

88%

Staff Attending Corporate Induction

QPC Annual ReportStrategic Workforce Report

Staff Health and Wellbeing Group


Top



Risk DescriptionHigh Med Low data quality score

18

18

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X XX X X X X X X Regular updates to QPC

X X i X iWorkforce Planning and Development Group X X i X iStaff Health and Wellbeing Group X X i X i

6. Clinical Supervision Internal Assurance Provided

Staff Partnership Committee

7. Induction / Probation Process People Services Performance Report (1)8. People Strategy Quality People Performance Report (1) Overpayments to staff (c)

4. Appraisal Process5. Compliance Matrix - ESR Self Service

2. NHSLA Standards3. Policies and Procedures

0 0

1. Performance Reports

Lead Sub-Group: Staff Partnership Forum (chaired by Amanda Rawlings / William Jones)


Risk Score Operational Risk Profile Lead KPIsThere is a risk to patients due to staff performance not being monitored and improved resulting in an adverse impact on the provision of high quality care (Risk Reg ID - 2365)

L2 x C5 = 10

Medium

Measure Month 8

Staff Attendance 95.95%Appraisal Completion 81%

0


Top




Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

3. Induction and Essential Training

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X Regular report to QPCXX X X X X


Strategic Workforce Report

Staff Health & Safety Review Action Plan Action plan completion (a)QPC Annual Report

2. NHSLA Standards

Controls Identified External Assurance Provided Gaps in Control (c)/Assurance (a)1. Performance Reports

TBC

Lead Sub-Group: Staff Health and Wellbeing Group (chaired by Rebecca Oakley) Reduction in HSE reported injurys TBC

Risk Score Operational Risk Profile Lead KPIsThere is a risk of harm to staff and reputation of the trust due to both a lack of ownership and inadequate management of Health and Safety and compliance with relevant legislation. (Risk ID - 2604)

L3 x C4 = 12

Medium

Measure Month 8

1 25 6Datix Reports- Increased reporting measured January to December TBCIncident Investigation Reports completed for all lost time injurys TBCReduction in paid injury claims. 2013 versus 2014


Top




18

18

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X X XX X X X X X X Regular updates to QPC

X X i X iWorkforce Planning and Development Group X X i X i

X XFrancis, Berwick and Keogh Report X

Bank and Agency spend (clinical) as a % of total workforce cost

8. Risk Register Quality People Performance Report (1) Overpayments to staff (c)

6. Appraisal process Internal Assurance Provided7. Workforce Equality Monitoring

Responsive Workforce Update (6)

5. Essential Learning

People Services Performance Report (1)

4. Induction and probation

Staff Partnership Committee

Risk Score Operational Risk Profile Lead KPIs There is a risk to the organisation in not attracting, recruiting and retaining the right number of high quality, effective and compassionate employees with the appropriate and necessary levels of skill and experience (Risk Reg ID - 2366)

L3 x C5 = 15 High

Measure Month 8

11.44%

130.9

45Vacancies

1 25 6

Lead Sub-Group: Workforce Planning & Development Group (chaired by Lynn Walshaw) 3.00%

Staff Turnover

Health Visitor FTE

Controls Identified External Assurance Provided Gaps in Control (c)/Assurance (a)1. People Strategy2. Attraction Strategy3. Recruitment and selection process and procedures


Top



Risk Description


n/a

n/an/a

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X XX X X X X X X Regular Updates to QPC

Staff Health and Wellbeing Group X X i X iXX X X X XX

People Services and Employee Relations Report X X X Improvement PlanCapacity issues impacting on timecales (c)

7. Risk RegisterQuality People Performance Report (1)People Services Performance Report (1)

Overpayments to staff (c)8. Organisational Development System

QPC Annual ReportStrategic Workforce ReportStaff Health and Wellbeing Project Proposal

3. Appraisal Process

6. People Strategy Internal Assurance Provided

4. Staff Survey Process5. Staff Pulse Checks

0 0 0




Lead Sub-Group: Staff Health and Wellbeing Group (chaired by Rebecca Oakley)

There is a risk to organisation due to the loss of staff engagement resulting in poor patient outcomes (Risk Reg ID - 2367 )

L2 x C5 = 10

Medium

Measure 2013/14 Annual Figure

Improvement in Staff Survey participation rates (%) 64.2% 13-14Improvement in Staff Survey engagement and staff satisfaction scores (no.) 3.76% 13-14Staff Net Promoter Question Result (no.) 3.78 13-14

Gaps in Control (c)/Assurance (a)1. Performance Reports


Top



Risk Description


n/a

n/a

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec


X X i X iStaff Health and Wellbeing Group X X i X i

X Three month workplan in place

Quality People Performance Report (1) Overpayments to staff ©

Staff Health and Safety Annual Report (3) No evidence of outcomes

Staff Partnership Forum

6. Workforce Planning Process Internal Assurance Provided7. Project Management Office Process People Services Performance Report (1)

2. Policies and Procedures3. People Strategy

There is a risk to organisation due to poor change management resulting in an adverse impact upon ability of Trust to implement future plans (Risk Reg ID - 2368)

L3 x C3 = 9

Medium

Measure Month 8

Number of Grievances (regarding Organisation Change) 0

Number of Appeals against Redundancy 00 1 0


Lead Sub-Group: Staff Health and Wellbeing Group (chaired by Rebecca Oakley)

Controls Identified External Assurance Provided Gaps in Control (c)/Assurance (a)1. Performance Reports

4. Risk Register5. Organisational Development System


Top



Risk Description


3% 28% 58%

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec


X X i X iX X i XX X i X i

X X Regular report to QPCX

Workforce Equality Report Opportunities for staff to disclose information (a)

Overpayments to staff ©

EDS Action Plan

10. Risk Register Staff Partnership Committee

Workforce Planning and Development GroupEquality, Diversity and Inclusion Leadership Forum

7. Patient and Public Engagement People Services Performance Report8. Induction Quality People Performance Report

6. Equality Impact Assessments Internal Assurance Provided

3. Equalities Action Plan4. Workforce Equality Monitoring5. Service User Equality Monitoring

1. People Strategy

There is a risk to the organisation in the failure to effectively embed equalities good practice across all aspects of DCHS' business, which will result in our not meeting our legislative duties under the Equalities Act 2010 and the requirements of the NHS Equality Delivery System2 (EDS2). (Risk Reg ID - 2369)

L2 x C5 = 10

MediumMeasure

EDS2 grading outcomeEIA completion ratesEqualities Action Plan (% completion rate)

0 1 0


Developing82%

Month 8

2. Equality Strategy

Lead Sub-Group: Equality, Diversity and Inclusion Leadership Forum (chaired by Amanda Rawlings)



Top



Risk Description


Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X X i X

X XRegular report to QPC

XX X X X

X X XStaffing for Quality

8. Risk Register Workforce Equality Reportopportunities for staff to disclose information (a)

Strategic Workforce ReportQPC Annual Report

6. Appraisal process Internal Assurance Provided7. Workforce Equality Monitoring Equality, Diversity and Inclusion Leadership Forum

1. People Strategy2. Equality Strategy3. Attraction Strategy4. Recruitment and selection policies and procedures5. Induction / probation process

Lead Sub-Group: Equality, Diversity and Inclusion Leadership Forum (chaired by Amanda Rawlings)

Controls Identified External Assurance ProvidedGaps in Control

(c)/Assurance (a)

There is a risk to the organisation in not attracting, recruiting and retaining a diverse workforce that reflects today's society and which represents the multiplicity of our service users and therefore is better able to meet their needs. (Risk Reg ID - 2657)

L2 x C5 = 10 Medium

Measure Month 8

0 0 0

BME : 128

BME : 2

BME : 0

Workforce equality profile (overall) Not Stated : 77White: 3875


Equality profile of leavers

Equality profile of recruits Not Stated : 0White: 36

Not Stated : 2White: 36


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This iteration of the BAF focuses on: QUALITY BUSINESS

Objective - To ensure an effective, efficient and economical organisation which promotes productive working and which offers good value to its community and commissioners

Lead Committee is the Quality Business Committee, chaired by Tony Okotie (Non-Executive Director)

Lead Director is Chris Sands (Director of Finance, Performance and Information)

Lead Executive Director Summary of Quality Business BAF Risks:

The Trust has two red risks on the Quality Business section of the BAF. There is the risk to delivery of the IBP due to a change in commissioner priorities. In both the North and South of the county, commissioners have engaged consultants to support the development of integrated 5 year plans. These plans are developing in line with our IBP. However, there remains uncertainty due to the recent publication of the 5 Year Forward View and Dalton Review which could impact on commissioner strategies. In addition, we are likely to get further clarity on the future direction of the NHS after the General Election in May 2015. Due to this uncertainty, it is felt to be sensible to keep this strategic risk at 15. The month 8 financial position, and forward view, continues to highlight financial risk going forward. The delivery of cost improvement plans, and the pressures on activity in block contracts continues to be a pressure. This will need to be addressed through contract negotiations, and through the setting of realistic and achievable cost improvements going forward. The BAF risk has been maintained at a 15 to reflect the level of financial risk.


Top




profile Current

Risk Score

Previous BAF Score


Month 8 Month 7

3.1.1 There is a risk to the organisation achieving strategic objectives due to a lack of integrated planning resulting in poor outcomes across the DCHS Way (Risk Reg ID - 2370)


Low - 0

L2 x C 5

= 10 (medium)

14/15 Q2 - 10 14/15 Q1 - 10 13/14 Q4 – 10 13/14 Q3 – 10

Plan delivered to TDA schedule Yes Yes

Delivery of routine quality, finance and other performance KPIs

As reported

As reported

All papers presented for Assurance in Quarter 3 were received positively with the exception of: Cost Improvement Report

Identified Gaps in Control (c) /Assurance (a): CIP delivery (a)

Action planned to address (and timescales): A plan to be developed for 2015/16


profile Current

Risk Score

Previous BAF Score KPI Month

8 Month 7

3.1.2 There is a risk of loss of business due to not actively managing the more competitive environment resulting in financial loss (Risk Reg ID - 2371)


Low - 0

L3 x C4 =

12 (medium)

14/15 Q2 - 12 14/15 Q1 - 12 13/14 Q4 – 12 13/14 Q3 – 12

Market opportunities won / maintained / lost (number and value)

TBC

Commissioner feedback TBC

GP feedback TBC All papers presented for Assurance in Quarter 3 were received positively.




Top




profile Current

Risk Score


8 Month 7

3.1.3

There is a risk to delivery of the IBP due to change in commissioner priorities and national policy (Risk Reg ID - 2441)


Low - 0

L3 x C5 = 15 (high)

14/15 Q2 - 15 14/15 Q1 - 15 13/14 Q4 – 15 13/14 Q3 – 15

Formal evidence of commissioner discussions showing plan alignment TBC TBC

All papers presented for Assurance in Quarter 3 were received positively with the exception of: No papers presented




profile Current

Risk Score


8 Month 7

3.1.4NEW RISK in Q1 14-15

There is a risk to the effective and efficient provision of DCHS services due to the impact of funding cuts in social services resulting in greater activity being directed towards health services (Risk Reg ID - 2729)


Low - 0

L3 x C4 =

12 (medium)

14/15 Q2 - 12 14/15 Q1 - 15 13/14 Q4 – n/a 13/14 Q3 – n/a

Delayed Transfers of Care 10.1% 7.9%

All papers presented for Assurance in Quarter 2 were received positively with the exception of: No papers presented




Top




profile Current

Risk Score

Previous BAF Score KPI Month 8 Month 7

3.2.1 There is a risk to the organisation due to poor estate impacting upon patient care resulting in poor outcomes (Risk Reg ID - 2372)


Low - 0

L2 x C4 =

8 (medium)

14/15 Q2 - 12 14/15 Q1 - 12 13/14 Q4 – 12 13/14 Q3 – 12

PLACE score 98% n/a

Total of Backlog Maintenance £192k £161.1k

Cumulative capital expenditure against plan 2225k £1710k

All papers presented for Assurance in Quarter 3 were received positively:




profile Current

Risk Score


8 Month 7

3.2.2 There is a risk to the organisation due to poor asset utilisation impacting upon the efficient use of resources (Risk Reg ID - 2373)


Low - 0

L3 x C3 =

9 (medium)

14/15 Q2 - 9 14/15 Q1 - 9 13/14 Q4 – 9 13/14 Q3– 10

Facilities Unutilised Space (%) n/a n/a

Available beds (no.) inpatient 198





Top




profile Current

Risk Score


8 Month 7

3.2.3 There is a risk to the organisation due to the inability to meet financial targets, specifically cost improvement plans, as set out in Annual Plan and IBP resulting in financial risk and reputational damage. (Risk Reg ID - 2374)


Low - 0

L3 x C5 = 15 (high)

14/15 Q2 – 15 14/15 Q1 - 15 13/14 Q4 – 10 13/14 Q3– 15

CIP achieved 35.9% 35.6%

Financial Risk Rating 3 4

Continuity of Service Rating 4 4

Cash Position

£15.4m £13.8m





profile Current

Risk Score


8 Month 7

3.2.4 There is a risk to the organisation due to the inability to meet contractual activity targets, resulting in financial risk (Risk Reg ID - 2375)


Low - 1

L2 x C4 =

8 (medium)

14/15 Q2 - 8 14/15 Q1 - 8 13/14 Q4 – 8 13/14 Q3– 8

Activity Plan TBC Income Plan TBC





profile Current

Risk Score


8 Month 7


Top



3.2.5 There is a risk to the delivery of the organisation's plans through non-delivery or slippage in the enabling IMT plans, resulting in objectives not being achieved. (Risk Reg ID - 2377)


Low - 0

L3 x C4 =

12 (medium)

14/15 Q2 - 8 14/15 Q1 - 12 13/14 Q4 – 8 13/14 Q3– 8

Progress against Plan TBC Proportion of services on an electronic system TBC





profile Current

Risk Score


8 Month 7

3.2.6 There is a risk to the organisation due to poor decisions being made due to poor data quality resulting in poor outcomes and financial loss (Risk Reg ID - 2378)


Low - 0

L3 x C4 =

12 (medium)

14/15 Q2 - 12 14/15 Q1 - 12 13/14 Q4 – 12 13/14 Q3– 12

Community Information Dataset Completeness - Referral to treatment information (%)

83.1% 82.5%

Community Information Dataset Completion - Referral information

75.4% 74.7%

Community Information Dataset - Treatment activity information (%)

75.4% 74.7%





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Risk Score


8 Month

7

3.2.7

There is a risk to the Trust’s activities, due to an emergency or severe disruption, resulting in an impact on patient care, inability to meet targets, loss of revenue (Risk Reg ID - 2484)


Low – 0

L2 x C5 -

= 10 (medium)

14/15 Q2 - 10 14/15 Q1 - 10 13/14 Q4 – 10 13/14 Q3 – 10

Director (Gold level ) training 85% 85%

On-Call team (Silver level) training 85% 85%

Compliance against the NHS England’s Core Standards for EPRR

97% 97%

All papers presented for Assurance in Quarter 3 were received positively with the exception of: No papers presented.

Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales):



Risk Score


8 Month

7

3.3.1 There is a risk to the organisation due to failure to maintain a positive reputation, resulting in impact upon future demand for services (Risk Reg ID - 2380)


Low - 0

L2 x C5 =

10 (medium)

14/15 Q2 - 10 14/15 Q1 - 10 13/14 Q4 – 10 13/14 Q3– 10

Positive media stories (no.) 23 22





Top





Risk Score


8 Month

7

3.3.2 There is a risk to the organisation due to ineffective governance as a result of not maintaining a representative involved membership resulting in poor engagement with the local community (Risk Reg ID - 2381)


Low - 0

L2 x C3 =

6 (medium)

14/15 Q2 - 6 14/15 Q1 - 6 13/14 Q4 – 6 13/14 Q3– 6

FT membership (no.) 12520 12295

Representative Membership TBC

Pulse Check - Recommend DCHS to Friends and Family if they needed care or treatment

90%


71%






Risk Score


8 Month

7

3.3.3 There is a risk to the organisation due to delivering integrated care through poor relationships with partners resulting in poor outcomes for patients (Risk Reg ID - 2382)


Low - 0

L2 x C4 =

8 (medium)

14/15 Q2 - 8 14/15 Q1 - 8 13/14 Q4 – 8 13/14 Q3– 8

market opportunities won /maintained / lost (number and value)

n/a





Top




Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Planning Control System

2. LTFM3. Annual Plan4. Annual Plan updates


Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

6. PMO reports X X X X report to July QBCX X X Xi i

X X

X X X A plan to be developed for 2015/16X Contracts planned to be signed off July 2014


Long Term Financial Model Activity and Income Assumptions (2)Planning for 2014/15-2018/19 (to Board)8. Contract report


Plan delivered to TDA scheduleDelivery of routine quality, finance and other performance KPIs

There is a risk to the organisation achieving strategic objectives due to a lack of integrated planning resulting in poor outcomes across the DCHS Way (Risk Reg ID - 2370)



Yesas reported

Risk Score

L2 X C5 = 10

medium

1. IBP

0 1 0

Lead KPIs

Lead Sub-Group: Strategic Programme Group (chaired by Tracy Allen)

Measure at month 8

lack of CIP discussionContract Report (8)Strategic Programme Group Summary Report Internal Assurance Provided

Risk to CIP delivery (a)Contracts not signed off (c)

Cost Improvement ReportInter-Trust Agreement Report

Long Term Financial Model (2)


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3.1.2


Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Business Development System

2. Commercial Strategy

5. Tender oversight and analysis

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X X X XX X X X X X X X

Inter-Trust Agreement ReportLessons Learned from Contracts / Tenders X Changes to be implemented

0


There is a risk to the organisation due to loss of business as a result of not actively managing the more competitive environment resulting in financial loss (Risk Reg ID - 2371)

L3 x C4 = 12

Medium

Measure at month 8

Market opportunities won / maintained / lost (number and value) TBCCommissioner feedback TBC

GP feedback TBC

0 4

Lead Sub-Group: Tender Oversight Group (chaired by Tracy Allen)


1. Business Development Reporting

4. Competitor and market analysis3. Business development framework (eg inve

Gaps in processes (c)

Market Risk Assessment (2)


Business Development Report (1) Nottinghamshire Obesity - tender process (a)Tender Oversight Summary Report


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3.1.3


Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X X X XX X X X

NB - new risk (escalated from operational risk register following July 2013 Board)

Contract Report (1)

Internal Assurance ProvidedStrategic Programme Group Summary Report no CIP discussion (a)

TBC3 0

External Assurance Provided Gaps in Control (c)/Assurance (a)

0

1. Contract management and negotiation process

3. Analysis of commissioning intentions as part of planning process4. CIP plans indicate level of commissioner support


2. Executive team meetings with Commissioner Chief Officers / teams

Lead Sub-Group: Strategic Programme Group (chaired by Tracy Allen)

Controls Identified

Lead KPIsThere is a risk to delivery of the IBP due to change in commissioner priorities and national policy (Risk Reg ID - 2441)

L3 x C5 = 15 High

Measure at month 8

Formal evidence of commissioner discussions showing plan alignment


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3.1.4


Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

NB - new risk in Q1 14-15

Risk Score Operational Risk Profile Lead KPIsThere is a risk to the effective and efficient provision of DCHS services due to the impact of funding cuts in social services resulting in greater activity being directed towards health services (Risk Reg ID - 2729)

L3 x C4 = 12

Medium

Measure at month 8

0 0 0

Delayed Transfers of Care 10.1%

Lead Sub-Group: Trust Management Executive (Chaired by Tracy Allen)

Controls Identified External Assurance Provided Gaps in Control (c)/Assurance (a)1. Health and Wellbeing Board2. Contract Management Board3. Transformation groups



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3.2.1


Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Estates Planning System

2. Progress Reports against Estates Strategy

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X X X X X X

Estates Strategy Delivery Targets (2)X

0 8 3

Controls Identified External Assurance Provided Gaps in Control (c)/Assurance (a

1. Capital Planning System


Lead Sub-Group: Captial and Estates Planning Group (chaired by William Jones)

There is a risk to the organisation due to poor estate impacting upon patient care resulting in poor outcomes (Risk Reg ID - 2372)

L2 x C4 = 8 Medium

Measure at month 8

£192k£2225k

98%PLACE Score

Total of Backlog MaintenanceCumulative capital expenditure against plan

Capital Investment Plans (1)

Captial & Estate Planning Gp Self Assessment (1)

3. Planned Preventative Maintenance System4. Policies and procedures

Internal Assurance ProvidedCapital and Estate Planning Gp Summary report (1)


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3.2.2


n/a18

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Estates Planning System

2. Progress Reports against Estates Strategy

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X X X X XX

Treasury Management Report X X

0

Risk Score Operational Risk Profile Lead KPIsThere is a risk to the organisation due to variable site utilisation impacting upon the efficient use of resources (Risk Reg ID - 2373)

L3xC3 = 9 Medium

Measure at month 8

Facilities Unutilised Space (%) n/aAvailable beds (no.) inpatient 198

0 0

Lead Sub-Group: Captial and Estates Planning Group (chaired by William Jones)


1. Captial Planning System

Capital and Estate Planning Gp Summary report (1)Capital Investment Plans (1)



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3.2.3


n/an/a

n/a

n/a

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X X X X X X X X monthly report to QBC

XX X X X X X XX X X X X monthly report to QBC

X X

CIP report (2)

£14.8m

Controls IdentifiedFinancial Control System

Lead Sub-Group: Trust Management Executive (chaired by Tracy Allen) Cash position

Not meeting planned performance (a)

Financial Planning Assumptions 14/15Draft Financial Plan 14/15

1. Finance Reports

5. Policies and procedures

Risk Score

2. CIP Reports3. LTFM4. Treasury Management Reports

Operational Risk Profile Lead KPIs

There is a risk to the organisation due to the inability to meet financial targets, specifically cost improvement plans, as set out in Annual Plan and IBP resulting in financial risk and reputational damage. (Risk Reg ID - 2374)

L3 x C5 = 15 High

Measure at month 8

CIP achieved - recurrent 29%Financial Risk Rating 4

Continuity of Service Rating 4

0 7 0

External Assurance Provided Gaps in Control (c)/Assurance (a)

Treasury Management Report (4)

Finance Report (1) Outcomes (a)Internal Assurance Provided

Long Term Financial Model Activity and Income Assumptio Reference Costs Report (1)

Charitable Funds Annual Report (1)Continuity of Service Report(1)

Charitable Funds Group Summary Report (1)Mitigation Plan - Treatment Centre (1)CIP Slippage - Lessons Learnt (2)


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3.2.4


Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X i X X X X XX X X X X X X monthly report to QBC

X

X X

Performance Report (2)Finance Report (2)

Income Plan


1 9 1

TBCTBC

3. LTFM




There is a risk to the organisation due to the inability to meet contractual activity targets, resulting in financial risk (Risk Reg ID - 2375)

L2 x C4 = 8

Medium

Measure at month 8

Activity Plan


1. Finance ReportsContractual Control System


Service Line Reporting (1, 2)

Contract ReportsPatient Care Contracting Update

Missed targets for Breatfeeding and smoking quitters (a)outcomes (a)


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3.2.5


Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X X X Informatics action plan in placeX

Informatics Programme Quarterly Update X Informatics action plan in placeX

IM&T Strategy Quarterly Update (2)TPP connectivity issues in the community(a)

Lead Sub-Group: Information Management & Technology Group (chaired by Chris Sands)

IM&T Strategy Group Summary ReportInternal Assurance Provided

2. IM&T Strategy

IM&T Control System



There is a risk to the delivery of the organisation's plans through non-delivery or slippage in the enabling IMT plans, resulting in objectives not being achieved (Risk Reg ID - 2377)

L3 x C4 = 12

Medium

Measure at month 8

0 4 0

Roll out of TPP (a)

Progress against Plan TBCTBCProportion of services on an electronic system

TPP Systm One Roll-out

1. IM&T Reporting

Mobile Working Evaluation (1)


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3.2.6


n/an/a

n/a

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Data Quality Control System

2. Data Quality Kitemark

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

IM&T Strategy Group Summary Report X X X Informatics action plan in placeX

Informatics Programme Quarterly Update X Roll out of TPP (a) Informatics action plan in placeX

IM&T Strategy Quarterly Update (4)TPP connectivity issues in the community(a)

83%69%

4. IM&T Strategy



Community Information Dataset Completion - Referral information

Community Information Dataset - Treatment activity information (%)


1. Performance Reporting - Data Quality issues

TPP Systm One Roll-out


There is a risk to the organisation due to poor decisions being made due to poor data quality resulting in poor outcomes and financial loss (Risk Reg ID - 2378)

L3 x C4 = 12 Medium

Measure at month 8

Community Information Dataset Completeness - Referral to treatment information (%)

75%

Lead Sub-Group: Information Management & Technology Group (chaired by Chris Sands)

0 1 0


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3.2.7


85%

85%

97%

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X X7. Site Contingency Plan in-place8. Pandemic Influenza Contingency Plan in-place9. Fuel Disruption Contingency Plan in-place

2

Risk Score Operational Risk Profile Lead KPIsThere is a risk to the Trust’s activities, due to an emergency or severe disruption, resulting in an impact on patient care, inability to meet targets, loss of revenue (Risk Reg ID - 2484)

L2 x C5 = 10 Medium

Measure at month 8

85%Director (Gold level)

97%

On-Call Manager (Silver level)0 3 85%

Compliance against the NHS England’s Core Standards for EPRR

1. Accountable Emergency Officer appointed2. Member of the multi-agency Local Health Resilience Partnership3. Member of the multi-agency Local Resilience Forum

EPRR Control SystemControls Identified External Assurance Provided Gaps in Control (c)/ Assurance (a)

5. Quarterly reporting to the board via QBC


Emergency Preparedness, Resilience & Response (EPRR) Report (5, 6 and 11)Pandemic Flu Plan (9)

10. Internal assessment against NHS England's Core Standards for EPRR undertaken

6. Major Incident Plan/Business Continuity Plan

4. Framework for Responding to Industrial Action in-place



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3.3.1


n/a

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X iCommunications Quarterly Report (1)

23

3. Staff and service user friends and family test

4. Staff survey Internal Assurance Provided


Further KPIs from Communications to be developed


2. Board level lead for communications and marketing1. Communications and marketing strategy


There is a risk to the organisation due to failure to maintain a positive reputation, resulting in impact upon future demand for services (Risk Reg ID - 2380)

L2 x C5 = 10 Medium

Measure at month 8

Positive media stories (no.)

0 1 0


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3.3.2

Risk Description


n/a

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X i


Quarterly communications reportInternal Assurance Provided

Representative Membership

4. Spot Checking Programme

1. Membership Report

3. 6 monthly newsletters2. Programme of Activity

Lead Sub-Group: CFT Board (Chaired by Prem Singh) Pulse Check - Recommend DCHS to Friends and Family if they needed care or treatment 71%


There is a risk to the organisation due to ineffective governance as a result of not maintaining an engaged and representative involved membership resulting in poor engagement with the local community (Risk Reg ID - 2381)

L2 x C3 = 6

Medium

Measure at month 8

FT membership (no.)


0 0 0

90%

12520

TBC


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3.3.3


n/a

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X iX X X X X X XX X X X X


Quarterly communications update (1)Internal Assurance Provided


L2 x C4 = 8 Medium

Measure at month 8

Market opportunities won /maintained / lost (number and value)

0 0 0

TBC

Nottinghamshire Obesity - tender process (a)Business development reportTender Oversight Group report (3)


1. Communications and marketing strategy

3. Tender oversight includes review of necessary partnership arrangements

2. Partnership strategy and governance

There is a risk to the organisation due to delivering integrated care through poor relationships with partners resulting in poor outcomes for patients (Risk Reg ID - 2382)


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Derbyshire Community Health Services Board Assurance Framework – Quarter 2 2014-15




The Chief Executive’s Department are responsible for the collation of the Board Assurance Framework. Please direct any queries to Kirsteen Farrar or Melanie Curd (01773 525065).


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This iteration of the BAF focuses on: QUALITY GOVERNANCE

Objective - To manage and develop a successful organisation Lead Committee is the Audit & Assurance Committee, chaired by Nigel Smith (Non-Executive Director)

Lead Director is Kirsteen Farrar (Trust Secretary)

Lead Executive Director Summary of Quality Governance BAF Risks:

There are currently no high risks within the Quality Governance section of the BAF. All of the risks are currently scoring between 12 and 8. There was one paper which received limited assurance during Quarter 3; the Clinical Audit Update – at the October meeting the Committee acknowledged the good work and took assurance from the Audit Programme and schedule but this was limited because there was no evidence of successful completion of plans and outcomes and there was still work to be completed to overcome bureaucratic processes that make requests for audit support complicated. Two risks have been removed from this section of the BAF during the quarter; 4.3.1 There is a risk to the organisation due to the inability to deliver transformational, system-wide change whilst managing our FT application process resulting in missed opportunities (Risk Reg ID - 2711) and 4.3.2 There is a risk to the organisation due to an unsuccessful application to become a CFT resulting in organisational uncertainty (Risk Reg ID - 2712) as FT status was achieved on the 1 November 2014. All other papers presented during the quarter received positive assurance.


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4.1


Current Risk

Score

Previous Months


Month 8 Month 7

4.1.1 There is a risk to the organisation due to not having strong corporate governance systems in place resulting in Trust vision not being delivered (Risk Reg ID - 2383)


Low - 0

L2 x C 5

= 10 (medium)

14/15 Q2 - 10 14/15 Q1 - 10 13/14 Q4 – 10 13/14 Q3 – 10

To be developed 14/15

All papers presented for Assurance in Quarter 3 were received positively with the exception of: Clinical Audit Update

Identified Gaps in Control (c) /Assurance (a): No evidence of outcomes from the programme

Action planned to address (and timescales): Continue with Audit Programme and schedule


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4.2 BAF ID Risk Description Operational risk

profile

Current Risk

Score

Previous Months KPI Month 8 Month 7

4.2.1 There is a risk to the organisation due to not meeting regulatory, contractual or legal obligations resulting in sanctions (Risk Reg ID - 2384)


Low - 0

L2 x C5 =

10 (medium)

14/15 Q2 - 10 14/15 Q1 - 10 13/14 Q 4 – 10 13/14 Q3 – 10

CQC internal assessment rating

Governance Risk Rating 1 1 Continuity of Service rating 4 4





Current Risk

Score

Previous Months KPI Month 8 Month 7

4.2.2 There is a risk to the organisation due to not having strong risk management controls in place resulting in failure to put effective mitigation plans in place promptly (Risk Reg ID - 2385)


Low - 0

L2 x C4 =

8 (medium)

14/15 Q2 - 8 14/15 Q1 - 8 13/14 Q4 – 8 13/14 Q3 – 8

NHSLA Rating 1 1





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4.1.1

Risk Description

High Med Low

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

X X XX

3. Quality Governance reporting X4. Internal Audit Reports5. Counter Fraud Reports X X X X6. External Audit Reports X7. Scheme of Delegation X X8. Self Certification Reporting X9. Board Assurance Framework X X Investigation by the Head of Medicines Management 10. Clinical Audit Programme Internal Audit Annual Report/Head of IA Opinion (4) X

11. Annual Governance Statement

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X X X XX X X XX X X XX XX X X XX X X X Paper to September QBCX X Continue with Audit Progarmme and schedule

XXX X X X XX X X X X X X X X X X XX X X X X X X XX X X X X X X X

X X X XX X X X

MHAC Summary Report X

X X X XReview of Audit Committee Handbook XStatutory Submissions - Progress Report XBusiness and Attendance of Board/sub-Commitees XStatutory Submissions Lessons Learned XQuality Governance Assurance Framework X

Quality Committee BAF: Lead Executive Presentation

Payroll Data mining (5)

Counter Fraud Annual Plan (5)

DCHS Priority Clinical Audit Programme (10)

Charitable Funds Summary Report

No evidence of outcomes (a)

Quality Service Committee Summary Report (2)

Annual Governance Statement (11)Audit & Assurance Committee Summary Report (2)

Clinical Audit Update (10)

Quality Account 2012-13 Progress Report

Council of Governors Summary Report

Data Quality Update

0 2 0

Compliance with Governance arrangements (3)

Counter Fraud Annual Report (5)

NHS Protect Provider Standards

External Audit Progress Report (6)

Quality Account Review - External Audit

Compliance with Board Statements (8)Self-Certification Report - Financial (8)


Self-Certification Report - SOM (8)

Medication Error incidents (c)

Quality Business Committee Summary Report (2)Quality People Committee Summary Report (2)

Head of Internal Audit Opinion (4)

Risk Score Operational Risk ProfileLead KPIs


There is a risk to the organisation due to not having strong corporate governance systems in place resulting in Trust vision not being delivered (Risk Reg ID - 2383)

L2 x C5 = 10 Medium

Measure

To be developed

No Lead Sub-Group, papers presented to Audit & Assurance Committee. Papers to Board are in italics

1. Corporate Governance Manual Counter Fraud Report (5)2. Board Committee Reporting

Delays in roll out of TPP (c) Board Assurance Framework (9)

Internal Audit Progress Report (4)


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4.2.1

Risk DescriptionHigh Med Low

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X X XX X XX X XX X X X X X X X X X XX X X X X X X X X X XX X X X X X X X X X X

X

X2013-14 Annual Accounts Planning X

XX

Statutory Submissions Lessons Learned XQuality Governance Assurance Framework X

Going Concern ReportContracting Update

HMRC Compliance AuditContracting Action Plan

Self-Certification Report - SOM (2)Internal Assurance Provided

Missed Increments Briefing PaperPlan for Year End Reporting

Self-Certification Report - Financial (2)Compliance with Board Statements (2)Performance Report (3)

Quality Report (3)Finance Report (3)

2. Shadow Monitor Self-Certification 3. Performance Reporting



There is a risk to the organisation due to not meeting regulatory, contractual or legal obligations resulting in sanctions (Risk Reg ID - 2384)

L2 x C5 = 10

Medium

Measure Month 8

CQC registration, internal rating

1. CQC Compliance Reporting

Governance Risk Rating 1

Continuity of Service Rating 4


0 1 0


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4.2.2

Risk DescriptionHigh Med Low

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec Action Planned

X

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

X X X XX X X XX

X

5. Annual Governance Statement

Quality Governance Assurance Framework

Internal Assurance ProvidedBoard Assurance Framework Report (2)

Annual Governance Statement (5)Quality Committee BAF: Lead Executive Presentation

3. Risk Register4. NHSLA Standards

1. Risk Management Strategy Head of Internal Audit Opinion (5)2. Board Assurance Framework




There is a risk to the organisation due to not having strong risk management controls in place resulting in failure to put effective mitigation plans in place promptly (Risk Reg ID - 2385)

L2 x C4 = 8

Medium

Measure Month 8

1NHSLA Rating

0 1 0


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TRUST BOARD

Document Title: Chief Executive’s Report

Presenter/Title: Tracy Allen, Chief Executive

Contents of Paper were previously discussed by: N/A

Author/Title: Tracy Allen, Chief Executive


[email protected] 01629 817892




Information x Decision Assurance

Purpose of Paper

The report provides information on strategic policy, legislative and developmental issues affecting the organisation and includes: • Winter pressures • Planning for 2015/16 - the Forward View into Action • A briefing on introduction of the Care Act • Progress with the Extra Mile Awards • Headline organisational performance – ‘the Big 9’

Recommendations

The Board is recommended to note the report.


Planning and service transformation relate to the following BAF risks: 3.1.1, 3.1.2, 3.1.3, 3.1.4, 3.2.3 and 1.3.2. Winter pressures service continuity relates to BAF risk 3.2.7. Care Act implementation relates to BAF risk 3.1.4.

Financial Impact

No direct financial impact.

22�Chief�Executive�Report.pdf

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Chief Executive Report January 2015

1. Purpose of report

This report provides the Board with information about policy, legislative and developmental issues and changes which affect the organisation and local initiatives across the organisation in the past month.

2. Winter pressures : Supporting the system over the holiday period Board Members will be aware from national media coverage that since the beginning of December the NHS and Social Services have been under significant pressure due to increasing demand for urgent and emergency care. Levels of demand in primary care, 111, Out of hours, ambulance 999s and emergency department visits have been much higher than in previous years. So far no single reason has been identified for this. Locally in Derbyshire demand for acute, community and social care beds has been very significant. DCHS have been making a major contribution in maintaining the flow of patients through the system. We have contributed to regular conference calls across the whole system ensuring that patients are in the correct category of care for their condition, minimising delayed transfers of care and working closely with all parts of the health and social care system. This year we have more services operating on a 7 day basis than in previous years e.g. community OT and physiotherapy, SPA and clinical navigation operating at both Chesterfield Royal Hospital and Derby Hospitals Foundation Trusts. We have on several occasions opened additional community hospital beds in response to demand and our on call operational managers have responded at weekends to ensure responsive services. As a Trust we have been fortunate in maintaining all our services with very little impact from community infections and our colleagues have worked extremely hard, many doing extra hours and extra shifts in response to patient need. Some headline indicators of performance in the last 6 weeks include:

• An inpatient length of stay of 17 days • An increase of 30% in transfers to community hospitals (including 15% increase in

weekend transfers) • An increase of 30% in weekend discharges, with almost 50% of discharges occurring

in the morning • An increase of 32% in SPA referrals.

I know the Board will want to join me in thanking our community nursing and therapy teams, and inpatient colleagues, along with all the other clinical and non-clinical support staff who have delivered this level of service. 3. Planning for 2015/16 - the Forward View into Action Just prior to Christmas the 2015/16 planning guidance – The Forward View into action: planning for 2015/16, was published by NHS England, Monitor, The NHS Trust


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Development Authority, the Care Quality Commission, Public Health England and Health Education England. Key headlines from the guidance include a requirement for NHS organisations to refresh their operational plans for 2015/16, with an emphasis on including:

• aligned, realistic activity and financial assumptions; • a clear demonstration of how current access and performance requirements will be

consistently met, and; • emerging visions for the future of health and care systems based on units of planning.

Nationally defined access and performance targets remain largely consistent with 2014/15, with the addition of new access targets for some mental health services, and a requirement for Clinical Commissioning Groups (CCGs) to increase spending on mental health services.

3.1 General themes in the guidance:

• Preparing for transformation, building partnerships and looking at new models of care:

o support and funding available for pioneers; o the need to look afresh at medium-term plans.

• Getting serious about prevention:

o reducing health inequalities and improving outcomes in health and wellbeing (smoking, alcohol, obesity and diabetes);

o helping people stay in work or return to employment; o workplace health programmes (physical and mental health).

• Empowering patients:

o digital health record; o personal health budgets (also integrated with social care budgets) including for

people with learning difficulties and children; o patient choice, particularly in mental health and maternity.

• Engaging communities:

o support for carers, particularly young carers and those in work; community volunteers;

o getting funding in place faster for charities and voluntary sector.

• Primary care: o Support plan to be published in January; o not just GPs, but also community pharmacy, dentistry and aspects of eye care.

• Improved quality and patient safety:

o priorities and work plan for revitalised National Quality Board to be published in summer 2015;

o commendation of Medical Royal Colleges’ Guidance for taking responsibility: accountable clinicians and informed patients;

o continued drive to embed improvements in safe and compassionate care.

• Parity of Mental Health: o introduction of access and waiting time standards in mental health services;


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o provision of mental health support as integral part of NHS111, 24/7 Crisis Care Home Treatment Teams and enough capacity to prevent children, young people or vulnerable adults undergoing mental health assessment in police cells;

o investment in community child and adolescent mental health services; o community-based specialist teams for children and young people with eating

disorders.

• Learning disabilities (LD): o reduction in reliance on inpatient care for people with LD or autism.

• IMT:

o aiming for paperless NHS; o using data and technology to transform outcomes for patients and citizens; o expand provision of online services; o use of NHS patient ID number in all services; o electronic prescriptions, structured and coded discharge summaries; o interoperable digital records.

• Modern health and care workforce:

o workforce able to work across acute and community and beyond traditional professional demarcations with flexible skills and ability to adapt and innovate;

o creation of plans to develop existing and future workforce to deliver transformation and new models of care;

o introduction of nursing and midwifery revalidation from end Dec 2015. The Board will be considering the Trust’s developing operational plan in its January development session and the guidance broadly reflects our strategy and priorities. It provides assurance that the overall shape and focus of our system-wide transformational programmes in North and South Derbyshire are appropriate. Given this fit, and the progress being made on system transformation across Derbyshire, a key question will be the appetite for submitting applications to be part of the ‘vanguard’ or pioneer programme that is being initiated nationally. NHS England is looking for local systems who want to accelerate the development of the new models of care described in the Five Year Forward View. Further guidance on this is awaited and discussions with CCGs and other partners are ongoing. There will be an opportunity to discuss this in mode detail in the Board development session. 4. The Care Act The Care Act 2014 is a hugely significant development in the provision of social care. Having received Royal Assent in May last year, April 2015 sees the introduction of the first phase of Act, placing a new range of statutory duties on local authorities.

Phase two is concerned with the major reforms to the way that social care is funded, including the care cap and the care account, which will not come into operation until April 2016. Part 1 of the Act consolidates and modernises the framework of care and support law and includes: new duties for local authorities and new rights for service users and carers.

Parts 2 and 3 of the Act deal with recommendations from the Francis report (Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry), quality failure in health care


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providers and setting up a new performance rating system for health and care providers as well as establishing Health Education England and the Health Research Authority.

In summary the Act:

• modernises the framework of care and support law; • aims to make care and support clearer and fairer and to put people’s wellbeing at the

centre of decisions, and embed and extend personalisation; • places new responsibilities on Local authorities to support all local people, including

self-funders, and; • significantly changes the way that people will access the care and support system.

The Act has three main themes:

Wellbeing Principle: there is a new emphasis on wellbeing, with a new statutory principle of individual wellbeing underpinning the Act and as the driving force behind care and support. All local authorities have a general duty “… in the case of an individual, [is] to promote that individual’s wellbeing” and it applies equally to adults with care and support needs and to their carers. In certain circumstances it can also apply to children, their carers and to young carers in transition.

Prevention: local authorities (and their partners in health, housing, welfare and employment services) must now take steps to prevent, reduce or delay the need for care and support for all local people.

The Act attempts to rebalance the focus of social care on postponing the need for care rather than only intervening at crisis point. The aim is that the care and support system intervenes early to support individuals, helps people retain or regain their skills and confidence, and prevents needs or postpones deterioration wherever possible.

Integration: the Act includes a statutory requirement for local authorities to collaborate, cooperate and integrate with other public authorities e.g. health and housing when carrying out their care and support functions. It also requires seamless transitions for young people moving to adult social care services. The guidance identifies that it is important that engagement in the planning, preparation and delivery of the Act is wider than the adult social care function elements of local authorities, for example in relation to prevention, and information and advice.

In addition to placing very significant new demands on our Local Authority partners the act has implications for the Trust and other NHS organisations:

• NHS, housing and children’s services share the duty to integrate. • Partners and providers will find:

o a need to respond to the wellbeing principle (as reflected in 2015/16 Planning Guidance);

o greater local authority focus on promoting diversity and quality in the market and market intelligence about self-funders needed;

o greater local authority involvement in services focused on prevention and delay o national, not local, eligibility criteria; o new, statutory safeguarding arrangements.


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The implementation of the Act is being reported and considered through the Derbyshire Health and Wellbeing Board. This ensures that the wider implications are recognised and managed in related partnership workstreams such as the Better Care Fund implementation and our system transformation work. 5. Progress with the Extra Mile Awards Over the last three weeks Board colleagues have been involved in the judging panels for this year’s Extra Mile Awards, along with public and staff governors. With a record breaking number of nominations this year this has been an incredibly positive, uplifting and somewhat challenging process. I would like to thank everyone who has volunteered their time and participated so energetically. We have a fantastic range of shortlisted finalists and winners to look forward to recognising and celebrating with in March. 6. Headline organisational performance – ‘the big 9’

Month 9 performance against the Big 9 priorities for 2014/15 is attached.



Planning and associated transformation will be built on organisational and system engagement with governors.

Are there Equality & Diversity implications?

Our organisational and system plans and transformational programmes will involve service developments and changes. These will be co-developed with the community and subject to equality impact assessment.


Transformational programmes include engagement and communication workstreams.

Risk Register

Is the issue on the current Risk Register? N/A

Risk Number on Register N/A

Does this update recommend a change in the current risk score? (If so, please provide your rationale below) N/A


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Summary Report from Quality Business Committee



Name of Reporting Committee / Group: Quality Business Committee


Presenter: Tony Okotie, Chairman


Key Issues

7/15 Board Assurance Framework Quarterly Review - KF informed the Committee that an overview of Quality Business had been reviewed by the January Audit Committee. Owing to timing issues, the BAF had also been reviewed by the January Audit Committee prior to it appearing at this meeting of QBC. The Committee considered the level of risk assigned to each strategic risk and whether there were any further ‘Gaps in Assurance or Control’. CS recommended that: • 3.1.3 Risk to delivery of IBP due to changes in Commissioner priorities - the wording is to be extended to also include "and national policy" • 3.2.1 Estates - reduce the score from 12 to 8 • 3.2.5 IMT plans - increase the score from 8 to 12 (3 by 4) It was agreed that for 3.1.2 competitive environment - the score will be reviewed in March once we know the outcome of the Children's tender. The Committee took assurance from the report. 9/15 Performance Framework - CS discussed the proposed changes to the Trust Performance Framework. The document includes the learning from the successful foundation trust application, and the refinements required to adapt for the changing external environment we operate in. CS said that the updated version explicitly links to the BAF and its Key Performance Indicators. Each of the Board subcommittees will address the relevant sections of the Performance Framework in the new year. The Committee took assurance from the report. 10/15 2015/16 Planning Annual Planning TB updated the Committee regarding progress towards meeting the requirements from Monitor planning guidance and the one year operational plan. TB discussed good progress with work in conjunction with partner organisations. A draft plan will presented to Board in January Board and Monitor will receive a high level summary in February with sign off in April. A further session is to be arranged with the governors.

24�QBC�Summary�Report�Jan�2015

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Financial Plan CS presented an early view of the financial plan for 2015/16 and builds on the financial planning work undertaken as part of the development of the Trust’s Long Term Financial Model in 2014. Key work-streams are to be completed over the next couple of months before the final sign off of the plan in March 2015. The plan will be refined over the coming weeks as contract negotiations are completed, a review of the current level of reserves being planned for is undertaken and further detailed work around the Trust’s CIP programme is concluded. QBC will receive further updates in February and March which will inform the submission to Monitor in February and April. The Committee took assurance from the progress of the work.

11/15 Capital & Estate Programme Group Summary Report - WJ updated QBC that the majority of the Capital Programme 2014/15 projects are making satisfactory progress. Good progress is also being made with the 2015/16 programme and a paper will be presented to the February QBC meeting. WJ also informed the Committee that: the purchase of 84 Whitecotes Lane has now been completed; a Bariatric bed has been purchased; and that the action plan from 360 Assurance has been signed off. WJ went on to review the major decisions made by the group. The Committee took assurance from the work reported through the Summary Report. 12/15 Emergency Preparedness & Response (EPRR) Report - CWi reviewed the last six month’s activities to demonstrate compliance with NHS England’s Core Standards for EPRR and the requirements of the Civil Contingencies Act 2004. The Committee discussed:

The successful support that DCHS provided for the NHS England Dental Advice Line. The Committee thanked CWi, Melanie Curd and staff for their hard work. Their good work had been welcomed by NHS England

The failure of a number of GEM IT Services email servers in August 2014 causing roughly half of DCHS staff to lose access to their @dchs.nhs.uk accounts. The failure was thought to be down to the volume of data being stored in the email servers. The Committee asked CS to provide a report regarding the lessons learnt by GEM and what has been put in place to prevent a recurrence

The minimal disruption from recent industrial action and DCHS preparations for the forthcoming days of action

The Committee took assurance from the paper.

13/15 Informatics Programme Update including IM&T Summary Report - CS reported progress of the existing Informatics Programme including:

The rollout of TPP SystmOne in the Chesterfield locality.

Plans to extend the presence of VoIP telephony are on hold due to the requirement of significant capital investment to upgrade the existing VoIP platform. A business case is currently in development to assess the potential return on investment from any expenditure.

The Committee took assurance that that all appropriate steps are being taken to progress the Informatics programme in support of services and the Trust’s wider business objectives.


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14/15 Provision of Finance/Accounting and Payroll Systems and Service – Lessons Learnt - the Committee reviewed the lessons learnt from the procurement of financial accounting / payroll services. The Committee discussed the impact of capacity availability during the work. The contract with SBS has now been renegotiated with an 11.5% saving on the 2014/15 baseline contract. The Committee took assurance from the work to learn the lessons. 15/15 Analysis of Mileage Claims - AR provided analysis of mileage claims which shows an increase in mileage so far this financial year compared to a reduction target. The Committee considered the impact of the transition in patient care from community hospitals to community nursing - staff are working differently and mileage has increased. The brief analysis correlated increased mileage with increasing workload in community nursing. The Committee also identified the impact of where teams are not yet integrated, where the work is increasingly complex and where electronic support for mobile working is not yet in place. The Committee also agreed that future contract discussions should consider the travel costs of community nursing activity. TO said that it was important for staff working arrangements to be effective. The General Managers and Team Leaders should consider the most appropriate arrangements for allocation of workloads. To support the management of the work, there should be clarity regarding targets at a granular level which takes into account transport costs. The Committee took limited assurance from the report. TB was asked to include in the planning for next year: best practice elsewhere, understandable targets for activity and costs, and a toolkit for supporting manager ownership. 17/15 Performance Report - the Committee discussed performance highlights including red RAG rated KPI’s identified. People AR discussed work to improve the red RAG training performances. AR said that QSC had reviewed the Safeguarding training performance and it is noted that the compliance target is for achievement over three years. A trajectory for the training will be agreed. Absence has increased in line with seasonal expectations. Following the flu campaign, Occupation Health will refocus to support the work around long term sickness. Service WJ highlighted:

A&E Total Time in the A&E Department – at Buxton the longest wait of 480 minutes against target has been red rated. An exception report will be presented to the Board and relates to an ambulance delay

RTT Waits - 78.2% of Leicestershire Dental patients have been seen within 18 weeks against a target of 90%. WJ said that deterioration was due to University Hospital of Leicester cancelling all non-elected surgery owing to urgent care issues. This has been escalated with their Chief Nurse

Delayed Transfers of Care, OPMH - in December this was 7.9% against the target of 7.5%.


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The year to date score is 6.5%. The Monitor compliance score for quarter 3 is 8.4% and is also red rated. CS has asked Jo Furley to provide a report regarding the reasons for the deterioration and what actions are in place to improve performance.

Inpatients Average Length of Stay – this is now below the aspirational target of 20 days and is green rated. The service continues to work on reducing the average length of stay.

QSC had reviewed the performance of Total Harm Free Care elimination of the four harms which is green rated

CS and CW will discuss work required to improve our Clostridium difficile performance The Committee took assurance from the report. 18/15 Finance Report - CS reported that in Month 9 the accounts showed a surplus position of £1.10m, which represents a £0.43m adverse variance against the planned surplus of £1.55m. A year end forecast surplus of £1.6m is now expected due to delays in delivering the Cost Improvement Plan and increased pressures within the Clinical Services. The reduction in the year-end forecast surplus is a reflection of the increased financial pressures being experienced driven by overspending within Integrated Care Based Services (ICBS) and non-achievement of CIP plans. It also reflects the increased financial risk as we enter the winter period. The Trust is forecasting that it will meet all its statutory financial duties for the year. CS brought to the attention of the Committee:

Income - Cost and Volume activity is over performing by £0.15m in Month 9. The main areas driving this over performance are Planned Care Outpatient/Day Case £0.27m and Physiotherapy £0.16m. It is too early to identify this as a trend

CIP – There was an underachievement at month 9 of £648k. This is the net position after mitigations have been included. The Trust continues to develop further mitigating schemes, which will be used to address schemes that are under delivering

The Committee took assurance from the report.

19/15 Cost Improvement Plans (CIPs) Cost Improvement Plan Report - the Committee reviewed progress against the PMO schemes and transactional schemes and considered the shortfalls between actual and target figures. The report highlighted the slippages against expected CIP outturn and detailed any mitigation plans or non-recurrent savings that can be used to offset this. The Committee discussed the shortfalls regarding the IFM schemes and what work will now take place next year. TB confirmed that the PMO had received its final feedback regarding governance arrangements form 360 Assurance. All actions have been completed. Strategic Programme Group Summary Report - the Committee reviewed the key issues including approval of the project to transfer Stanton day unit services to the community. The Committee took limited assurance from the papers regarding the CIP. 20/15 Treasury Management Report - CS updated the Committee regarding management of the working capital. The Committee took assurance from the report.


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31/15 Board Assurance Framework, Risk and Self-Certification Issues - the meeting discussed and recorded assurance taken with respect to each appropriate paper as well as an evaluation of all risks discussed. Papers with limited or no assurance were: 15/15 Analysis of Mileage Claims 19/15 Cost Improvement Plan Report


No new risks were identified.


12/15 Emergency Preparedness & Response (EPRR) Group Terms of Reference - the Committee reviewed and approved the updated Terms of Reference, subject to one small amendment.

Items/issues referred to/from another Committee

During the meeting the Committee discussed three matters referred from Board: 10/15 The first draft of the CIP plan 14/15 Provision of Finance/Accounting and Payroll Systems and Service – Lessons Learnt 15/15 Analysis of Mileage Claims looked at the increase in transport costs There were no matters raised for Board briefing Issues for Governor Briefing - TB is to arrange a further annual planning session with the governors.

In Attendance

Tony Okotie TO Chair, Non-Executive Director

Tim Broadley TB Acting Director of Strategy




Amanda Rawlings AR Director of People and Organisational Effectiveness


Carolyn White CW Chief Nurse & Director of Quality

David Boddy DB Corporate Governance Manager (Minute Taker)

Chris Wildsmith CW Head of Emergency Planning


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TRUST BOARD

Document Title: Performance Framework Review

Presenter/Title: Chris Sands, Director of Finance, Performance and Information


Trust Management Executive, Quality Business Committee

Author/Title: Chris Sands, Director of Finance, Performance and Information


[email protected]




Information Decision X Assurance

Purpose of Paper

The purpose of the paper is to discuss the proposed changes to the Trust Performance Framework. The paper has been updated for comments made at the Quality Business Committee. Changes to the previous framework have been included in red.

Recommendations

Board members are asked to discuss the paper


4.2.1 – There is a risk to the organisation due to not meeting regulatory, contractual or legal obligations resulting in sanctions.

Financial Impact

None direct


25�Performance�Framework�Revie

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Draft Performance Framework

1. Introduction

This document sets out an overarching framework for an integrated approach to performance management within the Trust that supports the Trust’s commitment to being a leader of high quality healthcare services. The document includes the learning from the successful foundation trust application, and the refinements required to adapt for the changing external environment the Trust is operating in. It defines a way forward for improving the performance of the organisation through the areas outlined within the ‘DCHS Way’ - quality service, quality people and quality business. It supports the concept of service line management, driving down responsibility to service lines at the point of service delivery. This will be underpinned by a comprehensive reporting structure that delivers information to support the management of service lines. It provides a strategic framework to enable overall coordination of all performance management activities across the Trust and ensure alignment with the Trust’s business strategies and strategic objectives and underpins the Trust’s Board Assurance Framework. 2. Context The external environment and market place will provide a number of challenges that the organisation must address or mitigate in order to ensure a high standard and levels of performance. These include:

Requirements of the regulators and commissioners

Introduction of community quality performance indicators, and increasing focus on outcome measures

New models of care, and new contractual models for delivery of care

Development of internal and external benchmarking to access the organisations fitness for purpose

Care Quality Commission (CQC) Registration process and the legislation to support it

Need to evidence benefits from innovation, which can then be spread quickly across the organisation

Increasing competitive marketplace, and the need to evidence performance improvement to retain and win new business

Continued financial downturn

Sustained cost improvement programme (CIP) achievement to deliver annual surpluses

Requirement for better business information to make better decisions Increasingly over time the Trust Management Executive will develop as a “regulator” of the performance delivered by the Trust. Key to this strategic approach is the combined development of responsibility and decision making within the organisation. In tandem the role of the Board will develop to ensure that the Directors fulfil this role effectively.

3. Aims & Purpose

This document aims to establish a framework for performance improvement that focuses on delivering safe, high quality, effective and efficient services and to ensure compliance with the regulator, other statutory requirements and the key performance improvement priorities of the Trust. It also aims to ensure that the Trust develops an approach to ensure comprehensive performance management, with a focus on high standards of compliance against performance targets.


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The performance framework provides a systematic and planned approach to performance management and performance improvement. This will be underpinned by appropriate and timely monitoring of performance and individual responsibility, identifying accountability for achieving performance and ongoing improvement. This framework will use the DCHS Way as the overarching strategy and guiding principles in its approach to performance management and regulation, with quality being core and central to everything we do and measure. The three domains of the DCHS way will drive the approach from service level through to reporting to the Board of Directors, which in itself will ensure a clear structure to providing the appropriate assurance through to the Board Assurance Framework. We will therefore ensure that our performance framework monitors progress against addressing our strategic risks on the Board Assurance Framework, as well as our operational targets and priorities. 4. A framework for our approach Monitor identifies five key components of an effective performance improvement system. These will act as the driver and the spine of DCHS performance management and provides a clear framework from which we can continuously review our structures and internal accountability: 1. Clear targets and accountabilities linked to effective planning

A justification for each KPI included on the performance framework – Regulatory, Contractual or local

Clear KPI’s broken down to sub-organisational level

Each target is linked to a formal accountability with a lead manager, and lead Committee

2. The right, ‘forward looking’ performance tracking Efficient data collection

Reliable, user friendly information systems

Consistent format and frequency

Forecast data to highlight expected trends

Scenario planning with risk identification and mitigation plans

Clear actions and plans in place prior to any projected breach

Use of statistical techniques to identify random, causal fluctuation and variation from plans

3. Effective review meeting structure Clear and consistent sequence of review meetings

Clear terms of reference for each meeting

4. Good performance conversations The right behaviour and mindsets

A solution/action focused meeting process

5. Rewards and consequences

Recognition of strong performance, a culture of celebrating success

Rewards linked to achievement of specific, agreed targets

Clear remedial actions linked to under-performance

Collaborative mechanisms to prevent divisions/services behaving to the determent of the whole trust’s benefit

An initial assessment will need to be undertaken to understand the detailed implementation plan with an on-going review of our performance against this framework.


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5. Involvement It is clear that for any organisation to achieve high performance standards, the goals, objectives, targets and the actual performance needs to be owned at the appropriate level. The stakeholders and critical success factors for the delivery of each target at a service level need to be identified and brought into the performance cycle where influence can be captured. By having a devolved performance management system, the Trust will promote involvement from all its key stakeholders including staff, service users, carers, members and commissioners. This will help to connect the proper use of performance indicators with the achievement of the organisations objectives and goals.

6. Implementation

Successful implementation of the performance framework assumes that there is a clear and agreed process for annual review and target setting that is linked to business planning and strategy review. This is underpinned by the framework described in section 4. The Trust has a strong over-arching strategy in place for its vision, objectives, culture and values through the creation and implementation of the DCHS Way. Through the DCHS Way, the organisation has a clear path of informing objectives from individual staff objectives up to the Integrated Business Plan. However, for these to influence our performance, five specific key enablers will be in place to support an effective performance management culture and the framework itself: A full assessment will be undertaken to understand the current position against each ‘component’ highlighted above. This will form a high level implementation plan to ensure the framework is embedded within the Trust. This must be cross referenced to the underpinning values of the framework described in section 5.


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7. Reporting & Monitoring

The diagram below describes the high level process for formulation of objectives and targets along with the organisational reporting and monitoring cycle.

Formulation & Reporting

The diagram above highlights the relationship between the planning and target setting cycle with the performance tracking and accountability processes. This relationship is vital to ensure the organisation can measure its progress and achievement against strategic objectives but also so individual services can understand how they contribute and influence achievement of wider organisational priorities.

Underpinned by

‘Board to Front Room’

culture and philosophy

CQC

Registration

Local

Targets

Monitor

Complianc

e

QPMR by

division using

real time

information

Clear targets

and

accountabilities

at ‘The DCHS

Way’,

Divisional &

Internal

monthly review

process through

TME

Formal monthly

review through

Quality

Committees

Actions and

mitigation with

rewards and

consequences

Setting

Strategic

Direction

Based On

Vision Strategic

Objectives, and

Business plan

development

Performance

Strategy

development

Agree

reporting framework

Targets broken down

with clear metrics as a result of target setting

Conversations

Dashboards

and structured

reports and

reporting

periods

Analysis of information and

a clear

understanding

of the picture

Linked to

agreed

outcomes

To include dialogue

with deliverers of care at all tiers in

the hierarchy

Key

Stakeholder

Requiremen

ts

Strategic

Annual

Review


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7.1 Performance Tracking

In order to ensure that performance can be tracked effectively there are a number of processes that need to be working effectively not least the delivery of information requirements.

As part of the Information Management & Technology Strategy, further implementation and review of management information and business intelligence systems will be key in meeting the Trust’s needs and allow the presentation of information and data back to managers that can be scrutinised and analysed at the appropriate level in the performance hierarchy to allow the speedy identification of areas of concern, to enable “drill down” to find the root cause, provide a consistent format for the presentation of data at each level of the organisation and ensure reports are available to all decision makers within the Trust.

Furthermore, this will be reviewed annually as part of the review of the long term IM&T strategy and the annual plan.

Increasingly the Trust will be measured on a wider range of indicators, particularly as community specific targets are developed and introduced. Therefore performance measurement is fundamental to the success of the organisation. Therefore the organisation must develop the appropriate ‘culture’ within the

Monitor (2009)

Week 1 Week 2 Week 3 Week 4

Internal team

performance review

Internal Performance Meetings

Each service line reviewed

Divisional Performance

review (Quarterly)

Trust Management Executive

meeting:

Trust priorities and cross-

divisional / service issues

External developments and implications

Critical specific service issues

Trust Executive

AD Division

Service / General

Manager

Team Level

Trust KPI Report Specific KPI

Report

KPI Report from

service line

Divisional KPI

report

Required

reports


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Trust to encourage and create the right behaviour, mindsets and solutions focussed approach. This will be adopted through the values and principles described in the DCHS Way.

7.2 Performance Meetings

As highlighted in both the two previous diagrams, performance conversations in every part of the organisations formal and informal structures are essential. However, the structure and objectives of formal performance meetings should be clear and transparent.

Formal performance reviews will be held on a quarterly basis with each division and the executive team and will be focused around delivery against the domains of the DCHS Way but will also focus on the risks and mitigation plans for each division. More informal meetings will take place monthly with the Director of Finance, Performance and Information.

The key issues from the performance reviews will be reported through to the Trust Management Executive (TME) and the Board of Directors. These issues will be discussed on an exception basis.

Each of the Trust Committees will take responsibility for their domains of the DCHS Way, and will provide assurance to the Board on the actions being taken to improve performance where required. The KPIs will be reviewed and assigned to each of the Board Committees.

The framework highlighted in section 4 will obviously drive the content and style of the actual reviews.

7.3 Performance Systems

Highlighted within the key enablers is the critical need for robust, reliable and real time information. The Information Management & Technology Strategy sets out the vision and plan for not only a suitable system to provide and produce performance reports but also the fundamental data collection systems and process to ensure complete and accurate information is driving, ultimately, our decision making.

The Trust has invested in Business Intelligence, and is now starting to populate the new Microstrategy product with KPIs. The strategic roadmap for this system plans to move the production of all KPIs through this system, which will allow the requirements for Board, Committees, Divisional meetings and point of delivery meetings to be sourced from one place.

Through the implementation of both this performance framework and the IM&T Strategy, consideration will need to be given to the timing of information in terms of this support real time, speedy decision making. The use of forward looking, predictive analysis tools and flash reporting should be considered to allow the organisation to be as flexible as possible in both reactive and proactive responses and actions.

The diagram under section 7 describes the importance of an annual review of the performance framework and its relationship with other strategies.

8. Data Quality

Good quality data is a fundamental requirement for the delivery of high quality services. To that end the IM&T Strategy has placed specific emphasis on enabling services to record clinical information at the point of care (or as close to) via the implementation of TPP. A strategic roadmap is in place to deliver on this with key priorities being the completion of the TPP rollout across the ICBS community services in the north of the county, the migration of hospital-based services from iPM PAS to TPP, and the extension of the TPP mobile working solution for peripatetic staff.


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Allied to the rollout of electronic solutions is the need to provide automated reporting in near real time to effectively manage data quality at a service level. There is a desire to provide this from the centralised business intelligence (BI) portal and the ownership of the data must be the responsibility of those users who enter it. System ownership of data quality must ultimately lie with the information Asset Owner (IAO) for each service/KPI. The quality of all source system data and KPI reporting thereon will be governed by the full roll out of the data quality kitemark. This will be the central point of assurance for all data reported internally and externally for the Trust. It is vital that service ownership of the kitemark is established and embedded to improve awareness of the process and to also support the ongoing maintenance programme, which is currently managed by the informatics team. The oversight of the full KPI list and source data related to this will be owned by informatics in partnership with the performance team with executive approval.

9. Performance Cycle

The diagram above outlines the process that the Trust should take at a minimum on an annual basis. As in year reviews of the Trust take place then these will feed into the process and be written into performance relationship or contract with each tier of the performance hierarchy.

10. Performance Overview

This document provides the framework and sets a structure for our performance culture. This framework will need to be underpinned by an implementation plan which strongly links to the Trusts performance culture and behaviour as set out within the DCHS Way and the subsequent approach to service line management as a whole.

Review of last year’s performance and any on-going/remedial action

Agreeing local action to deliver new targets, standards, contracts, etc

Develop performance and actions and if necessary improvement plans at each level with clear roles and responsibilities

Develop data collection processes and reporting framework

Develop benchmarks and trajectories and agree for each level & monitor

Review and refine performance framework as a mechanism for deliver of performance structure in light of the above.

Identify and agree business support for improving performance

CQC QRP Requirements, New National and local targets, internal targets


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APPENDIX 1

ACTION PLAN

Action Detail Responsibility Timeline

1. Review of all KPIs on performance framework

KPIs to be reviewed and:

Assigned to domain of DCHS Way

Reviewed to ensure KPIs are relevant, and none missing

Agreed with Executive lead

Agreed with Board Committee

Sign off by Board

Senior Management Accountant

February 2015

2. Review of strategic risks on BAF, and review of performance KPIs

KPIs for the Board Assurance Framework to be reviewed to ensure all strategic risks are covered, and that

Senior Management Accountant

February 2015

3. Documentation of each KPI

All KPIs to have a Control Sheet completed which sets out:

The purpose of the KPI

The committee responsible for the KPI (QPC, QBC, QSC)

The source of the KPI; national, local, or commissioner

The definition of the KPI

The source of the data

The KPI owner

Head of Information / Senior Management Accountant

March 2015

4. Development of Business Intelligence to Capture all KPIs

KPIs to be automated on the Business Intelligence system. Progress to be monitored through

Head of Information

TBC pending agreement of KPIs

5. Identification of Data Quality / KPI leads for each division

To support the development of good data quality for all KPIs, divisions to identify a lead to work with informatics to promote the data quality kitemark initiative in each area

Assistant Directors

January 2015

6. Expansion of kitemark across all KPIs

Head of Information

TBC pending agreement of KPIs

7. Review timings of divisional performance meetings to feed TME and Board

Divisional meetings are currently scheduled for the week after Board and TME which does detract from a full discussion at these meetings. Propose that future meeting take place the week of TME and Board

Director of Finance, Performance and Information

January 2015 for implementation May 2015

8. Review of presentation of performance report

Head of Information / Senior Management Accountant

May 2015


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A robust performance framework is required in place to report progress to Governors against regulatory KPIs

Are there Equality & Diversity implications? There may be implications in the choice of KPIs


There may be implications in the choice of KPIs

Risk Register




Yes No N/A


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TRUST BOARD

Document Title: Performance Report – January 2015

Presenter/Title: Chris Sands, Director of Finance, Performance & Information


Author/Title: David Caddy, Management Accountant, Performance & Costing Kate Davis, Head of Costing and Performance

Contact Email and Telephone Number: [email protected] 01246 253042

Date of Meeting: 29 January 2015. Agenda Item No: 26/15



Information x Decision Assurance x

Purpose of Paper

The Board Performance Report sets out a summary of DCHS’ performance against the three DCHS Way focus areas of Quality People, Quality Service and Quality Business. The Balanced Scorecard has been reviewed to incorporate the contractual and other performance regime changes in 2014/15. There are 115 green, 30 amber, 25 red and 50 unrated year to date indicators this month. The Overview of Measures at page 13 gives further details. The table below summarises the red rated year to date KPI’s. These are the key issues for the Board to focus on from a performance perspective. There are 23 red rated KPI’s identified below, all of which have exception reports provided within this report. In addition there are 2 red rated Benchmarking KPI’s which aren’t listed due to these not being specific DCHS performance measures. Individual Scorecard measures are also excluded, since they already have an overall rating in the Performance Report.

26�Performance�Report�Jan�2015

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Recommendations

Note and comment


3.1.2 There is a risk to the organisation due to loss of business as a result of not actively managing the more competitive environment resulting in financial loss (Risk Reg ID - 2371) 3.2.3 There is a risk to the organisation due to the inability to meet financial targets, specifically cost improvement plans, as set out in Annual Plan and IBP resulting in financial risk and reputational damage. (Risk Reg ID - 2374) 3.2.4 There is a risk to the organisation due to the inability to meet contractual activity targets, resulting in financial risk (Risk Reg ID - 2375)


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3.2.6 There is a risk to the organisation due to poor decisions being made due to poor data quality resulting in poor outcomes and financial loss (Risk Reg ID - 2378)

Financial Impact

The report contains a number of issues and risks that have a financial impact on the organisation. These are detailed clearly within the report including, where appropriate, any mitigation plans and strategies that are in place.


Attached



The Governors will hold the Board to account for the performance of this organisation.


There may be Equality and Diversity implications for Individual KPI’s


The public and stakeholders will hold the Board to account for the performance of the organisation.

Risk Register


Risk Number on Register Smoking Cessation – 2417 Breastfeeding Sustrainment-2549 Avoidable Pressure Ulcers-2225


At QBC on Wednesday 19 March 2014, the Committee discussed what should be recorded on the Cover Sheet with respect to the issues in the Performance Report that are also on the Risk Register. It was agreed that new exceptions, that impact on risks currently on the Risk Register or raise a new risk should be recorded in the Risk section.


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Board Performance Report – January 2015 Background The Board Performance Report sets out a summary of DCHS’ performance against the three DCHS Way focus areas of Quality People, Quality Service and Quality Business. Section Index Document Page No’s Summary Document - Overview 2 – 3 Risk Assurance Framework Scorecard 4 Monitor Organisational Health Scorecard 5 Summary Document – DCHS Balanced Scorecard 6-11 Overview of Measures 13 DCHS Balanced Scorecard 14 – 18 HCAI Scorecard 20 CQUIN Scorecard 21 HWI Scorecard 22 RTT Waiting Times Scorecard 23 Exception Reports 25 – 39 Glossary 40 – 42 Key for RAG, arrows and Data Quality Kitemark 43


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OVERVIEW Summary Overview

This month there are 115 green, 30 amber, 25 red, and 50 unrated indicators. The Overview of Measures at page 13 gives further details.

2013/2014 targets were reviewed by the Quality Business Committee at its April 2014 meeting. Contributors have been given the opportunity to propose changes to internal measures and we will continue to review and confirm all targets.

Benchmarking measures have been reviewed by the Aspirant Community Benchmarking Club. Measures have been removed and added as indicated in the report. New measures will be added as information becomes available.

Following a Board discussion, the Exception Report template has been revised to include separate areas for the summary of issues, an action plan, including assignment of responsibility for the action and a section for timescales. We introduced forecasted positions from month 5 (August) onwards.

The Trust is continuing to improve Performance Reporting within the Business Intelligence solution. These developments will facilitate consolidation of measures, improved efficiency in the collection of information, and provide greater sophistication in the rating of measures.

Data Quality Kitemark ratings have been included in the Balanced Scorecard where available. This Kitemark acts as a visual indication of data quality. Further information regarding this can be at page 43.

A secondary set of Monitor Organisational Health Indicators is now included

at page 5. These measures are derived from the Monitor Consultation on updates to the Risk Assessment Framework, published in December 2014.


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Details – Monitor Risk Assurance Framework Scorecard The Monitor Risk Assurance Framework Scorecard – This is presented at

page 4. The Monitor Compliance Delayed Transfer of Care is 8.4% and is red rated. Following discussions with Commissioners, the revised Monitor measure for Clostridium Difficile lapses is 0 for December and 1 for the year to date. This has been green rated.

A secondary set of Monitor Organisational Health Indicators is now included at page 5.


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Monitor Risk Assurance Framework Indicators

Measure Measure-Sub GroupRAF Appendix

A AreaRAF Target

2014/15Q1 14/15 Q2 14/15 Q3 14/15 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Narrative

RTT Waits - admitted patients 90th percentile (weeks)

See note 1 1 90% 93.3% 94.7% 95.5% 94.0% 95.0% 93.3% 93.1% 90.7% 94.7% 95.2% 92.8% 95.5%Quarterly scores are quarter ending

scores

RTT Waits - non admitted patients 95th percentile (weeks)

2 95% 99.0% 98.5% 98.4% 99.0% 99.0% 99.2% 98.6% 100.0% 98.5% 97.5% 99.6% 98.4%Quarterly scores are quarter ending

scores

RTT Waits - incomplete pathway 92nd percentile (weeks)


scores

A&E 4 Hour Wait for A&E Attendances (%) 4 >95% 100.0% 100.0% 100.0% 99.5% 99.8% 100.0% 100.0% 99.9% 100.0% 100.0% 100.0% 100.0%Quarterly scores are quarter ending

scores

Healthcare Care Associated Infections - Clostridium difficile lapses (no.)

14 12 (year) 1 1 0 0 0 1 1 0 0 0 0 0Quarterly figures are just for the

quarter

Delayed Transfer of Care for OPMH - Monitor compliance framework calculation (%)

16 <7.5% 6.6% 4.4% 8.4% 7.1% 5.1% 6.6% 4.3% 4.9% 4.4% 8.7% 8.7% 8.4% Monitor quarterly calculation.

Mental health data completeness: identifiers 17 97% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Certification against compliance with requirements regarding access to healthcare for people with a

learning disability19 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

To be reported to EDS & quarterly to QSC

Data completeness: community services , comprising:

referral to treatment information


scores


referral information 20 50% 74.7% 74.7% 75.4% 74.7% 74.7% 74.7% 74.7% 74.7% 74.7% 75.4% 75.4% 75.4%Quarterly scores are quarter ending

scores


treatment activity information


scores

Governance Score Rating 0 0 1 0 0 0 0 0 0 1 1 1

Monitor & TDA reporting periods are shown

Note 1 - Delayed Transfer of Care calculation for October has been revised from 10.6% to 8.7%Note 2 - Changes to April & June Clostridium Difficile figures made in Novemberote 3 - Clostridium Difficile Figures now relate to lapses

Reporting Method TDA

Only measures applicable to DCHS are show

Monitor


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Monitor - Organisational Health Indicators

Measure Measure-Sub GroupTarget

2014/15Q1 14/15 Q2 14/15 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Narrative

Patient Metrics-Patient Satisfaction - Friends and Family

Patient >71 89.0 91.0 84.0 90.0 89.0 88.0 87.0 91.0 87.0 89.2 90.9 Quarterly scores are quarter ending scores

Staff Metrics-Executive Turnover Staff2 or less in 6 months

0 0 0 0 0 0 0 0 0 0 1 Quarterly scores are quarter ending scores. Board turnover figure

Staff Metrics-Staff Satisfaction-Engagement Rates Staff 76.8% 76.2% 76.0% 76.2% 76.2% 76.2% 76.0% 76.0% 76.0% 76.0% 76.0% Quarterly scores are quarter ending scores

Staff Metrics - Pulse Check - Recommend DCHS to Friends and Family as a Place to Work

Staff 72% 71.0% 71.0% 71.0% 71.0% Quarterly scores are quarter ending scores

Staff Metrics-Sickness Absence Rate Staff 3% 3.0% 4.0% 4.3% 3.6% 3.4% 3.9% 3.6% 3.7% 4.1% 4.1% 5.0% Quarterly scores are quarter ending scores

Staff Metrics-Proportion of Temporary Staff (Agency & Bank) as a % of total workforce costs

Staff 3.8% 3.2% 2.0% 3.5% 3.8% 3.3% 2.7% 3.2% 3.0% 2.4% 2.3% Quarterly scores are quarter ending scores

Overal Score Rating 2 3 1 1 2 2 3 2 2 2 2

Reporting Method TDA Monitor


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Board Performance Report – January 2015

Details – DCHS Balanced Scorecard QUALITY PEOPLE HEADLINES : (page 14) Key Issues

Total Workforce Costs (£,000) – The year to date costs for our workforce are £83,478k against our target of £83,450k and is amber rated.

Health Visitor WTE (no) – The Trust has target of 145.0 Health Visitors for the year to date and a total of 146.5 Health Visitors for the year end. In December, we had a total of 132.5 Health Visitors and 6 Family Nurse Partnership staff, making a total of 138.5. This has been amber rated.

Staff Attendance (%) – Attendance in December has decreased to 94.99%. The rolling 12 month attendance is 96.03%. Our December absence rate is 5.01%. Long term sickness is 3.06% and short term is 1.95% (long term is those absences over 30 days). Anxiety, Musculoskeletal and Colds, Coughs and Influenza were the main issues this month. The Attendance Management Group meets on a monthly basis to address attendance issues.

Board Turnover (no) –A Non-Executive member of the Board resigned in December. The previous resignation was recorded in July 2013. This has been green rated since the target is 2 or less resignations within a six month period.

Staff Turnover (%) – This measures the movement of employees joining and leaving DCHS and can be an indication that DCHS is viewed as a good place to work. Staff turnover was 9.41% which is green rated against a plan of 14%.

Vacancies - Average Length of Time (days) – The Average Length of Time

to Recruit is 53.4 days and is green rated against a target of 60 days. The Average Length of Time from Offer to 1st Working Day is 38.0 days against a target of 40 days and in green rated. The average Length of Time for Pre Appointment checks is 16.1 days against a target of 21 days and is green rated. In December, 5.64 wte posts were not filled first time due to candidates not being suitable or a limited amount of candidates being available for interview.


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Essential Learning (% Compliance) – The Essential Learning day covers

the key areas of Core Mandatory Learning identified by DCHS and supports compliance with the NHS Litigation Authority and CQC requirements. All staff are required to complete the Essential Learning Course every two years. 94% of staff have completed their Essential Learning within the past 2 years, as at the end of December. This remains amber rated. Alternative methods of delivering the training including e-learning are being developed to help improve this level of performance.

Information Governance Training (% Compliance) – Information Governance Training needs to be completed annually by all staff. This training can be undertaken by attending the Essential Learning day, completing a workbook or via e-learning. The Trust has a target that at least 95% of staff complete this training annually. As at the end of December the Trust’s performance is 91% of staff being compliant with this training requirement and is amber rated.

Fire Training (% Compliance) – DCHS staff are required to complete annual Fire Training. There are a number of delivery methods for this training including e-learning. The Trust has a target that at least 95% of staff receive this training annually. However, this still remains a challenging target with a compliance of 90% in December. This target is amber rated.

Training - Resuscitation & Safeguarding (% Compliance) – Resuscitation

and Safeguarding compliance have now been reported under separate headings. Analysis of compliance shows that • 84% of clinical staff have completed Resuscitation Training, • 69% have completed Safeguarding Children Level 2 • 84% have completed level 3, where this is required for their role. • 59% have completed Safeguarding Adults level 2. The Level 1 element for both Adults and Children’s safeguarding is included within the Essential Learning programme that all staff (clinical and non-clinical) undertake every 2 years. Safeguarding is green rated against each levels’ year to date target. Resuscitation is red rated against a target of 95%. The Resuscitation exception report is presented at page 25.

Staff with Appraisal Completed (% Compliance) – 100% of our staff are expected to receive an annual appraisal. The aim of appraisals is to provide a comprehensive review of the performance of individual staff, identify any training and development needs and to record their overall contribution to the organisational goals of DCHS. Performance in December remained below this target, with 86% of staff having received an appraisal in the last year. This measure has again been red rated. Directorates are being reminded that they should have a robust process in place to ensure all out of date appraisals are chased and put back on track. Given the current performance, this remains a


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key area of focus for DCHS. Further details regarding current performance and improvement plans are provided in an exception report at page 26. QUALITY SERVICE HEADLINES: (pages 15 - 16) Key Issues

The HCAI summary is presented at page 19. A review has been undertaken during January 2015 of Clostridium difficile infections data to ensure that it reflects the national reporting requirements. Commissioners, in reaching their decision on whether an individual case of C. difficile should count towards the aggregate number of cases on the basis of which contractual sanctions are calculated, may take into account information about the extent to which individual CDIs are linked, or not with lapses in care by the relevant organisation reporting the infection (Clostridium difficile infection objectives for NHS 2014).

To date there have been 12 positive results reported for DCHS. Clostridium Difficile figures now include an agreed lapse count, following agreement with our Commissioners. The number of cases identified as having a lapse in care is the reporting data required by Monitor. The actual number of agreed lapses in care is 1 for the year to date against a target of 9. This is discussed in the Quality Report. There are a further 6 cases where Root Cause Analysis (RCA) is in progress.

The CQUIN summary is presented at page 20. The reduction in the prevalence of pressure ulcers by 1.5% is green rated for the month and has been red rated for the year to date. An exception report is presented at page 27.

The RTT Waiting Times scorecard is presented at page 23. An exception

report is also included for the 35 13 week waiters in the AHP Respiratory Service at page 38.

Complaints (no) – The number of complaints received in December was 8. This information has been reconciled to DATIX and confirmed by the Patient Support Team.

A&E Total Time in the A&E Department (non admitted) - Longest (mins) – We had a longest wait of 480 minutes at Buxton against a target of 360 minutes. This has been red rated. An exception report is presented at page 29.


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RTT Waits - admitted patients seen within 18 weeks - (%) (target) (1A) –

78.2% of Leicestershire Dental patients have been seen within 18 weeks against a target of 90%. This has been red rated. An exception report is presented at page 39.

Patients who have operations cancelled for non clinical reasons on the day (%) – In December no patients had operations cancelled against a target of 0.8. This has been green rated. The year to date figure is 0.54% and is green rated.

Delayed Transfer of Care - OPMH (%) – DCHS have a target to reduce the time patients stay in an OPMH bed as a result of transfer delays. In December this was 7.9%. This is above the target of 7.5% and is therefore red rated. The year to date score is 6.5%. The Monitor compliance score for quarter 3 is 8.4% and is also red rated. An exception report is presented at page 29.

Inpatients Average Length of Stay (no) – DCHS have a target to reduce the average time patients stay in an inpatient bed by increasing the amount of care provided in the community. The average length of stay in December was 17.7 days and the 3 month year to date performance decreased to 19.4 days. This is now below the aspirational target of 20 days and is green rated. The service continues to work on reducing the average length of stay.

Total Harm Free Care, in accordance with Safety Express (%) – The elimination of the four “harms” of Pressure Ulcers, Falls, Urinary Tract Infections and New Venous Thromboembolism falls to an green rated score of 93.78% for December, against the Trust target of 93%. Our year to date target is amber rated at 92.31%. Further information will be presented in the Quality report.

Avoidable grade 2, 3 & 4 Pressure Ulcers – Avoidable grade 2, 3 & 4

Pressure Ulcers (no) – In December 3 instances were recorded. This target is red rated and is discussed in the Quality Report.

Falls resulting in severe injury or death (no.) – There were 3 falls reported

on STEIS in December. This measure remains red rated. Further information will go to the Quality Service Committee (QSC). Falls prevention strategies continue to be developed to reduce the risk of an event. An exception report is presented at page 30.

Breastfeeding sustainment from 10 days to 6-8 weeks after birth (%) –With our support, 79% of mothers have sustained breastfeeding for 6-8 weeks after birth for the year so far. We had planned to achieve 84%. This measure is red rated. An exception report is presented at page 31.


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Integrated Wellbeing-Smoking Quitter & Weight Management Indicators

– The New integrated Wellbeing Service contract began in December 2014, replacing the previous smoking measures. This has been given an overall red rating. A more detailed summary set of measures have been included at page 21. Exception reports have been presented at pages 32 to 34. QUALITY BUSINESS HEADLINES: (pages 16 - 17)

The Monitor Risk Assurance Framework Scorecard – This is presented at page 4. The Monitor Compliance Delayed Transfer of Care is 8.4% and is red rated. Following discussions with Commissioners, the revised Monitor measure for Clostridium Difficile lapses is 0 for December and 2 for the year to date. This has been green rated.

A secondary set of Monitor Organisational Health Indicators is now included at page 5. These measures are derived from the Monitor Consultation on updates to the Risk Assessment Framework, published in December 2014. Key Issues

Better Payment Practice Code (%) – DCHS is signed up to the Better Payment Practice Code (BPPC) which means we aim to pay at least 95% of suppliers within 30 days. In December we were green rated for the value measure with a score of 96.84%. The year to date score is green at 97.29%. We are red rated for the volume measure with a score of 91.79% for December and a year to date score of 96.93%. Delays in the authorisation of one invoice for payment to a supplier meant that the invoice was paid late. Further training for the relevant parties has been carried out. This was discussed in the Treasury Management Report at the Quality Business Committee (QBC).

Activity Performance (no.) – Activity Performance (no.) – The majority of service lines are either overperforming against their year to date profiled activity plans, or have very low and therefore recoverable levels of underperformance. Activity in December has been maintained for most specialties. An Exception report for Vasectomies has been included at page 35.

FT Membership (no.) – Our Foundation Trust Membership has increased to

12,541 members against our aspiration of 12,502 members is green rated.


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We are aiming to have recruited between 12,500 and 13,000 members by the end of March 2014/15.

Health Visiting (all measures ) – We screened 90.5% of babies within 10-14 days in December, against a target of 95%-100% giving a year to date figure of 90.1% which is amber rated. The percentage of mothers who received an antenatal contact in December was 68.4% against a target of 95%. This has been red rated. The year to date measure is 66.3%, which is also red rated. An exception report is presented at page 36.

Chlamydia Screening (no.) - We screened 61 clients in December giving a

year to date figure of 1,307 which is below our plan of 2,706 clients and is therefore red rated. An exception report is presented at page 37.


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DCHS

Board Performance Management Reports January 2015


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Month

Measure

Monitor Risk Assurance Framework Scorecard

Scorecards-Monitor Risk Assurance Framework 11 (11) 10 (10) 0 (0) 1 (1) 0 (0)

Scorecards-Monitor Organisational Health Indicators 6 (6) 2 (2) 2 (2) 0 (0) 2 (2)

Totals 17 (17) 12 (12) 2 (2) 1 (1) 2 (2)

DCHS Balanced Scorecard

Quality People 28 (28) 9 (7) 8 (7) 2 (5) 9 (9)

Quality Service - Service User Experience 22 (22) 11 (12) 2 (2) 3 (2) 6 (6)

Quality Service - Service User Safety 18 (16) 11 (10) 2 (2) 3 (2) 2 (2)

Quality Service - Clinical Effectiveness & Planning 4 (4) 0 (0) 1 (1) 3 (3) 0 (0)

Quality Business - Finance 3 (3) 2 (2) 0 (0) 1 (1) 0 (0)

Quality Business - Business & Marketing 17 (17) 6 (7) 3 (3) 3 (2) 5 (5)

Quality Business - IM&T 5 (5) 4 (5) 1 (0) 0 (0) 0 (0)

Quality Business - FT Regime 6 (6) 5 (5) 1 (1) 0 (0) 0 (0)

Aspirant Community FT Benchmmarks 20 (20) 12 (14) 6 (4) 2 (2) 0 (0)

Totals 123 (121) 60 (62) 24 (20) 17 (17) 22 (22)

Other Scorecards

Scorecards-Healthcare Associated Infections 17 (16) 15 (14) 2 (2) 0 (0) 0 (0)

Scorecards-CQUIN 14 (14) 10 (8) 2 (3) 1 (1) 1 (2)

Integrated Wellbeing 49 (0) 18 0 6 25

Totals 80 (30) 43 (22) 4 (5) 7 (1) 26 (2)

Grand Total 220 (168) 115 (96) 30 (27) 25 (19) 50 (26)

Percentages Allocated 100% 77% 52% 44% 14% 12% 11% 9% 23% 13%

The previous month totals are shown in bracketsMeasures included:

Quality ServiceCQC Non-Compliance with Essential Standards resulting in Enforcement ActionHealthcare Care Associated Infections - Clostridium difficile -lapses count (no.)Measures removed:

Derbyshire Community Health Services Board Performance Overview of Measures

January-15

Total Number of YTD

Measures Rated Green

Total Number of YTD

Measures Rated Amber

Total Number of YTD Measures

Rated Red

Total Number of YTD Unrated

Measures

Total Number of Measures


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Measure Type Frequency Director 2013 / 14 Outturn

2014 / 15 Full Year Target

Year to Date Target

Year to Date Q1

Year to Date Q2

Year to Date Q3

Oct-14 Nov-14 Dec-14 Trend Year to Date Narrative

Total Workforce Cost (£000s) 12 Internal Monthly DoHR 120,703 110,992 83,450 27,952 55,683 83,478 9,317 9,235 9,225 83,478 Includes Agency & Bank. Plan revised to match QBC Finance report.

Temporary Staffing Costs - Agency (£000's) 12 External Monthly DoHR 3,394 0 0 620 1,225 1,679 173 154 127 1,679 Funded by vacancies budget.

Temporary Staffing Costs - Bank (£000's) 12 External Monthly DoHR 1,765 0 0 434 880 1,306 161 129 136 1,306 Funded by vacancies budget.

Agency & Bank Spend (Clinical) as a % of total workforce costs (%) 12 External Monthly DoHR 3.3% 5.0% 5.0% 3.1% 3.1% 2.9% 3.0% 2.4% 2.3% 2.9%

Headcount (no.) 18 Internal Monthly DoHR 4,354 4,077 4,101 4,063 4,093 4,080 4,063 4,063 ytd is month 12 average. LCR staff transferred 1st April.

Health Visitor WTE (no.) 18 External Monthly DoHR 140.5 139.0 134.0 129.2 138.5 130.9 131.2 132.5

Family Nurse Partnership & Specialist Nurses (no.) External Monthly DoHR 6.0 6.0 6.0 6.0 0.0 6.0 6.0 6.0

Staff Attendance (%) 18 Internal Monthly DoHR 96.00% 97% 97% 96.00% 95.98% 96.03% 95.95% 95.92% 94.99% 96.03% Year to Date is rolling 12 month average. YTD absence rate is 4.03%. NHS absence rate is 4.25% (4.20% East Midlands).

Staff Turnover (%) 18 Internal Monthly DoHR 10.16% <14% <14% 9.62% 9.34% 9.59% 11.44% 10.07% 9.41% 9.59% Year to Date is rolling 12 month average. Changes to ESR data took place in October.

Board Turnover (no.) 12 Internal Monthly DoHR 2 2 or less in 6 months

2 or less in 6 months

0 0 1 0 0 1 1

Redundancy (no.) 18 External Monthly DoHR 13 1 3 17 14 0 0 17

Vacancies-Average Length of Time To Recruit (days) External Monthly DoHR 60 60 54.1 54.4 53.4 55.2 55.3 53.4 53.4 The average length of time from an approved vacancy being advertised on NHS Jobs to an agreed start date of employment being confirmed including time taken to complete pre-employment checks. The monthly figure is the rolling 12 month figure.

Vacancies-Average Length of Time From Offer to 1st Working Day (days) External Monthly DoHR 40 40 32.9 38.0 38.0 38.0 38.5 38.0 38.0 The average length of time from an agreed offer of employment being made to the applicant commencing employment with DCHS. The monthly figure is the rolling 12 month figure.

Vacancies-Average Length of Time For Pre Appointment Checks (days) External Monthly DoHR 21 21 20.9 25.0 16.1 17.3 17.0 16.1 16.1 The average length of time for pre-employment checks to be completed. The monthly figure is the rolling 12 month figure.

Vacancies-Externally Filled (no.) Internal Monthly DoHR 58 32 13 42 17 13 13

Vacancies-Internally Filled (no.) Internal Monthly DoHR 2 11 8 10 13 8 8

Advertised Vacancies (no.) 18 Internal Monthly DoHR 584 54 49 48 45 46 48 48

Essential Learning completed (% compliance) 18 Internal Monthly DoHR 97% 95% 95% 94% 93% 94% 93% 93% 94% 94% Year to Date is rolling 12month average-shows compliance to the renewal date.

Information Governance Training (% compliance) 18 External Monthly DoHR 95% 95% 95% 90% 88% 91% 87% 89% 91% 91% Year to Date is rolling 12 month average.

Fire Training (% compliance) 18 External Monthly DoHR 93% 95% 95% 89% 88% 90% 88% 89% 90% 90% Year to Date is rolling 12 month average.

Training - Resus (% compliance) External Monthly DoHR 95% 95% 85% 84% 84% 65% 81% 84% 84% Essential Training. Exception report at page 25.

Training - Safeguarding (overall rating) External Monthly DoHR 95%

New starters attending induction (% compliance ) 18 Internal Monthly DoHR 98% 95% 95% 100% 95% 100% 93% 98% 100% 100% Year to Date is rolling 12 month average-assignment data.

Staff with appraisal completed (% compliance) 18 Internal Annually DoHR 93% 100% 100% 87% 81% 86% 81% 82% 86% 86% Year to Date is rolling 12 month average-ESR data. Exception report at page 26. New starters with less than 12 months service have been excluded from October.

Improvement in Staff Survey Engagement Rates (%) Internal Annually DoHR 64.2% 76.8% 76.4% 76% 76% 76% 76% 76% 76% 76% Big 9 figures used.

Pulse Check - recommend DCHS to friends and family as a place to work (score) Internal Annually DoHR 3.76 Annual.

Pulse Check - Recommend DCHS to Friends and Family If They Needed Care or Treatment (%) Internal Quarterly DoHR 90% 90% 90% 90% 90% 90% Quarterly.

Pulse Check - Recommend DCHS to Friends and Family as a Place to Work (%) Internal Quarterly DoHR 72% 72% 71% 71% 71% 71% Quarterly.

Staff Net Promoter Question Result (no.) Internal Quarterly DoHR 3.78 Annual.

QU

ALIT

Y PE

OPL

E

FEED

BACK

WO

RKFO

RCE

MET

RICS

TRAI

NIN

G

DCHS BOARD PERFORMANCE REPORT BALANCED SCORECARD

Data Quality ScoreFocus Area

Family Nurse Partnership Specialist Nurse WTE contribute to the overall WTE for Health Visiting and have been added as a separate line.

142.0 137.9


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Year to Date Target

Year to Date Q1

Year to Date Q2

Year to Date Q3




Patient Revolution Friends & Family Test (no.) External Monthly DoNQ 90.4 >71 >71 89.0 91.0 90.9 87.0 89.2 90.9 90.9 YTD is current month score. NHS England will change the calculation for the January 15 collection.

Complaints Received (no.) External Monthly DoNQ 192 29 60 95 11 16 8 95 One complaint in December related to November.

PLACE (score) External Quarterly DoSD 97% 95% 95% 94.9% 98.0% 89.0% 89.0% 89.0% Q1-Looks at the environment in which care is provided and the quality of non-clinical services - food and privacy and dignity. Q2-Looks at cleanliness. Q3-external verification.Q4=Q1.

Certification against compliance with requirements regarding access to healthcare for people with a learning disability External Monthly DoNQ Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes To be reported to EDS & quarterly to QSC.

A&E A&E Targets (rating) 18 External Monthly DoSD Longest wait Buxton 480 minutes. Exception report at page 28.

RTT Waiting Times (Scorecard) 18 External Monthly DoSD Leicester Dental. Exception reports at page 39.

Choose and Book Targets (rating) Internal Monthly DoSD Choose & Book - Appointment slots available - no of patients unable to book (%) 3.2% December 3.7% ytd.

Diagnostics - Patients exceeding 6 weeks wait (%) External Monthly DoSD 0.3% <1% <1% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Patients who have operations cancelled for non clinical reasons on the day (%) External Monthly DoSD 0.8% <0.8% <0.8% 0.0% 0.3% 0.5% 1.0% 1.4% 0.0% 0.5% 4 patients in November - Endoscopy failure. All patients re booked for a December procedure.

Patients who have operations cancelled for non clinical reasons receiving treatment within 28 days (%) External Monthly DoSD 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Mixed Sex Accommodation Breach Rate (No) External Monthly DoSD 0 0 0 0 0 0 0 0 0 0

Delayed Transfer of Care (%) External Monthly DoSD 8.6% <12.5% <12.5% 9.5% 8.8% 8.6% 9.7% 6.2% 7.9% 8.6% Percentage of patients whose discharge is delayed for non clinical reasons (DTOC). Contract calculation for Inpatients & OPMH.

Delayed Transfer of Care for Inpatient (Rehab & Urgent Care) - contract calculation (%) External Monthly DoSD 9.3% 10.4% 10% 9% 10% 6% 8% 9.2%

Delayed Transfer of Care for OPMH - contract calculation (%) External Monthly DoSD 6.6% <7.5% <7.5% 6.6% 6.6% 6.6% 8.7% 8.7% 7.9% 6.5%

Delayed Transfer of Care for OPMH - Monitor compliance framework calculation (%) External Monthly DoSD 6.9% <7.5% <7.5% 5.1% 5.1% 8.4% 8.7% 8.7% 8.4% 8.4% Year to date is the Quarterly monitor calculation. Exception report at page 29.

Inpatient (Rehab & Urgent care) Average Length of Stay (days) 18 Internal Monthly DoSD 67.9 20.0 20.0 22.8 20.6 19.4 21.9 19.4 17.7 19.4 Linked to achievement of IBP. Year to Date is 3 month rolling average.

Older Peoples Mental Health Average Length of Stay (days) Internal Monthly DoSD 64.6 53.7 62.8 66.1 51.5 56.5 62.8

Inpatient (RUC) Occupancy (%) External Monthly DoSD 80.1% 78.6% 80.5% 86.9% 85.8% 83.3% 80.5%

Older Peoples Mental Health Occupancy (%) External Monthly DoSD 88.3% 86.0% 86.8% 89.0% 89.6% 91.6% 93.2% 89.0%

LD Occupancy (%) External Monthly DoSD 76.9% 80.1% 74.4% 73.4% 72.4% 76.3% 64.4% 73.4%

Achievement of consultation /involvement/engagement inclusion priorities (%) Internal Monthly DoHR 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Discussions to take place over this measure.

New or revised policies/procedures/strategies supported by EIAs (%) Internal Monthly DoHR 83% 87% 87% 83% 83% 84% 84% 84% 84% 84%

CQC Registration - Internal (rating) External Monthly DoNQ DCHS peer review action plans require updating. Awareness sessions being developed.

CQC Registration - Impact Governance Scores (rating) External Monthly DoNQ Impact on SHA Performance Report and Compliance Framework GRRs-TDA have discontinued the report. Clostridium difficile is 0 for October, 7 ytd against a ytd target of 7.

CQC Warning Notices External Monthly DoNQ 0 0 0 0 0 0 0 0 0 0

CQC Non-Compliance with Essential Standards resulting in Enforcement Action External Monthly DoNQ 0 0 0 0 0 0 0 0 0 0

CQC Non-Compliance with Essential Standards resulting in a Major Impact on Patients External Monthly DoNQ 0 0 0 0 0 0 0 0 0 0

CQC Non-Compliance with Essential Standards resulting in Enforcement Action (Civil and or Criminal) External Monthly DoNQ 0 0 0 0 0 0 0 0 0 0

Total Harm Free Care, in accordance with Safety Express (%) External Monthly DoNQ 92% 93% 93% 91.87% 91.88% 92.31% 93.20% 92.37% 93.78% 92.31%

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Year to Date Q1

Year to Date Q2

Year to Date Q3




Avoidable Grade 2, 3 & 4 Pressure Ulcers developed or deteriorated in DCHS care (no.) 16 External Monthly DoNQ 16 0 0 30 44 52 5 1 2 52 To be discussed in the quality report.

Total Grade 3 & 4 Pressure Ulcers developed or deteriorated in DCHS care (no.) 16 External Monthly DoNQ 201 76 116 151 16 11 8 151

Incidence of Newly Acquired Pressure Ulcers (no.) 16 External Monthly DoNQ 192 59 119 165 25 21 14 165 Figure amended to reflect actual ST numbers.

Medication Errors causing Serious Harm (no.) 16 External Monthly DoNQ 0 0 0 0 0 0 0 0 0 0 Top 2 Tiers of medication errors (amber/red).

NHSLA Rating (no.) External Monthly DoNQ 1 1 1 1 1 1 1 1 1 1 DCHS keeps its 13/14 rating.

Falls resulting in severe injury or death (no.) External Monthly DoNQ 13 0 0 7 14 21 2 2 3 21 Falls reported on Steis. Months of Incidents are-Apr (1 Mar 2 Apr)-May (1 April 2 May)-Jun (1 May)-Jul (2 July 1 Jun)-Aug (1 July)-Sept (3 Sept)-Oct (1 Oct 1 Sept)-Nov (2 Nov)-Dec (3 Dec). Exception report at page 30.

Duty of Candour - Failure to notify relevant person of a reportable incident (no) External Monthly DoNQ 0 0 0 0 0 0 0 0 0 0 All reporting requirements are met.

Healthcare Care Associated Infections - MRSA bacteraemia (no.) 16 External Monthly DoNQ 0 0 0 0 0 0 0 0 0 0

Healthcare Care Associated Infections - Clostridium difficile (no.) 16 External Monthly DoNQ 9 12 9 6 9 12 0 0 3 12

Healthcare Care Associated Infections - Clostridium difficile - lapses count (no.) 16 External Monthly DoNQ 12 9 1 1 1 0 0 0 1

Healthcare Care Associated Infections - E Coli & MSSA (no) 16 External Monthly DoNQ 0 0 0 0 0 0 0 0 0 0

Breastfeeding sustainment from 10 days to 6-8 weeks after birth (%) 18 External Monthly DoSD 76% 84% 84% 76% 75% 75% 67% 73% 79% 75% Exception reports at page 31.

Monitor Risk Assurance Framework Scorecard (RAF) (rating) External Monthly All 0 0 0 0 0 1 1 1 1 1 Ex TDA Report. Now Monitor Risk Assurance Framework (RAF). DTOC 8.7%. See page 4.

CQUIN Scorecard (rating) External Monthly DoSD Reduce prevalence of pressure ulcers by 1.5%, undertaking of a complaints satisfaction survey, peer reviews of complaints and agreed milestones arising from peer reviews. Exception report at page 27.

IWB overall Measures (rating) Exception reports at pages 32 to 34.

Smoking Quitter Targets (rating) 12 External Monthly DoSD See new IWB overall measures for December onwards.

CIP Achieved-Recurrent(%) Internal Monthly DoFPI 100% 67.4% 35.9% 50.0% 58.5% Discussed in the Finance Report

CIP Achieved-Non Recurrent (%) Internal Monthly DoFPI 0.0% 0.0% 0.0% Discussed in the Finance Report

Better Payment Practice Code - by value (%) External Monthly DoFPI 97.69% >95% >95% 96.89% 97.87% 97.29% 99.52% 91.96% 96.84% 97.29% Discussed in the Finance Report

Better Payment Practice Code - by volume (%) External Monthly DoFPI 97.40% >95% >95% 97.83% 97.77% 96.93% 98.10% 95.30% 91.79% 96.93% Discussed in the Finance Report

Positive media stories (no.) Internal Monthly DoSD 192 68 125 185 23 23 14 185

MIU Activity (no.) 18 External Monthly DoSD 56,032 53,756 43,507 15,079 30,432 43,131 4,630 4,053 4,016 43,131

Community Beds -Discharged Occupied Bed Days (no) 18 External Monthly DoSD 65,684 49,078 19,070 30,432 47,586 5,082 4,845 3,984 47,586 Discharged Rehab & Urgent Care beds.

Outpatient and Daycase Activity (no.) 18 External Monthly DoSD 42,100 41,534 31,718 10,853 22,386 33,607 3,845 3,906 3,699 33,607

Vasectomy Service Activity (no.) 18 External Monthly DoSD 455 429 311 102 210 293 31 29 23 293 Exception report at page 35.

Podiatric Surgery Activity (no.) 18 External Monthly DoSD 14,225 13,559 10,860 3,511 7,173 11,098 1,541 1,268 1,116 11,098

Community Podiatry Activity-Non AQP (no.) 14 External Monthly DoSD 135,151 137,671 106,299 33,634 68,529 102,683 12,853 11,149 10,152 102,683

Community Podiatry Activity - AQP (no.) External Monthly DoSD 4,542 3,390 3,270 6,905 10,588 1,382 1,247 1,054 10,588 Contracted on a episodes of care basis. Previous months activity wrongly included follow-ups activity, this has been corrected in August to give correct year to date figure.

Physiotherapy Activity (no.) 15 External Monthly DoSD 116,980 115,972 85,150 28,554 58,906 88,487 10,475 9,949 9,157 88,487

35.6%15.8%

See HCAI Report. Two incidents in November related to April & June. Actual monthly figures amended accordingly. The lapses count for C diff has been agreed with Commissioners. Total cdiff cases are still recorded nationally.

58.5%90% 58.5%

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Speech and Language Therapy Activity (no.) 14 External Monthly DoSD 15,815 16,393 12,260 4,269 8,012 12,729 1,702 1,730 1,285 12,729

Diagnostic Imaging (no.) External Monthly DoSD 2,259 2,268 1,697 653 1,266 1,959 78 388 227 1,959

Health Visiting Contract (rating) 18 External Monthly DoSD New birth visits amber rated. Antenatal contact red rated. An exception report will be presented to the next Board. Exception report at page 36.

Health Visiting Activity (no.) 18 External Monthly DoSD 104,431 26,541 52,346 76,802 8,662 8,295 7,499 76,802

Community Nursing Activity (no.) 10 External Monthly DoSD 517,092 135,462 274,811 397,318 44,856 40,645 37,006 397,318

Community Matron Activity (no.) 15 External Monthly DoSD 15,897 3,618 7,604 12,607 1,423 1,543 2,037 12,607 TPP Amber Valley, Erewash, NED & SD & DD only.

Rehabilitation and Intermediate Care Activity (no.) 9 External Monthly DoSD 96,782 24,172 51,222 78,820 10,208 9,077 8,313 78,820 Includes Amber Valley & Erewash, South DD TPP data for the year. Both eCSAC & TPP data now includes NFTF data & Group Data.

Chlamydia Screening Positive Activity (no.) 12 External Monthly DoSD 2,375 2,872 2,706 242 872 1,307 99 275 61 1,307 Exception report at page 37.

Community Information Dataset Completeness-Referral to treatment information (%) External Quarterly DoFPI 67% >50% >50% 83% 83% 83% 83% 83% 83% 83%

Community Information Dataset Completeness-Referral information (%) External Quarterly DoFPI 69% >50% >50% 69% 69% 69% 69% 69% 69% 69%

Community Information Dataset Completeness-Treatment activity information (%) External Quarterly DoFPI 69% >50% >50% 75% 75% 75% 75% 75% 75% 75%

Information Governance Incidents Reported via IG toolkit - Level 2 or above (no.) External Quarterly DoFPI 6 0 0 0 0 0 0 0 0 0

Information Governance Toolkit Achievement - measures scoring 2 or better (no) External Monthly DoFPI 38 39 35 24 32 24 28 32 32 IG training expected to be on target by end of March 15.

Financial Risk Rating (FRR) External Monthly DoFPI 3 3 3 3 4 3 3 3 Discontinued November 2014

Continuity of Services-Liquidity Ratio (days.) (Monitor Shadow Format) External Monthly DoFPI 4 4 4 4 4 4 4 4 4 4

Continuity of Services-Capital Servicing Capacity (times.) (Monitor Shadow Format) External Monthly DoFPI 4 4 4 4 4 4 4 4 4 4

Continuity of Services-Risk Rating (Monitor Shadow Format) External Monthly DoFPI 0 0 0 4 4 4 4 4 4 4

FT Membership (no.) Internal Monthly DoSt 12,281 12,500 12,500 12,298 12,295 12,541 12,520 12,502 12,541 12,541

Sickness & Absence Rates - Long Term Absence (%) 18 External Monthly DoHR 2.15% 3.0% 3.0% 2.00% 2.02% 3.06% 2.28% 2.17% 3.06% 3.06% 2.23% in July 2013.

Sickness & Absence Rates - Short Term Absence (%) 18 External Monthly DoHR 1.79% 3.0% 3.0% 1.42% 1.70% 1.95% 1.76% 1.91% 1.95% 1.95% Short Term = < 30 days. Benchmarking measure requires = <28 days. 1.87% in September 2013.

Turnover - Planned (%) 18 External Monthly DoHR 4.06% 4.06% 4.83% 4.11% 4.02% 4.02% DCHS planned turnover changes.

Turnover - Unplanned (%) 18 External Monthly DoHR 7%-17% 7%-17% 6.61% 5.96% 6.02% 6.02% Employee generated turnover changes.

New SIRIs reported per month (excluding pressure ulcers) (no.) External Monthly DoNQ 34 0 0 1 6 4 5 3 4 4

Injurous Falls per 1,000 inpatient occupied bed days (no.) External Monthly DoNQ 5.0 4 4 4.1 3.3 5.6 4.0 4.5 5.6 5.6 Rehab Inpatients Only-injurious falls-Year to Date represents current month.

Injurious and non Injurious Falls per 1,000 Inpatient Occupied Bed Days External Monthly DoNQ 12.6 9.08 9.08 13.9 8.7 9.8 10.0 9.8 11.8 11.8

Number of incidents (causing harm or otherwise) per 1,000 WTE budgeted staff (no) External Monthly DoNQ 291 181 181 308 286 283 301 282 283 283

Number of Formal Complaints Reported per 1,000 WTE Budgeted Staff External Monthly DoNQ 4.1 5.2 5.2 5.1 4.4 5.0 3.4 5.0 2.5 5.0

Safety Thermometer - Percentage of 'Harm Free' Care (New harms only) External Monthly DoNQ 98% 92% 92% 97.36% 97.66% 97.54% 97.77% 97.27% 98.56% 97.85% New benchmarking measure.

Face to face contacts per whole time equivalent (wte) community nurse per working day (no.) External Monthly DoSD 9.2 6.9 6.9 9.1 8.5 7.0 7.9 8.1 7.0 7.0

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Total pay cost per wte community nurse (£) External Monthly DoSD 3,052 3,132 3,132 3,284 3,229 3,087 3,557 3,077 3,087 3,087 Year to Date is average for Year to Date

Face to face contacts per whole time equivalent (wte) health visitor per working day (no.) External Monthly DoSD 3.1 5.3 5.3 3.1 2.9 3 2.8 3.0 2.6 3.0

Total pay cost per wte health visitor (£) External Monthly DoSD 2,956 3,203 3,203 3,129 3,067 2,819 2,914 2,446 2,819 2,819

Average length of stay (days) 18 External Monthly DoSD 22.9 28 28 20.8 20.0 19.5 20.6 20.3 17.7 19.5 Inpatient Older Peoples' Mental Health & Learning Development Wards.

Percentage occupancy of community hospital beds (%) 18 External Monthly DoSD 85% 85%-95% 85%-95% 81% 82% 85% 89% 86% 85% 85% Inpatient & Older Peoples' Mental Health. See Quality Service section for a split.

Data Completeness-NHS Number (%) External Monthly DoSD 99.9% 99.0% 99.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Data Completeness-Ethnicity code (%) External Monthly DoSD 43.6% 90.0% 90.0% 41.7% 56.8% 61.6% 56.5% 61.2% 61.6% 61.6%

Data Completeness-Postcode (%) External Monthly DoSD 99.9% 90.0% 90.0% 99.9% 99.9% 99.9% 99.9% 99.9% 99.9% 99.9%

Data Completeness-GP Practice code (%) External Monthly DoSD 99.8% 99.0% 99.0% 99.8% 99.8% 99.8% 99.8% 99.8% 99.8% 99.8%

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DCHS HCAI, CQUIN and Integrated Wellbeing Scorecards January 2015


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Measure2014/15 Full Year

TargetYTD Target Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 YTD

Forecast Outturn

MRSA Infections - Avoidable (No.) 0 0 0 0 0 0 0 0 0 0

MRSA Infections - Possible (No.) 0 0 0 0 0 0 0 0 0 0

MRSA Infections - Unavoidable (No.) 0 0 0 0 0 0 0 0 0 0

ESBL - Avoidable (No.) 0 0 0 0 0 0 0 1 0 1

ESBL - Possible (No.) 0 0 0 0 0 0 0 0 0 0

ESBL - Unavoidable (No.) 0 1 0 0 0 0 1 0 0 2

Norovirus outbreaks (No.) 2 0 0 0 0 2 1 0 0 5

MRSA Bacteriaemia - Avoidable (No.) 0 0 0 0 0 0 0 0 0 0

MRSA Bacteriaemia - Possible (No.) 0 0 0 0 0 0 0 0 0 0

MRSA Bacteriaemia - Unavoidable (No.) 0 0 0 0 0 0 0 0 0 0

MRSA Screenings - Elective Surgery (%) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

MRSA Screenings - Non Elective Admissions (%) 100% 100% 94% 89% 100% 100% 100% 94% 100% 92% 100% 98%

MRSA Screenings - Sexual Health (%) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Clostridium Difficile - Avoidable (No.) 0 0 0 0 0 0 0 0 0 0

Clostridium Difficile - Possible (No.) 0 0 0 0 0 0 0 0 0 0

Clostridium Difficile - Lapsed Care (No.) 12 9 0 0 1 0 0 0 0 0 0 1

Clostridium Difficile - Unavoidable (No.) 12 9 2 1 3 2 0 1 0 0 3 12

During the review of the data, it has become evident that DCHS requires access to the National HCAI Database to validate the Clostridium difficile samples attributed to DCHS. Currently DCHS relies on each of the CCGs to provide the data. The IP&C Matron will be approaching Public Health England to identify whether DCHS is able to have administration rights to view the database.

Lapse in CareFuture Dashboard reports will include a summary of the RCAs where a lapse in care has been identified.

Overview of trendsAn overview of trends and wards where infections have occurred will be included separately.

As avoidability is no longer the measure for Monitor, it is proposed that Appendix A below is no longer updated within this report from January 2015 onwards. However it is acknowledged prior to becoming a Foundation Trust, this information was required.

Norovirus OutbreaksThere were no outbreaks to report for December, a small number of bays were placed under barrier precautions and monitored for 48 hours but no wards were closed.

MRSA ScreeningThe MRSA screening score for December is 100%

HEALTHCARE ASSOCIATED INFECTION SCORECARD 2014-15

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Avoidable InfectionsThere were no avoidable infections to report.

Possible Avoidable InfectionsThere were no possible avoidable infections to report.

Unavoidable InfectionClostridium difficile – Linden Ward, Bolsover This patient was transferred from Chesterfield Royal Hospital Foundation Trust (CRHFT) for rehabilitation on 26.11.14. The patient developed symptoms of diarrhoea on 8.12.14 and a stool sample sent the same day confirmed a diagnosis of Clostridium difficile infection. The patient’s diarrhoea symptoms were originally thought to be caused by an exacerbation of their underlying bowel condition when at CRHFT and had settled prior to the patient’s transfer to Linden Ward. There is no obvious trigger for the return of the symptoms i.e. antibiotic therapy and the symptoms settled following treatment with Metronidazole. The patient had an antibiotic history relating to an earlier admission to CRHFT during September/October 2014.

All appropriate measures were instigated by the ward team and there was clear communication between the IP&C team and ward staff.

Clostridium difficile infectionsThe table below provides a breakdown of the Clostridium difficile infections according to whether the diagnosis occurred within 72 hours of the patient being admitted to DCHS services. If a positive Clostridium difficile result is obtained within 72 hours of the patient’s admission to DCHS care, it is unlikely that the cause of the infection is the result of the care provided by DCHS. This would be confirmed/challenged within the RCA process.

Month National HACI

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Lapses in Care agreed with

Commissioners April 2014 2 1 1 0 May 2014 1 0 1 0 June 2014 3 3 0 1 (*2 RCAs in

progress) July 2014 2 0 2 (relapse) (*1 RCA in

progress) August 2014 0 0 0 0 September

2014 1 1 0 0

October 2014 0 0 0 0 November

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December 2014

3 1 2 (*3 RCAs in progress)

January 2015 February 2015

March 2015 Total 12 6 6 1 (*6 RCAs in

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CQUIN INDICATORS 2014-15

Measure TypeFrequency of

ReportingDirector 2014/15 Full Year Target YTD Target Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Trend YTD

Forecast Outturn

Narrative

Friends and Family Test - Improve Experience of Patients

National 1.1

Annually DoNQ Now timetabled for Q4 in line with DCHS staff survey timeframe

NHS Safety Thermometer - Data CollectionNational

2.1Monthly DoNQ

Reduction in the prevalence of pressure ulcers to an average of 5.5% November-March 2015

13/14 Baseline 7.1% / Last 5 months target

5.5% average prevalence.

8.0% 5.8% 7.7% 8.25% 5.96% 7.42% 5.90% 6.08% 7.00%CQUIN target of 5.5% average prevalence from November-March 2015.

Current average prevalence YTD is 7.0% which demonstrates the high risk of not achieving target due to the limitations of ST data.

Dementia - Clinical LeadershipNational

3.2Quarterly DoNQ

Dementia training programme for 2014/15 now being rolled out is incorporating community staff throughout the year.

Dementia - Supporting CarersNational

3.3Monthly DoNQ

Carer support data collection launched across all general inpatient wards in Q2 with champions supporting.

Local 4.1 Twice Yearly DoNQJoint peer review panels with Chesterfield Royal Hospital held 27th & 28th

of November in conjunction with commissioners.

Local 4.2 Quarterly DoNQJoint peer review panels with Chesterfield Royal Hospital held 27th & 28th

of November in conjunction with commissioners.

Local 4.3Thee Monthly

ReportsDoNQ

Packs now received from Patient Association. Contract variation on revised timescales and reporting now submitted.

Local 4.4 Quarterly DoNQImprovement plan will now be based on report from Patient Association

following November peer review panels and review of outcomes. Improvement plan likley to roll-over to 2015-16.

Pressure Ulcers - Improve patient and carers non-compliance with treatment

Local 5 Quarterly DoNQReview of patient non-compliance RCAs with patient, public and staff

engagement now in progress.

Compassion and Culture - Improve Compassion and Culture across the organisation

Local 6 Quarterly DoNQCompassion and culture launch event being held 19th June 2014.

Workstreams being co-ordinated across the organisation. Action plan now signed off by commissioners.

Local 7.1 Quarterly DoNQ

EoL training programme developed and roll-out commenced. Contract variation submitted for sign-off by CMG with focus now on training in line

with launch of Derbyshire EoL toolkit in lieu of the Individualised Transitional EoL Care Plan.

Local 7.2 Quarterly DoNQ Training priorities now confirmed by Derbyshire Alliance.

Community Nursing - Assuring staffing for quality within the community nursing workforce

Local 8 Quarterly DoNQ7 day Hurst review undertaken by all community nursing teams from 18th

May 2014. High level internal findings reported during October. Further analysis and workstreams now being undertaken against HURST data.

Transfer of Care and Patient Flow - Joint CQUIN with CRH to improve the discharge and patient transfer of care pathway between providers.

Local 9 Monthly DoSD Monthly meetings and joint action planning with CRH on-going

NHS NORTH DERBYSHIRE LEAD COMMISSIONER CCG AND ASSOCIATES CONTRACT

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Implementation of staff FFT as per guidance, according to the national timetable. Staff to be given the opportunity to respond to the FFT test once per quarter and

results uploaded to unify2.

Named lead clinician for dementia and appropriate training for staff including feedback of the Dementia training programme delivered throughout 2014/15.

Demonstrate a monthly audit of Carers of people with dementia on DCHS OPMH wards

Conduct one or more peer reviews of complaints (a minimum of 24 complaint files).

Review of patient non-compliance in all incidences of Pressure ulcers which identify this as a contributing factor

End of Life - Improving coordination and communication

Review and development of community staff workload and dependency tool, leading to twice yearly assurance in relation to staffing levels plus facilitating the

most efficient use of frontline resources in relation to the delivery of safe and effective clinical care.

Patient Experience - Improve Patient Experience through improved complaints management in the Provider Setting

Joint CQUIN with CRH to improve the discharge and patient transfer of care pathway between providers.

DCHS will development a number of cross-Healthcare Professional forums to promote sharing of EoL best practice and develop patient pathways e.g. MacMillan

Nurses, Community and Inpatient service staff and primary care.

The provider will develop an improvement plan with agreed milestones based on the themes arising from peer reviews and survey results.

The Provider will undertake a complainant satisfaction survey, using the Patient Association methodology with 100% complainants.

Take part in one external peer review of patient complaints (min of 3 complaint files to be submitted) to be reviewed against the Patients Association Good

Practice Standards on complaints handling.

Enhance patient experience of compassionate care across the organisation and ensure delivery of a relevant work programme to improve care.

To develop and deliver a training programme in line with the launch of the DCHS Individualised Transitional EoL Care Plan across inpatient services in order to

promote advanced care planning and support quality of care for patients on the end of life pathway, in particular DNAR and preferred place of care.


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1.1 DCHS Integrated Wellbeing Service Key Performance Indicators

Ref Focus Area Measure FrequencyActual Year to Date Q1

Actual Year to Date Q2

Actual Year to Date Q3

Dec-14 Jan-15 Feb-15 Mar-15Actual Year

To DateTrend Narrative

1 PRIMARY CONTRACTOR Rating Monthly

2 WEBSITE Rating Monthly Procurement underway

3 WELLBEING Rating MonthlyNumber of New Clients. Number of Clients completing personal wellbeing plans. Exception Report at Page 32.

4 SPECIALIST WEIGHT MANAGEMENT Rating Monthly All measures unrated

5 SPECIALIST STOP SMOKING SERVICES Rating Monthly

5SPECIALIST STOP SMOKING SERVICES -

PREGNANCY FINANCIAL INENTIVE SCHEME Rating Monthly

6 MECC Rating Monthly All measures unrated

7 COMMUNITY WEIGHT MANAGEMENT Rating Monthly12 week completers. 5% Weight Loss at 12 weeks and 52 weeks. Exception Report at page 31.

8 COMMUNITY STOP SMOKING SEVCIES Rating Monthly 4 week Quitters. Exception Report at page 30.

DCHS PERFORMANCE REPORT - DERBYSHIRE INTEGRATED WELLBEING SERVICE


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AHP-Led Referral to Treatment Schedule in Weeks (December 14) - Clocks ended in December

Service Line 0-6 7 - 12 13 - 17 18+Total Waiters

Max Waiter

>6 week waiter total

% Waiting over 6w


% Waiting over 13w

Planned CareAV&E MSK, Physio, OT, Podiatry 1924 279 12 0 2215 17 291 13.1% 12 0.5%CHE MSK, Physio, OT, Podiatry 1359 76 4 3 1442 26 83 5.8% 7 0.5%HPD MSK, Physio, OT, Podiatry 1310 87 0 0 1397 12 87 6.2% 0 0.0%Speech and Language Therapy 512 70 0 0 582 11 70 12.0% 0 0.0%

ICBSAMBER VALLEY 277 75 9 1 362 19 85 23.5% 10 2.8%EREWASH 296 27 7 1 331 21 35 10.6% 8 2.4%S DERBYS & S DALES 224 6 0 0 230 10 6 2.6% 0 0.0%CHESTERFIELD 190 36 3 1 230 18 40 17.4% 4 1.7%Traumatic Brain Injury Service 11 1 0 0 12 7 1 8.3% 0 0.0%Respiratory Services 51 24 15 20 110 82 59 53.6% 35 31.8%Learning Disabilities 19 7 3 5 34 29 15 44.1% 8 23.5%

All Services 6173 688 53 31 6945 82 772 11.1% 84 1.2%

Consultant-Led Referral to Treatment Schedule in Weeks (December 14) - Clocks ended in December - Admitted Patient Care

Specialty 0-6 7 - 12 13 - 17 18+Total Waiters

Max Waiter


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% Waiting over 18w

Planned CareGeneral Surgery 7 24 18 0 49 17 42 86% 0 0%Urology 20 21 7 0 48 16 28 58% 0 0%Trauma & Orthopaedics 15 12 5 5 37 28 22 59% 5 14%Ear, Nose & Throat (ENT) 1 3 3 0 7 15 6 86% 0 0%Ophthalmology 27 38 12 3 80 36 53 66% 3 4%Oral Surgery 0 0 0 0 0 0 0 0% 0 0%Neurosurgery 0 0 0 0 0 0 0 0% 0 0%Plastic Surgery 0 0 0 0 0 0 0 0% 0 0%Cardiothoracic Surgery 0 0 0 0 0 0 0 0% 0 0%General Medicine 0 0 0 0 0 0 0 0% 0 0%Gastroenterology 0 0 0 0 0 0 0 0% 0 0%Cardiology 0 0 0 0 0 0 0 0% 0 0%Dermatology 4 12 24 0 40 17 36 90% 0 0%Thoracic Medicine 0 0 0 0 0 0 0 0% 0 0%Neurology 0 0 0 0 0 0 0 0% 0 0%Rheumatology 0 0 0 0 0 0 0 0% 0 0%Geriatric Medicine 0 0 0 0 0 0 0 0% 0 0%Gynaecology 0 4 0 0 4 10 4 100% 0 0%Other

Dental 72 75 16 12 175 36 103 59% 12 7%All Services 146 189 85 20 440 36 260 59% 20 4.5%

Consultant-Led Referral to Treatment Schedule in Weeks (December 14) - Clocks ended in December - Non-Admitted Patient Care

Specialty 0-6 7 - 12 13 - 17 18+Total Waiters

Max Waiter


% Waiting over 6w


% Waiting over 18w

Planned CareGeneral Surgery 19 7 2 0 28 17 9 32% 0 0%Urology 2 0 4 0 6 16 4 67% 0 0%Trauma & Orthopaedics 64 31 21 0 116 17 52 45% 0 0%Ear, Nose & Throat (ENT) 53 18 7 2 80 19 27 34% 2 3%Ophthalmology 70 8 23 0 101 17 31 31% 0 0%Oral Surgery 0 0 0 0 0 0 0 0% 0 0%Neurosurgery 0 0 0 0 0 0 0 0% 0 0%Plastic Surgery 0 0 0 0 0 0 0 0% 0 0%Cardiothoracic Surgery 0 0 0 0 0 0 0 0% 0 0%General Medicine 1 0 0 0 1 4 0 0% 0 0%Gastroenterology 2 4 1 0 7 15 5 71% 0 0%Cardiology 4 4 1 5 14 21 10 71% 5 36%Dermatology 32 49 3 1 85 20 53 62% 1 1%Thoracic Medicine 0 0 0 0 0 0 0 0% 0 0%Neurology 0 0 0 0 0 0 0 0% 0 0%Rheumatology 0 0 7 0 7 15 7 100% 0 0%Geriatric Medicine 7 0 1 0 8 13 1 13% 0 0%Gynaecology 25 9 1 0 35 17 10 29% 0 0%

OtherOther 9 0 2 0 11 17 2 18% 0 0%

All Services 288 130 73 8 499 21 211 42.3% 8 1.6%


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DCHS Performance Exception Reports January 2015


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Measure Type Frequency Director2014/15 Full Year Target

YTD Target Q2 Oct-14 Nov-14 Dec-14 YTD

Resus Training (% compliance) External Monthly DoSD 95% 95% 84% 65% 81% 84% 84%

1-Summary of Issues:

3-Timescales

4-Effect of this Exception on the Forecast Plan (how we get to our final forecast

Exception Report Analysis

Lower than anticipated levels of compliance for Resuscitation training. Due to the monthly compliance reporting structure (as opposed to former reports where staff retained a competence across the whole financial year), once staff pass their competence expiry date they appear on ESR as non-compliant even if they are booked on a future session.

Whilst every effort is being made to mitigate lost training places by increasing capacity on sessions and setting up additional courses, the capacity of trainers and the availability of suitable venues is finite - so it is vital that service plan well in advance for release of staff across the year, and look at ways to decrease places lost through non-attendance and late withdrawals.

A revised version of the Resuscitation matrix will be re-launched early in 2015 to clarify training requirements for all clinical roles from April 2015 onwards.In future, training dates will be released every 6 months to enable staff to book training places well in advance.

Capacity has already been increased on existing resuscitation courses, and the option of booking further CPR/ AED sessions is currently also being scoped. When annual training is planned, an over-provision of places (approx 30%) is factored in, but to use these effectively managers and staff must forward plan. A recent survey has identified some lack of clarity around which resucitation training staff need to complete, and this has led to some staff undertaking training at a higher or lower level than required. Monthly Resuscitation training figures are now broken down by each of the 7 courses that different staff groups need to undertake, enabling the Workforce Development trainers to identify and focus on courses with lower compliance rates.

2-Action Plan: (actions taken, including assignment of responsibility for this plan)

95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15

%ag

e Co

mpl

ianc

e

Month

Resus Training(%)

YTD Target (%)

Resus Training (% Compliance) - December


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Measure Type Frequency Director

2014/15 Full Year Target


Staff with appraisal completed (% compliance) External Monthly DoHR 95% 95% 81% 81% 82% 86% 86%



3-TimescalesA forecast of 95 % has been submitted for February 2015, with a forecast of 100% by end of March 2015.

December's performance is above the revised forecast submitted to Board last month.


Appraisal performance has improved by 4 % this month. This is above the revised forecast submitted to last month's Board. Further improvement is expected month on month ahead of the end of the financial year. As of December 31st 2014 a total of 586 staff are out of date with their annual appraisal.

4-Effect of this Exception on the Forecast Plan (how we get to our final forecast position from here)

During December, the Workforce Planning and Development Team issued reminder letters to managers who had overdue Appraisals within their area in order to highlight overdue Appraisals and seek assurance as to when they would be completed. 752 staff where reported as been non compliant on 30/11/14 however, the Workforce Planning and Development Team were advised of 40 staff whom had their appraisal completed on or before their anniversary date. Following further review it is was identified that the errors have arisen as a result of inaccurate hierarchies failure to update ESR and staff inaccurately entering compliance against wrong assignment number resulting in inaccurate data. A total of 172 ESR records have been updated post receipt of reminder letter. Where appropriate Mangers will be reissued with ESR mangers guide and tips with balance score card so as to clarify the process for those staff whom have more than one assignment number. The workforce Planning and development team will continue to monitor compliance on a monthly basis.

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

105.0%


% o

f Sta

ff At

tend

ing

Trai

ning

Month

Staff With Appraisals Completed (% compliance) - December

% Staff WithAppraisalCompleted

% Target Profile

Forecast


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2013/14 Full Year

TargetYTD Target Oct-14 Nov-14 Dec-14 YTD

CQUIN - Reduction in Prevalence of Pressure Ulcers CQUIN Monthly DoSD 5.5% 5.5% 5.90% 6.08% 5.50% 6.88%53.4% 53.4%

ACTION PLAN:1-Summary of Issues:

3-Timescales




DCHS is committed to reducing the incidence of pressure ulcers through the identified workstreams; however, there is limited assurance that Safety Thermometer prevalence data will reflect the on-going work given the limitations in the timeliness of the data collection and the inclusion of inherited pressure ulcers which are outside the control of DCHS to prevent.

The workstreams in place to support pressure ulcer prevalence reduction are reviewed monthly within the Safe Care Priority Group improvement plan.

A significant amount of work contiues to undertaken across the Trust to reduce the incidence of pressure ulcers. A number of key workstreams continue to be delivered through the DCHS Safe Care Priority Group:- A comprehensive review of pressure relieving equipment has been undertaken with involvement from the specialistTissue Viability team and in conjunction with the lead equipment provider for DCHS to ensure the most clinically effective and patient-friendly equipment is available to meet requirements. A staff guide has been devised for all staff who order equipment and authorisers to ensure the most clinically appropriate pressure relieving equipment or alternative is provided. The guide will be disseminated to all clinical teams, authorisers and on-call managers. Commissioners have also agreed to support a joint approach to ensuring equipment is reviewed appropriately within the contract framework.- A number of patient interviews have been conducted with patients who have experienced a pressure ulcer. The outcome of these interviews will be used to explore the theme of patient non-concordance with treatment and support staff learning and development; and learning from these has been shared with our commissioners through the Quality Assurance Group. ICBS are currently working with the Patient Experience Team to enable timely contact with patients who are identified via the RCA process and through contact with the community nursing teams to support continued engagement and feedback where appropriate.- One of the patient interviews is now being shared with Medequip to support wider learning on the impact of equipment on patients - A staff awareness campaign is being formulated as part of a wider communications strategy in order to highlight the importance of preventing pressure ulcers from developing and deteriorating.- A review of the pressure ulcer root cause analysis (RCA) process has been undertaken and this now supports a robust review of all grade 3 and 4 pressure ulcers reported, as well as any avoidable grade2 pressure ulcers, and incorporates support from senior clinical leads and the specialist Tissue Viability team in a timely manner, with clearly defined accountability and local ownership of all action plans.- Local ownership and accountability for understanding key themes and trends in pressure ulcer incidence has been further supported by a comprehensive monthly locality report , co-ordinated by the Business Managers, detailing the key actions being undertaken to reduce pressure ulcers and support a wider sharing of lessons learned across the county.- A pilot of mobile devices is now progressing to support the review of pressure ulcers in the community; all equipment and sim cards are now available and work is underway to action the pilot across operational staff and the specialist Tissue Viability team.

The CQUIN target of 5.5% is against the average prevalence from November-March 2015. The current average prevalence YTD is 6.88%, which demonstrates the high risk of not achieving the target due to the limitations of Safety Thermometer data. Safety Thermometer pressure ulcer data is collected on one day each month, and captures both old and new pressure ulcers, including those inherited from external providers. A significant amount of work is being undertaken to reduce the incidence of pressure ulcers; however, incident rate reduction is not reflected explicitly by Safety Thermometer pressure ulcer prevalence.

8.0% 5.8% 7.7% 8.3% 6.0% 7.4% 5.9% 6.1% 5.5% 0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%


Prev

alen

ce P

ress

ure

Ulc

ers (

%)

Month

Actual (%)

Target (%)

CQUIN - Reduction in Prevalence of Pressure Ulcers (%) - December


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Delayed Transfer of Care for OPMH - contract calculation (%) External Monthly DoHR <7.5% <7.5% 5.5% 8.7% 8.7% 7.9% 8.4%

Delayed Transfer of Care for OPMH - Monitor compliance framework calculation (%) External Monthly DoHR <7.5% <7.5% 4.4% 8.7% 8.7% 8.4% 8.4%



3-Timescales


DCHS continues to pro-actively manage patient flow across inpatient beds inorder to minimise the incidence of delayed transfers of care (DTOC). However, during December the overall reported incidence of DTOC has increased from 6.2 % in November to 7.9% in December.

Rehabilitation wards DTOC figure has increased from 5.5% in November to 7.8% in December. Contributing factors to the increase have been due to the significant increase in demand for health and social care services across Derbyshire and the complexity of several patient's discharge planning needs during December.

DCHS has supported a 30.5% increase in transfers and also a 15.2% increase in weekend transfers from acute hospitals to DCHS Community Hospitals since 1st December 2014, improving whole-system patient flow. Average length of patient stay has reduced from 19.4 days in November to 17.7 days during December, the lowest it has been reported throughout 2014. The Rehabilitation Inpatient wards target of 7% for March 2015 will continue to be the target to be achieved working closely with Social Care.

Older Peoples Mental Health (OPMH) wards have demonstrated a reduction in reported DTOC from 8.7% in November to 7.9% in December.

However, specific reasons identified for those patients in delay are as follows: Spencer Ward- 3 patients - 1 awaiting a Residential Home who has now been discharged. 1 whose family are looking for a suitable Nursing Home. 1 awaiting a financial assessment from Social Care. Riverside Ward- 2 patients- 1 awaiting a Nursing Home bed, now discharged. 1 patient awaiting Nursing Homes to visit ward to assess. Melbourne Ward- 1 patient awaiting specialist equipment, now discharged. Linacre Ward -2 patients, 1 patient awaiting nursing home bed, now discharged. 1 patient awaiting Nursing Home, first on the list.


1) Hospital Matrons continue to escalate issues as soon as identified- Action Hospital Matrons2) General Managers continue to lead Top Delay meetings - Action General Managers3) General Managers escalate issues to Deputy Director of Operations which cannot be resolved at ward level-Action General Managers4) DTOC to remain a standard agenda item at DCHS Patient Flow Strategy meeting-Action Capacity & Discharge Manager

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%


% o

f De

lays

Month

Delayed Transfer of Care (% compliance) - December

DTOC - Monitor QuarterlyCalculation %

DTOC - ContractCalculation %

% Target Profile


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YTD Target Oct-14 Nov-14 Dec-14 YTD

A&E Total Time in the A&E Department (non admitted) - Longest (mins) National Monthly DoSD <15 <15 145 237 480 480


3-Timescales

4-Effect of this Exception on the Forecast Position


Patient 1-27th December 2014 - 90 year old lady found wandering along the street in Buxton. She was found by the District Nursing Team and brought to MIU. She had significant bruising to the face and bilateral orbital bruising which can indicated base skull fracture. The patient lacked some capacity. Diagnosis was a head injury but also a possible collapse. Cause. Required head injury observation and medical assessment Inc; bloods to identify reason for lack of capacity. Also met criteria for head CT. Needed facial X-rays which could not be facilitated at MIU.

An ambulance was requested at 11.01. EMAS were contacted at 12:34 as no ambulance had arrived. At 17:39 a friend of the patients relative provided transport.This situation was still not ideal at 17:39 but on balance this offered the lowest risk as diagnostics significantly delayed.

The breach was due to unavailability of an ambulance to transfer patient to ED via the safest mode possible.Severe snow fall the previous night causing travel chaos impacting on ambulance transfers.

2-Action Plan: (actions taken, including assignment of responsibilty for this plan)

480

294

234

1 0 0 0 0

1

2

3

4

5

6

7

8

9

10

0

100

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400

500

600

Buxton Ilkeston Ripley Whitworth

Num

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f Bre

ache

s YTD

Min

utes

to A

sses

smen

t

Site

Individual Site Times -Longest Wait

Number of Breaches YTD

Target Time

Total Time in A&E Department - Longest - December


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Falls resulting in severe injury or death (no.) External Monthly DoNQ 0 0 14 2 2 3 21


2-Action Plan: (actions taken, including assignment of responsibilty for this plan)

3-Timescales

4-Effect of this Exception on the Forecast Position


During the December 2014 period, 3 falls resulted in serious harm, which are as follows:

W43970 occurred on Melbourne ward and relates to an 82 year old male patient with a history of falls and two recent falls during December. On this occasion a fall was suspected though unobserved, the previous falls were attributed to unsteady gait and agitation. Whilst the patient was on close level supervision by 2 members of staff the injury is suspected to have related to an unobserved fall. Other contributory factors include high agitation levels and that physically the patient was very unwell. He is now at Chesterfield Royal Hospital after suffering a fractured NOF.

W43899 occurred on Okeover ward and relates to an 84 year old female independent patient who walked across the room and caught her foot causing her to fall sustaining a basicervical (base of femoral head) fracture.

W43573 occurred on Linacre ward and relates to a 77 year old female patient with a history of falls both at home and on the ward, who, whilst under close supervision got up from the table and fell, sustaining a fractured left hip.

All the above incidents are currently under Root Cause Analysis review when full contributory factors and any identified improvement measures will be highlighted.

0

1

2

3

4


No

Month

Falls Resulting in Severe Injury or Death - December

Falls Resulting inSevere Injury (no)


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Breastfeeding sustainment from 10 days to 6-8 weeks after birth (%) External Monthly DoSD 84% 84% 75% 67% 73% 79% 79%



3-Timescales

It is unlikely that we will meet the final forecast position of 84% sustainment rate for breastfeeding. We are more likely to maintain the current cumulative sustainment rate of 76%


Sustainment rates continue to not meet the 84% set by commissioners however there was an increase in overall sustainment this month. The locality with the lowest percentage of sustainment is Bolsover and North East at 71% with 18 babies not having sustained breast feeding by 6 weeks. Of those babies 11 (61%) were being partially fed (given formula top ups) by 10 days and 4 22% had been given expressed breast milk as a main source of feeding by 10 days. 7 mothers felt they did not want to continue with breast feeding despite good support from the Health Visiting team. 1 mother reported pressure form the babies father to give formula. 3 mothers cited that the stress they associated with breastfeeding impacted on their decision to stop and one stated that part of this was due to being self employed stating "I fully understand the importance and health benefits of breastfeeding but the bills come first". 1 mother stated she did not like breast feeding. 1 mother was advised to give EBM (expressed breast milk) by the midwife and 1 baby was readmitted with weight loss and discharged having EBM and formula feeds. 1 mother was mainly giving formula by the time of the 10-14 day review. In South Derbyshire and Derbyshire Dales we achieved a sustainment of 85% with 7 mothers not sustaining however 1 of those babies had never had breast milk and is noted as a recording error. 1 mother had significant issues around attachment and EBM was commenced in hospital. 1 mother was made to feel by the baby's paediatrician that she was not giving enough milk to her baby and so stopped.

The action plan remains in place from last month. The strategic lead now has meetings with local providers of midwifery care across the organisation both secondary and primary care in the new year to look at raising specific concerns regarding the increase in partially fed babies , EBM and the impact on midwives following new local growth policies which have given rise to more mothers being advised to give formula top up feeds. The breastfeeding team are to undertake quality visits with all peer supporters and to look at undertaking specific quality reviews of support and advice given by health Visitors .Whilst the education audit continues to demonstrate that health visitors knowledge is still improving the competence of using this knowledge in practice is to be assessed. In addition each locality now has a specific action plan to ensure any local issues impacting on the sustainment rates are being identified and addressed. The role of the breastfeeding champion in each locality is being reviewed to enable them to have more time to support staff with knowledge and skills and have a remit to improve quality. All BFSW will be on erostering and this will avoid mothers not receiving the support as the county service can be managed more effectively.

Ongoing work with other providers and commissioners to take place over next 6 months.


76% 75% 76% 72% 77% 76% 67% 73% 79% 60%

65%

70%

75%

80%

85%

90%


% S

usta

inm

ent

Month

Actual In MonthSustainment (%)

Target

Breast Feeding Sustainment- 10 Days to 6-8 Weeks - December


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IWB Overall Measures (rating) External Monthly DoSD

Community Smoking Cessation - 4 week Quitters (no) External Monthly DoSD 752 94 7 7



The new contract delivery for Community Stop Smoking started on 1st December 2015 through an accredited provider market as per the service specifiaction, which included GPs and Pharmacies. An exit plan had been developed and implemented to take the previous Specialist Stop Smoking Service in DCHS and clients still engaged with the service, through the transition from previous service to newly commissioned service. The development and contracting of this and with this, accredited provider market, against a PBR tariff is in process. Negotiation with Alexin and the GP Federations is ongoing re engagement of GPs. Alexin have now withdrawn their initial agreement to contract with DCHS on behalf of the practices for delivery of Smoking Cessation.North Derbyshire GP Federation have confirmed that they will be contracting with DCHS on behalf of the practices for delivery of Smoking Cessation. Pharamies will be individually sub contracted to dleiver Community Stop Smoking and drug dispensing to support quit attempts.As clients are registered into the service from 1st December the achievement of 100% activity would not have been possible. From the exit plan any clients from previous LES providers ie GPs and Pharmacies were transferred over to the new service which has resulted in minimal activity for December. However the KPI relates to 4 week quitters which will not be achieved until this period of time has elapsed for clients engaging with the service throughout December.

The accredited provider market for the Integrated Wellbeing Service is managed by Tina Jones Service Manager operationally, supported by Tracy Gilbert Head of Strategyand Matt Eves Business Managere.Individual subcontracting arrangements will need to be made with GPs in the South and Erewash. Memorandum of understanding documents have been sent to interested GPs and Pharacists for individual sign up to service delivery. Negotiation continues to develop the agreement and risk sharing with North Derbyshire Federation. Pharmacies to be individually sub contracted to deliver services.



3-Timescales :

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700

800

Dec-14 Jan-15 Feb-15 Mar-15

Num

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f Qui

tter

s

Month

5 week Quitters(Actual)

4 week Quitters(Planned)

IWB Overall Measures - Communty Smoking Cessation - Cumulative - December


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Measure Type Frequency Director 2014/15 Full Year Target



Community Weight Management -12 Week Completers (no) External Monthly DoSD 651 163 36 36

Community Weight Management - Achieving >5% Weight Loss at 12 Weeks (no) External Monthly DoSD 196 49 15 15

Community Weight Management - Achieving >5% Weight Loss at 52 Weeks (no) External Monthly DoSD 196 49 9 9



The new contract delivery started on 1st December 2015. An exit plan had been developed and implemented to take the service and clients through the transition from previous service to newly commissioned service. As clients have been registered into the service from 1st December the achievement of 100% activity is not possible. From the exit plan any clients that fitted the criteria were transferred over to the new service which has reulted in some activity for December. However the KPIs relate to 12 week weight loss and 12 and 52 week completers which will not be achieved until this period of time has elapsed. Small numbers of clients as previoulsy stated have transferred into the service.

As per KPI requirements 12 weeks and 52 weeks.

Development of phased trajectories with David Caddy, Jackie Wagstaffe and Matt Eves to support reduced performance targets for first year from commissioners to support implementation and activity required from service against this.



3-Timescales :

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Num

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f Clie

nts

Month

12 Week Completers(Actual)

5% Weight Loss 12wks (Actual)

5% Weight Loss 24wks (Actual)

12 Week Completers(Planned)

5% Weight Loss 12wks (Planned)

5% Weight Loss 24wks (Planned)

IWB Overall Measures - Community Weight Management - Cumulative - December


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Number of new clients (no) External Monthly DoSD 2,600 650 480 480

Number of clients/engagements developing/completing personal wellbeing plans (minimum 3 goals) (no) External Monthly DoSD 1,400 350 165 165



The new contract delivery started on 1st December 2015. An exit plan had been developed and implemented to take the previous Health Traines service and clients through the transition from previous service to newly commissioned service ie Wellbeing Service.This includes clients who have been transferred to the new Wellbeing Service from Primary Care ,with staff who were TUPEd over to DCHS. The contract start date for delivery of the Service Specification was 1st December 2014 .As TUPE applied for staff working for other providers ,an induction process had to take place to DCHS and a local induction to the new service. This meant a significant proportion of the workforce who had TUPEd to DCHS, for this element of the Integrated Service, were unable to engage with clients for the fisrt 2 weeks of December. The Christmas period also had a significant effect on referrals into the service ie reduced and staff absence due to planned annual leave.

Trajectories to be in place by end of February 2015

Development of phasing of the trajectories for the required performance KPIs with David Cadd,Service Lead Jackie Wagstaffe, Matt Eves Business manager. This will reflect commissioners requirements for reduced outcomes/targets in year 1 to support service implementation and performance targets that service has to deliver.



3-Timescales :

0

500

1,000

1,500

2,000

2,500

3,000


Num

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f Clie

nts

Month

Number of New ClientsActual (cumulative)

Number of Clients PWBPlans Actual(cumulative)

Number of New ClientsPlanned (cumulative)

Number of Clients PWBPlans Planned(cumulative)

IWB Overall Measures - Wellbeing - Cumulative - December


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YTD Target Q2 cumulative Oct-14 Nov-14 Dec-14 YTD

Vasectomy Service Activity (no.) External Monthly DoSD 429 311 210 31 29 23 293

ACTION PLAN: 1-Summary of Issues:

3-Timescales

if the referrals are made by the GPs we will succeed in this target as we have vacant slots to achieve this.


The Vasectomy annual activity target is split into 12 equal months. Seasonal variations ie Summer holidays and Festive period. Female contraceptive methods LARC ( Long Acting Reversibile Contraception- coils/implants etc) are increasingly popular and this is impacting on the demand for Vasectomy as a method of contraception nationally.

Extra clinics are planned in February and March 2015 if the demand dictates. All Doctors AL will be covered to allow continuity of Service. GP and Health Visitor mailshots. Communiction made with Police/Fire Services. No Waiting list at any of our sites- Wheatbridge in Chesterfield, Long Eaton and Cavendish in Buxton.

GP mailshots in january 2015. Extra clinics to be published in Feb and March in Chesterfield and Long Eaton.


28

67

102

128

166

210

241

270 293

25

68

112

140

166

203

237

287 311

0

50

100

150

200

250

300

350


Activ

ity

Month

Cumulative Actual(no)

Cumulative Target(no)

Vasectomies (no.) - December


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Measure Type Frequency Director2014/15 Full Year

TargetYTD Target Q2 Oct-14 Nov-14 Dec-14 YTD

Health Visiting New Birth Visits within Contract Terms-10-14 days (%) External Monthly DoSD 100% 95%-100% 89.9% 89.6% 90.8% 90.5% 90.1%

Health Visiting - Number of mothers who have received a first face to face antenatal contact (%) External Monthly DoSD 100% 95% 69.9% 68.9% 68.4% 65.8% 66.5%



3-Timescales


1. Birth visits being undertaken out of timeframe for December was 42 in total (9.5%), audit of these out of time visits has been undertaken has shown that there were 5 (11%) premature babies in Neonatal Care Units, Christmas period had a major impact on achieving visits undertaken between 10-14 days, there were 24 (57%) visits that were no access visits or cancelled by parents at short notice. 7% of visits had to be re-arranged due to staff illness on day of appointment, 1 baby was admitted to hospital, 7 (16%) visits were late due to appointment admin errors.

2. Decrease in number of antenatal contacts being delivered. Data quality and reporting systems need to change to meet the definition of indicator C1 DH Commissioning requirements which are 'the number of mothers who receive a first face to face antenatal contact with a HV at 28 weeks onwards which is the count of numbers of mothers who receive a first contact with a HV before they give birth, this is defined as a count rather than percentage because of the difficulty of defining a denominator to which antenatal visits can be linked within current data collection systems. Currently, Antenatal visits undertaken are measured against number of births in previous year.

An action plan has been developed with clinical team leaders to support staff with the aim of improving scheduling of appointments to enable families to have some choice and flexibility of appointment offered within defined timescales of 10-14 days and to enable sufficient time where possible for follow appointments to be made when a no access visit occurs with initial appointment and achieve visit within 14 day time limit, this will be achieved by bringing forward the scheduling of appointments for the new birth visit as soon as the referral is received.

To improve coverage of antenatal contacts further work using SystmOne processes is being developed to utilise the functionality within the system to create waiting lists for mothers needing an antenatal visit during the last trimester of pregnancy, ultimately the aim is to use Business Intelligence (BI) to create a failsafe mechanism for recall and provide more accurate reports of expected/planned antenatal contacts, the resulting report will give a more accurate % of antenatal visits undertaken of maternity referrals received rather than based on last years birth rate.

Audit of births in December 2014 is being undertaken to check how many of these births had an antenatal contact, early results so far demonstrate that in Bolsover Locality 89.43% of all births in December did receive an antenatal contact compared to current performance measured against average births per month of 76.3%.

Staff to continue to complete DATIX reports for any late notification of births. SystmOne Admin Coordinator supporting and offering 1:1 training for practitoner to correct any data quality issues.

To continue with weekly exception reporting by HV teams to Clinical Team Leaders of out of time frame new birth visits to act as an early warning system and help mobilise workforce where there are vacancies or reduced staffing levels to ensure visits undertaken within timescale. Healthy Child Programme Lead and Quality Professional Lead will review these reports monthly to identify any data quality and workforce capacity issues.

Feb-15


90.7% 87.7% 90.9% 91.1% 90.0% 87.4% 89.6% 90.8% 90.5%

72.4% 65.8% 71.6% 73.6%

50.6% 61.9% 68.9% 68.4% 65.8%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%


Perc

enta

ge o

f co

ntac

ts

Month

No. of Actual Visits 10-14days (%)

Actual First Face to FaceAntenatal Contacts (%)

No. of Planned Visits 10-14 days (%)

Planned First Face to FaceAntenatal Contacts (%)

Health Visiting (%) - December


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Measure Type Frequency Director 2014/15 Full Year Target

YTD Target Q2 cumulative Oct-14 Nov-14 Dec-14 YTD

Chlamydia Screening Positive Activity - overall total (no.) External Monthly DoSD 2,872 1,664 872 99 275 61 1,307

Chlamydia Screening Positive Activity - DCHS element only (no.) External Monthly DoSD 987 661 464 91 48 53 656


We are close to achieving the target for DCHS, the challenge is around the activity recorded by the Chlamydia Screening Office from other providers, which forms part of our commissioned service - this issue is resolved when the CTAD data (national chalmydia screening programme data) is reported directly from the labs on a quarterly basis at which point the activity from other providers is received by DCHS in full. hopefully having all screens included on inform rather than seperate will increase the number of screens passing through core services where we know there is higher positivity.


Work is currently underway to review the screens delivered by the outreach programme, which may have an impact on the number of positive screens identified by the programme.Other providers involved with the programme are being engaged with in order to bring the number of positive screens identified within mainstream services back on target. There has been some training issues highlighted within the team.

• This risk to achieving the Chlamydia target is reviewed at divisional governance meetings and has been assessed at 6 medium level risk.• Meeting arranged to link C-Card and Chlamydia screening better to ensure that all 13 - 19 years olds get a C-Card and Chlamydia screen. This involves training all Outreach Workers in C-Card registration and collection, training arranged for Feb 12th. • Operational recovery meetings have been scheduled within ISHS to manage the deficit.• Increase in pick up bins (for postal kits) across DCHS and also partnership organisations including Children’s Centres. We have had identified 40 new sites that will now carry postal kits, these include pharmacies, childrens centres and drug and alchol venues. We have also updated the postal kits to bring them in line with other Chlamydia services.• Staff are actively promoting swabs versus urine samples for all female service users in all settings in the hope of further boosting positivity, we are just waiting on a delivery of female swabs to role this out to clinics now in order to increase uptake and positivity within clinics for the Chlamydia screening programme, with a view to rolling this out to whole programme by the end of the year.• Working with PET team do some patient engagement and consultation work around the whole programme and the sexual health service; looking at barriers to access, technology used and what young people want, this will be conducted via young persons groups, school nurses, school councils, youth workers, MAT teams and other partnership organisation. important links have been established with the school ursing team.• Increasing the re-testing of clients through a recall process, who have had a previous positive result, should pick up possible re-infections, this includes anyone who has had a positive screen in the last 3 months. • To look at adding screens onto Inform for clinics only at the moment to encourage screening in clinics and reduce the amount of paperwork staff have to complete. There will also be an engagement session with staff to look at barriers to screening in clinics which will encourage staff to increase screens - awaiting a date to commence the inform work.• We are re-testing all clients who tested positive 6-8 weeks following treatment.• Outreach rota is being reviewed to ensure that staff are focused in areas of high positivity reduced day time activity to focus more on the pubs and clubs work, this will in turn help work towards the 20 - 24yr old males target.• Currently looking at other NCSP programmes to see how they work and meet their targets, along with increased positivity - will be meeting other programmes to gain insight. Also meeting arranged with Debbie Shaw (East Midlands NCSP lead at PHE) to discuss ways to increase screens. • Working on the paperwork clients fill in to ensure that it is user friendly and we are only asking for data we need.• 3 Cs and HIV programme still being pursued with an aim of higher screening engagement from GPs - 10 practices engaged so far with consistent efforts being made to engage more. Work to be conducted with Comms Team in order to look at advertising, social media and web design, how young people can text in for a postal kit rather than email or phone. Engage with Outreach staff to find out their thoughts about how to increase screening. Contacting GP's that have engaged in 3C's to see how we can support them to provide screening and what the barriers are. • To meet with GP federations to discuss the importance of screening and try to support GP practices to increase screening. • Moving towards just one IT system for Chlamydia screening rather than two systems to ensure that all staff can access the system and results and reporting becomes simpler. • To contact G4S who look after the custody contract and see if we are able to offer screening in custody. • Contacted DHU with regards to screening in Foston and Sudbury prisons to ensure we offer wide distribution of screening, have a meeting on the 26th Janat Foston to look at how we take this forward. Plans are now in place to invest time and training into the Outreach team, focusing on quality of service. investment in sexual health awarenss training, regular days out for training.

Progress made since the previous exception report will be limited since any amendments or actions taken will take time have a positive impact.

Working thorugh the action plan to ensure that deadlines are met, moving things forward as we go with this.• Reviews at governance meetings• Internal operational meetings to manage operational issues• Increased self taken screenings• CSO are engaging with disengaged providers• Increased re testing• Transfer of good practice within ISHS meetings, now put all partner notofication work direct onto inform to ensure that information doesnt get lost or go missing., this we hope will increase the partner notification and bring in more contacts of positive clients. weekly email put out has this week included figures of where we are at with sccreening in clinics.this will hopefully inform clinical staff of the need to increase screening.4-Effect of this Exception on the Forecast Plan (how we get to our final forecast position from here)

83 166 249 331 414 496 579 661 740 80 143 222 331 403 464 555 603 656 113

226 339

832 945

1,058 1,171

1,661

2,706

89 156 242

723 805 872 971

1,246 1,307

0

500

1000

1500

2000

2500

3000


Posi

tive

Scre

ens

Month

No. of Planned Screens DCHS(Cumulative)

No. of Actual Screens DCHS(Cumulative)

No. of Planned Screens overall(Cumulative)

No. of Actual Screens overall(Cumulative)

Chlamydia Screening (no.) - December


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2013/14 Full Year

TargetYTD Target Oct-14 Nov-14 Dec-14 YTD

RTT Waiting Times-AHP-Respiratory Services (no) National Monthly DoSD 0 0 65 24 35 35RTT Waiting Times-AHP-Respiratory Services(%) National Monthly DoSD 0% 0% 31.9% 25.5% 31.8% 31.8%

53.4% 53.4%


3-Timescales




An immediate focus on managing and rationalising 'patient choice' breaches will bring the service back in line with the trajectory. This, combined with the proposed 'waiting list' breaches action plans will maintain the service towards achieving the expected RTT target. Any significant increase in referrals to all areas will have to be managed.

see above

1. Reduce the number of wrongly reported 'patient choice' breaches by ensuring correct and consistent practice in relation to RTT clock management. Work with informatics and ICBS lead to provide all areas with definative RTT protocol and guidance. Owner - David Muir, (Service Lead), timescale - 05/02/15. 2. With current PR prcactice the first opportunity to stop the RTT clock is when patient attends for pre programme assessment. These assessments can not be done too far advance of the programme the patient is expected to commence, (max 6 weeks before), so there is the potential for breaches to occur if assessment has to be held to be valid for programme. PR staff themselves have suggested that a triage appointment is introduced into the PR process. Not only would this give an earlier opportunity to stop the RTT clock, it may also reduce DNAs and improve programme completion rates. This option to be scoped and implemented. Owner - David Muir, Service Lead, timescale 1st April 2015. 3. Implement full (additional) assessment and programme capacity in Erewash CCG. Owner- David Muir, Service Lead, timescale - Jan 2015. 4. Secure alternative, (potentially additional), programme venue(s) in Derby City to increase service capacity. Owner - David Muir, Service Lead, timescale 1st April 2015.

Slight rise in number and percentage of patients breaching 13 wk RTT target in December, halting downward trend. All 32, (29%),breaches for Respiratory Services are for the Pulmonary Rehabilitation element of the service. Of the 32 breaches, 16, (50%) are reported as being due to 'waiting list issues' and 16, (50%), due to 'patient choice'. Majority of waiting list breaches are in SD CCG and Erewash CCG areas.

60.0% 58.1% 48.1% 71.9% 53.4% 56.5% 31.9% 25.5% 31.8%

21

36 37

82

62

78

65

24

35

75 75

60

40

10

0%

10%

20%

30%

40%

50%

60%

70%

80%

0

10

20

30

40

50

60

70

80

90


% o

f Pat

ient

s >1

3 W

eeks

Num

ber o

f Pat

ient

s

Month

% Patients >13weeks

Number ofPatients >13weeks

ForecastNumber ofPatients >13weeks

RTT Waiting Times - AHP - Respiratory Services (no & %) - December


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YTD Target Oct-14 Nov-14 Dec-14 YTD

RTT Waiting Times-Consultant Led-APC-Dental services (no) National Monthly DoSD 0 0 12 12RTT Waiting Times-Consultant Led-APC-Dental Services (%) National Monthly DoSD 10% 10% 21.8% 21.8%

53.4% 53.4%


3-Timescales




The forecast plan for 18 RTT for Leicestershire dental is at >20% and as such this excpetion report is in line with expectations.

The actions above to be complete by 31st March 2015 - however the provision of recurrent capacity is dependent upun funding from commissioners and capacity from acute provider, this currently does not appear likely.

1) Have already engaged with commissioners - who have made provision for additional non-recurrent funding in 14/15.2) Have already engaged with acute provider - have now got agreement for short term additional weekend waitin list intitiave lists to address some of waiting list.3) Undertake a full capacity and demand plan to support further engagement with commissioners/acute provider for recurrent additional capacity.4) Have agreed and put in place appropriate rules for management and reporting of 18 RTT for dental - including engagement with Trust Development Authority.These actions are managed within service but with close oversight by Director of Operations and Director of Finance.

There is not enough commissioned capacity to meet the demand for the general aneashetic dental service across Leciestershire. This demands is driven by Leciestershire being the highest area in terms of peadiatric dental health needs and disease incidence, along with difficulties accessing suitiable acute facilities.

21.8%

12

0%

5%

10%

15%

20%

25%

0

2

4

6

8

10

12

14


% o

f Pat

ient

s >1

8 W

eeks

Num

ber o

f Pat

ient

s

Month

% Patients>18 weeks

Number ofPatients >18weeks

ForecastNumber ofPatients >18weeks

RTT Waiting Times - Consultant Led - APC - Dental Services (no & %) - December


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Main QBC and Board Reports

Board Measure Description

Total Workforce Cost (£000s) Includes agency & bank. Plan revised to match QBC Finance report

Temporary Staffing Costs - Agency (£000's) Agency costs, usually funded by vacancies budget

Temporary Staffing Costs - Bank (£000's) Bank costs, usually funded by vacancies budget

Agency & Bank Spend (Clinical) as a % of total workforce costs (%)

Headcount (no.)

Health Visitor WTE (no.) Health visitors as reported by POEP within ESR

Family Nurse Partnership & Specialist Nurses (no.) Part of overall health visiting count

Staff Attendance (%) Staff attendance in month and on a ytd 12 month average

Staff Turnover (%) Staff turnover in month and on a ytd 12 month average

Board Turnover (no.)

Redundancy (no.) All posts made redundant to RATs for authorisation

Vacancies-Average Length of Time To Recruit (days)The average length of time from an approved vacancy being advertised on NHS Jobs to an agreed start date of employment being confirmed including time taken to complete pre-employment checks.

Vacancies-Average Length of Time From Offer to 1st Working Day (days)The average length of time from an agreed offer of employment being made to the applicant commencing employment with DCHS.

Vacancies-Average Length of Time For Pre Appointment Checks (days) The average length of time for pre-employment checks to be completed.

Vacancies-Externally Filled (no.) New measure

Vacancies-Internally Filled (no.) New measure

Advertised Vacancies (no.)

Essential Learning completed (% compliance) Year to Date is rolling 12month average - wte data

Information Governance Training (% compliance) Year to Date is rolling 12 month average-assignment data

Fire Training (% compliance) Year to Date is rolling 12 month average-assignment data

Training - Resus (% compliance)

Training - Safeguarding (overall rating)

New starters attending induction (% compliance ) New starters attending induction within 3 months / new starters requiring induction

Essential Training - (rating) Levels 1 - 3. Level 1 is Essential Learning

Staff with appraisal completed (% compliance) Staff who have a current completed appraisal

Improvement in Staff Survey Engagement Rates (%) Total staff participating / Total staff

Improvement in Staff Survey engagement and staff satisfaction scores (no.) Annual survey score

Pulse Check - Recommend DCHS to Friends and Family If They Needed Care or Treatment (%) Quarterly survey score

Pulse Check - Recommend DCHS to Friends and Family as a Place to Work (%)

Pulse Check - recommend DCHS to friends and family as a place to work (score) Quarterly survey score

Staff Net Promoter Question Result (no.) Quarterly survey score

Patient Revolution Friends & Family Test (no.) Service scores by patients

Complaints Received (no.) Level 2 and above complaints

PLACE (score)Q1-Looks at the environment in which care is provided and the quality of non-clinical services - food and privacy and dignity. Q2-Looks at cleanliness. Q3-external verification.Q4-PLACE

Certification against compliance with requirements regarding access to healthcare for people with a learning disability

To be reported to EDS & quarterly to QSC

A&E

A&E Targets (rating) Composite A&E targets measure

RTT Waiting Times Scorecard (rating) RTT composite measure

RTT Waiting Times (Scorecard)

Diagnostics - Patients exceeding 6 weeks wait (%)

Choose and Book Targets (rating) Composite of Choose and Book targets

Patients who have operations cancelled for non clinical reasons on the day (%)

Patients who have operations cancelled for non clinical reasons receiving treatment within 28 days (%)

Mixed Sex Accommodation Breach Rate (No)

Delayed Transfer of Care (%) Number of breaches / number of Finished Consultant Episodes

Delayed Transfer of Care for Inpatient (Rehab & Urgent Care) - contract calculation (%) Number of delayed transfers of care as a proportion of the number of occupied beds

Delayed Transfer of Care for OPMH - contract calculation (%) Delayed patient transfers from DCHS to other organisations

Delayed Transfer of Care for OPMH - Monitor compliance framework calculation (%) Delayed patient transfers from DCHS to other organisations

Inpatient (Rehab & Urgent care) Average Length of Stay (days) Composite of Rehab and Urgent Care length of stay

Older Peoples Mental Health Average Length of Stay (days) Average time in Urgent Care wards

Inpatient (RUC) Occupancy (%) Bed Occupancy rates

Older Peoples Mental Health Occupancy (%) Bed Occupancy rates

CCU

PAN

CY

QU

ALIT

Y PE

OPL

E

SERV

ICE

USE

R EX

PERI

ENCE

WO

RKFO

RCE

MET

RICS

TRAI

NIN

G A

ND

APR

AISA

LFE

EDBA

CKPA

TIEN

T SA

TISF

ACTI

ON

CHO

OSE

& B

OO

KIN

PATI

ENTS

Focus Area


REFE

RRAL

TO

TR

EATM

ENT


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Board Measure DescriptionFocus Area


LD Occupancy (%) Bed Occupancy rates

Achievement of consultation /involvement/engagement inclusion priorities (%) Bed Occupancy rates

New or revised policies/procedures/strategies supported by EIAs (%) Equality and diversity measure

CQC Registration - Internal (rating) Equality and diversity measure

CQC Registration - Impact Governance Scores (rating) Internal rating against CQC measures

CQC Warning Notices

CQC Non-Compliance with Essential Standards resulting in Enforcement Action

CQC Non-Compliance with Essential Standards resulting in a Major Impact on Patients

CQC Non-Compliance with Essential Standards resulting in Enforcement Action (Civil and or Criminal)

HAR

M

FREE

CA

RE Total Harm Free Care, in accordance with Safety Express (%)

Avoidable Grade 2, 3 & 4 Pressure Ulcers developed or deteriorated in DCHS care (no.)

Total Grade 3 & 4 Pressure Ulcers developed or deteriorated in DCHS care (no.)

Incidence of Newly Acquired Pressure Ulcers (no.)

Medication Errors causing Serious Harm (no.)

NHSLA Rating (no.)

Falls resulting in severe injury or death (no.)

Duty of Candour - Failure to notify relevant person of a reportable incident (no)

Healthcare Care Associated Infections - MRSA bacteraemia (no.)

Healthcare Care Associated Infections - Clostridium difficile (no.)

Healthcare Care Associated Infections - Clostridium difficile -lapses count (no.)

Healthcare Care Associated Infections - E Coli & MSSA (no)

Breastfeeding sustainment from 10 days to 6-8 weeks after birth (%) Number of partially and fully breastfed infants / total infants due a 6-8 week check

CQUIN Scorecard (rating)

IWB overall Measures (rating)

Smoking Quitter Targets (rating)

CIP Achieved-Recurrent(%) CIP Achieved / Total CIP required

CIP Achieved-Non Recurrent (%) CIP Achieved / Total CIP required

Better Payment Practice Code - by value (%) Value of invoices paid within 30 days / Total value of invoices paid

Better Payment Practice Code - by volume (%) No. of invoices paid within 30 days / Total no. invoices paid

Monitor Risk Assurance Framework Scorecard (RAF) (rating)

Financial Risk Rating (FRR)

Continuity of Services-Liquidity Ratio (days.) (Monitor Shadow Format)

Continuity of Services-Capital Servicing Capacity (times.) (Monitor Shadow Format)

Continuity of Services-Risk Rating (Monitor Shadow Format)

FT Membership (no.)

CAPA

CITY

Positive media stories (no.)The number of positive media stories reported for DCHS across all media outlets. A positive media story is classed as one that enhances the reputation of DCHS

MIU Activity (no.) All contract activity, compared against profiled activity plan

Community Beds -Discharged Occupied Bed Days (no) Replaces Rehab & Urgent Care Activity

Outpatient and Daycase Activity (no.) All contract activity, compared against profiled activity plan

Vasectomy Service Activity (no.) All contract activity, compared against profiled activity plan

Podiatric Surgery Activity (no.) All contract activity, compared against profiled activity plan

Community Podiatry Activity-Non AQP (no.) All contract activity, compared against profiled activity plan

Community Podiatry Activity - AQP (no.) All contract activity, compared against profiled activity plan

Physiotherapy Activity (no.) All contract activity, compared against profiled activity plan

Speech and Language Therapy Activity (no.) All contract activity, compared against profiled activity plan

Diagnostic Imaging (no.) All contract activity, compared against profiled activity plan

Rehabilitation and Intermediate Care Activity (no.)

Chlamydia Screening Positive Activity (no.) All contract activity, compared against profiled activity plan

Health Visiting Contract (Rating)

Health Visiting Activity (no.)

CLIN

ICAL

EFF

ECTI

VEN

ESS

&

PLAN

NIN

GO

C

EQU

ALIT

Y &

D

IVER

SITY

CON

TRAC

T AC

TIVI

TYH

EALT

H

VISI

TIN

G

QU

ALIT

Y BU

SIN

ESS

BUSI

NES

S &

MAR

KETI

NG

FIN

ANCE

FT R

EGIM

E

SERV

ICE

USE

R SA

FETY

CQC

PRES

SURE

ULC

ERS

HCA

IO

THER

SAF

ETY

MEA

SURE

S

QU

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Y SE

RVIC

E


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Board Measure DescriptionFocus Area


Community Nursing Activity (no.)

Community Matron Activity (no.)

Community Information Dataset Completeness-Referral to treatment information (%)

Community Information Dataset Completeness-Referral information (%)

Community Information Dataset Completeness-Treatment activity information (%)

Information Governance Incidents Reported via IG toolkit - Level 2 or above (no.)

Information Governance Toolkit Achievement - measures scoring 2 or better (no)

Monitor Risk Assurance Framework Scorecard (RAF) (rating)

Sickness & Absence Rates - Long Term Absence (%)

Sickness & Absence Rates - Short Term Absence (%)

Turnover - Planned (%)

Turnover - Unplanned (%)

New SIRIs reported per month (excluding pressure ulcers) (no.)

Injurous Falls per 1,000 inpatient occupied bed days (no.)

Injurious and non Injurious Falls per 1,000 Inpatient Occupied Bed Days

Number of incidents (causing harm or otherwise) per 1,000 WTE budgeted staff (no)

Number of Formal Complaints Reported per 1,000 WTE Budgeted Staff

Safety Thermometer - Percentage of 'Harm Free' Care (New harms only)

Face to face contacts per whole time equivalent (wte) community nurse per working day (no.)

Total pay cost per wte community nurse (£)

Face to face contacts per whole time equivalent (wte) health visitor per working day (no.)

Total pay cost per wte health visitor (£)

Average length of stay (days)

Percentage occupancy of community hospital beds (%)

Data Completeness-NHS Number (%)

Data Completeness-Ethnicity code (%)

Data Completeness-Postcode (%)

Data Completeness-GP Practice code (%)

HCAI Report

Board Measure Description

MRSA Infections - Avoidable (No.) Identified non compliance with IP&C standards which may have prevented occurrence

MRSA Infections - Possible (No.) Identified possible risk factors that may have contributed to the infection occurring

MRSA Infections - Unavoidable (No.) Identified that there were pre-disposing risk factors contributing to the infection

ESBL - Avoidable (No.) Extended Spectrum Beta Lactamases

ESBL - Possible (No.) Extended Spectrum Beta Lactamases

ESBL - Unavoidable (No.) Extended Spectrum Beta Lactamases

Norovirus outbreaks (No.)Considered unavoidable because DCHS is unable to influence transmission. Number of ‘outbreaks’ and therefore may include more than one patient.

MRSA Bacteraemia - Avoidable (No.) Identified non compliance with IP&C standards which may have prevented occurrence

MRSA Bacteraemia - Possible (No.) Identified possible risk factors that may have contributed to the infection occurring

MRSA Bacteraemia - Unavoidable (No.) Identified that there were pre-disposing risk factors contributing to the infection

MRSA Screenings - Elective Surgery (%) The % of elective surgery patients screened for MRSA

MRSA Screenings - Non Elective Admissions (%) The % of non elective admission patients screened for MRSA

MRSA Screenings - Sexual Health (&) The % of sexual health patients screened for MRSA

Clostridium Difficile - Avoidable (No.) Identified non compliance with IP&C standards which may have prevented occurrence

Clostridium Difficile - Possible (No.) Identified possible risk factors that may have contributed to the infection occurring

Clostridium Difficile - Unavoidable (No.) Identified that there were pre-disposing risk factors contributing to the infection

INFO

RMAT

ION

QU

ALIT

Y SE

RVIC

E

SERV

ICE

USE

R SA

FETY

& E

XPER

IEN

CE

HCA

I

QAU

ALIT

Y PE

OPL

E

Focus Area

INFO

RMAT

ION

QU

ALIT

Y BU

SIN

ESS

QU

ALIT

Y BU

SIN

ESS

COM

M N

URS

ING

QU

ALIT

Y SE

RVIC

E


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KEY TO COLOUR CODINGS

Indicator / Measure has met or exceeded targetIndicator / Measure has not met target but is within acceptable tolerances. An action plan is in place and is being monitoredIndicator / Measure has not met target and is beyond accepted tolerances. Immediate action and investigation has been instigated. An action plan is in place and is being monitored. Indicator / Measure is not available or in development

KEY TO SYMBOLS

↑ Performance has improved / is above target

↓ Performance has declined / is below target

↔ Performance is stable and on target to be delivered

Data Quality Kitemark scoring

Using data collected interview sessions with service staff; each system has been marked on the criteria of Audit, Timeliness, Sign off, Granularity, Completeness and Source/Process. A system can score as Not Sufficient, Sufficient or Exemplary in each of the six areas. These areas make up the outer segments of the Data Quality Kitemark Shield eg: A score of Sufficient or Exemplary marks the system as Green on the Kitemark Shield for that section and a score of Not Sufficient marks the system as red.

Data Confidence Score Each system will receive a Data Confidence Score calculated by the total overall scoring given by four key members of staff relating to the specified system from Information, Performance and within the service. Each contact is asked to give the system a confidence rating out of 5 to state how accurately the system data reflects service activity, where 5 is Complete Confidence and 1 No Confidence. The total of the four scorings will be displayed in the centre of the Data Quality Kitemark Shield.

Timeliness

Source/process

Sign off

Completeness

Granularity

Audit

12


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TRUST BOARD Document Title: Financial Performance Report

Presenter/Title: Chris Sands, Director of Finance, Performance and Information

Contents of Paper were previously discussed by: QBC Wednesday 21 January 2015

Author/Title: David Gray Head of Management Accounts

Contact Email and Telephone Number: [email protected]




Information Decision Assurance x

Purpose of Paper

The paper sets out the financial performance of the Trust as at 31 December 2014. The report details performance against statutory and internal targets. The Trust is reporting a surplus position of £1.10m at month 9, which represents a £0.43m adverse variance against the planned surplus of £1.55m. A year end forecast surplus of £1.6m is now expected due to delays in delivering the Cost Improvement Plan and increased pressures within the Clinical Services. The reduction in the year-end forecast surplus is a reflection of the increased financial pressures being experienced driven by overspending within Integrated Care Based Services (ICBS) and non-achievement of CIP plans. It also reflects the increased financial risk as we enter the winter period. The Trust is forecasting that it will meet all its statutory financial duties for the year.

Recommendations

The Board is asked to discuss the report and note the actions being taken to improve performance.


3.2. To ensure an effective, efficient and economical organisation which promotes productive working and which offers good value to its community and commissioners

Financial Impact

The report contains a number of issues and risks that have a financial impact on the organisation. The most significant of which are the delivery of the CIP programme and the financial position within the Integrated Community Based Services division. The report updates

27�Financial�Performance�Repor

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Committee members regarding the actions that are currently being taken and further mitigations that have been identified to support the overall financial position.


Attached.


Are there Governor Involvement implications? Governors will hold the Board to account around its financial position

Are there Equality and Diversity implications? No

Are there Patient, Public and Stakeholder Involvement implications? No

Risk Register





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WORKING CAPITAL14,092 G 11,801 G1,890 G (870) G

£m % £m % % £m % £m % £m % (2,296) G 379 GEBITDA (6.23) (5.19) (5.68) (4.73) (8.79) (7.83) (4.89) (7.85) (4.89) (0.01) 0.17 99.9 G 95.0 GNet (surplus)/deficit (1.55) (1.29) (1.10) (0.92) (28.85) (1.60) (1.00) (1.60) (1.00) (0.00) 0.00 99.1 G 95.0 G

96.3 G 95.0 GI&E SURPLUS I&E SUMMARY AS AT 31 DECEMBER 2014 97.5 G 95.0 G

VAR

ACTU

AL

PLANDECEMB

ER 2014

YTD

BPPC - NHS (by volume) (%)BPPC - NHS (by value) (%)

VAR

FOT

PLAN

FULL YEAR

EBITDA AND SURPLUS AS AT 31 DECEMBER 2014YTD 2014/15 FULL YEAR

DECEMBER 2014

FOTYTD

Current Assets Variance (£m)Cash at bank as per the ledger (£m)

Current Liabilities Variance (£m)£m

0.45

0.55

BPPC - Non-NHS (by volume) (%)BPPC - Non-NHS (by value) (%)

DERBYSHIRE COMMUNITY HEALTH SERVICES NHS FOUNDATION TRUST FINANCIAL PERFORMANCE REPORT

PLAN ACTUAL VARIANCE PLAN FOT VARIANCE

DECEMBER 2014 KEY FINANCIAL INDICATORS

RISK RATINGSContinuity of service - Liquidity (days) 13.75 G 12.57 G

(£m) (£m) (£m) (£m) (£m) (£m) Continuity of service - Liquidity rating 4 G 4 G(120.02) (120.17) (0.15) (160.23) (160.55) (0.32) Continuity of service - Capital Servicing (x times) 3.18 G 3.11 G

PAY 83.45 83.48 0.03 110.99 111.47 0.47 Continuity of service - Capital Servicing 4 G 4 GNON-PAY 30.34 31.01 0.67 41.41 41.24 (0.16)

OTHER 4.68 4.58 (0.10) 6.23 6.25 0.01 PERFORMANCE AND CIP YTD FOT(1.55) (1.10) 0.45 (1.60) (1.60) (0.00) Contract over/(under) performance (£m) 0.21 G 0.41 G

Over/(under)achievement of CIP target (£m) (0.65) R (1.23) RCAPITAL PROGRAMME MONTH END CASH BALANCE (Over)/underspend against investments (£m) G G

Net impact of CIP/investments/NR savings (£m) (0.65) R G

ADDITIONAL TRIGGERS YTD FOTReceivables aged over 90 days (%) 5.0 8.2 R 5.0 GPayables aged over 90 days (%) 5.0 20.6 R 5.0 GChange in Finance Director in last year 2 0 G 0 GInterim Finance Director in place over QE 2 0 G 0 GDays expenditure covered by QE cash 10 33.7 G 28.2 GCapital Expenditure % of plan (%) 75.0 50.9 R 92.3 G

VAR

ACTU

AL

PLAN

INCOME

TOTAL

DECEMBER 2014 VA

R

FOT

PLAN FOTYTD

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Cum

ulat

ive

surp

lus

(£m

)

Plan Actual Forecast

0.02.04.06.08.0

10.012.014.016.018.0

Cas

h at

mon

th e

nd (£

m)


-1.0

0.0

1.0

2.0

3.0

4.0

5.0

6.0

Cum

ulat

ive

capi

tal s

pend

(£

m)



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DERBYSHIRE COMMUNITY HEALTH SERVICES NHS FOUNDATION TRUST MONTHLY FINANCIAL PERFORMANCE REPORT FOR THE BOARD OF DIRECTORS

AS AT 31st DECEMBER 2014

1. Introduction The purpose of this report is to update and inform the Board on performance against key financial criteria for month 9 of the current financial year, 2014/15. The Trust is reporting a surplus position of £1.10m at month 9, which represents a £0.45m adverse variance against the planned surplus of £1.55m. A year end forecast surplus of £1.6m is now being reported following delays in delivering the Cost Improvement Plans and increased pressures within the Clinical Services. The reduction in the year-end forecast surplus is a reflection of the increased financial pressures being experienced driven by overspending within Integrated Care Based Services (ICBS) and non-achievement of CIP plans. It also reflects the increased financial risk as we enter the winter period. The general mitigation reserve has been allocated pro-rata at month 9.

2. Summary Financial Position The financial risk of the Trust is measured by the Continuity of Services (CoS) Rating as part of the provider license. A rating of 4 is low risk, whilst a rating of 1 is high risk. The Trust is forecasting a rating of 4 at the year-end. This reflects the strong balance sheet of the Trust. Table One – Continuity of Service rating

Measure Indicator Weight Year to date Forecast outturn Value Rating Value Rating

Liquidity

Number of days operating expenditure covered by current working capital balances

50% 13.75 4 12.57 4

Capital Servicing Capacity

Revenue cover available to service debt repayments

50% 3.18 4 3.11 4

To move to a CoS rating of 3, there would need to be a deterioration in the income and expenditure position of £3.5m. A further reduction to the position of £2.2m or a total of £5.7m would move the overall CoS rating to a 2. On the basis of the strong CoS rating, the Trust is able to make positive finance declarations in its quarter 3 return to Monitor.

3. Income & Expenditure Appendix 1 details the Income & Expenditure Statement as at month 9.


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More detail on the income and expenditure position is provided below.

3.1 Clinical Income Month 9 position is showing £0.21m over performance in relation to clinical income. This is a worsening in the position since month 8 of approximately £0.02m. Cost and Volume activity is over performing by £0.15m in Month 9. The main areas driving this over performance are Planned Care Outpatient/Day Case £0.27m and Physiotherapy £0.16m. This is being offset by under performance in Podiatric Surgery £0.10m and Community Podiatry £0.19m. The cost and volume plans have been increased in Month 9 by £0.5m in line with the start of the new Integrated Wellbeing Tender on the 1st December 2015. At present the first months activity monitoring is not available and therefore the income has been assumed to deliver an under performance of £0.06m in line with the forecast expenditure under spend thus having nil impact overall. Once the first cut of data is received, a more robust financial forecast will be reflected for the Month 10 position. The block contract element is showing £0.06m over-performance due to CQUIN achievement in quarter 1 and 2 being greater than the planned 90%. We are experiencing increased activity in areas covered by the block.

The overall contract income is forecast to over-perform by £0.41m by the end of the year.

Activity against plans will continue to be closely monitored to ensure early identification of under / over –performance and any associated risks to income.

3.2 Non-Clinical and Other Income

Other Income is behind plan by £0.06m, mainly due to loss of income from Derbyshire Healthcare Foundation Trust following the Trust leaving a number of our premises. A focused piece of work is underway around implementing a better system for managing who is using our buildings, and identifying opportunities for new sources of room rental income to mitigate this income gap.

3.3 Expenditure Overall, the Trust is reporting an over spend against the expenditure plan of £0.45m at month 9. Pay costs are over plan by £0.03m. Underspends in divisions are offsetting a £0.51 million overspend in pay in ICBS (a reduction of £0.09m in month). We continue to experience a higher than planned level of spend on pay in the ICBS areas through high levels of bank and agency usage and delays in delivering the planned Cost Improvement Programmes. The Trust has submitted business cases for additional non-recurrent funding from the Resilience Fund (Winter Planning) and have had a number approved by commissioners. A business case has been prepared for commissioners to consider additional recurrent funding to address the increased activity and acuity of patients seen in a community setting. This builds on some of the business cases put forward for Resilience funding and will form part of the contract discussions for 2015/16.


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The Trust continues to utilise high levels of bank and agency staffing, however following the recent recruitment campaign the bank and agency costs continue to reduce and for the third month running there has been a further reduction across all services of £0.02m. The Finance and Workforce Planning team are working closely to monitor and forecast the new staff starting in post, and the impact upon staffing costs and bank and agency usage. The main areas of pay overspends within the ICBS division are principally Bolsover and North East Community and Inpatient Teams (£0.58m), Amber Valley Community Teams (£0.21m), and MIU Services across the County (£0.24m). There are a number of Vacancies within Health and Wellbeing, Planned Care, Estates and Corporate Services which is helping to reduce the variance against plan down to £0.05m Non-pay Costs are over plan by £0.67m with the main areas of overspend covering Travel costs (£0.40m), Drugs usage within Health and Wellbeing (£0.04m), Telephone and Mobile costs (£0.21m), increased spend on Wheelchairs (£0.47m) due to delays in receipting, External Consultancy Fees (£0.22m) and Opthalmic Implants within Planned Care (£0.11m). The Management Accountants are working closely with the Budget Holders to address these areas of overspend and agree mitigation plans to bring spend back in line with plan. We are reviewing non-pay budgets as part of the 2015/16 planning process. Following the start of the new Healthy Living Tender within the Health and Wellbeing the service now have a number of vacancies and overall show a combined underspend of £0.06m which has been offset by a reduction in income. This process will be reviewed once all reporting systems are in place and accurately reported from Month 10. The cost improvement plan is £0.65m behind plan at month 9 due to delays in delivering the Site Strategies around Service redesign and transformation. Further detail is provided in section 3.4 below. 3.4 Cost Improvements Plan The Trust has a CIP target of £7.3m for 2014/15. An underachievement against the planned schemes both at month 9 and year end of £648k and £1,227k respectively are being forecast. This is the net position after mitigations have been included. The Trust continues to develop further mitigating schemes, which will be used to address schemes that are under delivering. Further schemes are being worked up and will be included on the schedule for month 10. Further detail of the CIP position can be found in Appendix 2.

4.0 Statement of Financial Position Appendix 3 sets out the Statement of Financial Position.

4.1 Cash At the end of December the cash balance was £0.9m ahead of plan (actual: £14.1m, plan £13.2m). The I&E surplus is behind plan but working capital variances and slippage in the capital programme mean we are over performing in cash terms.


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The Trust is continuing to actively manage working capital, with a particular focus on debtors.

4.2 Working Capital A key part of the Trust’s financial strategy is management of working capital. Described below is the year-to-date performance against the Public Sector Payment Policy: NHS Non NHS

% % Value 100 96 Volume 99 97

The Committee will note that the Trust is able to report year-to-date compliance against all four targets of 95% for the month of December.

5. Capital Plans and Expenditure

The Trust’s capital programme for the year 2014/15 is valued at £4,925K. At month 9 the cumulative expenditure is £2,793k, which is behind the plan profile. Expenditure relating to renovations at Walton Hospital on Linacre and Peveril wards is ongoing. Other capital schemes have been delayed into next year including the DTC upgrade and endoscopy equipment at Ilkeston Hospital. The net impact of this is an under-spend against cumulative plan of £0.5m. IM&T projects (PAS and mobile working) are incurring slippage causing an under-spend to Month 9 of £0.5m. Another impact on the year to date and full year capital programme is the VAT reclaims relating to prior year totalling £0.2m. The total capital expenditure for the year is forecast to be below plan by £325K. It is planned to add the underspend on capital to the 2015/16 programme.

Further detail can be found in Appendix 5 attached.

6. Risks Delivery of the CIP programme remains a significant risk and therefore ensuring that the Trust’s CIP programme is robustly managed through the PMO process is crucial. The CIP programme is phased into the second half of the year, and it is vital that these schemes are implemented promptly. A further risk is the deterioration in the ICBS financial position. The division have been asked to include this on the risk register. General Managers have developed their mitigation plans and these are being reviewed on a regular basis. To mitigate against the deteriorating financial position, the following action is being taken:

• ICBS recovery plan is being reviewed with a particular focus on: o Agency and bank expenditure o Delivery of CIP plans


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• Review of planned care position with a focus on:

o Delivery of facilities management savings from CIP schemes o The robustness of income forecasts, and the costs required to deliver this income

• Strong control of corporate costs with a review of all agency costs and vacancies

• Continuation of underspends in areas where they are being delivered to offset

overspending in other areas

• Negotiate additional income in areas of the block contract where activity is exceeding plan

• Increased control of discretionary spend Discussions have already commenced with commissioners to address some of the service pressures being experienced in the ICBS division, to find a recurrent solution to the increasing level of activity, and acuity of patients, being experienced in the community.

7. Summary

Board members are asked to note the month 9 position against the financial targets. Chris Sands Director of Finance, Performance and Information


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Appendix 1

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

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Annual Annual

Actual Plan Variance Actual Actual Actual Actual Actual Actual Actual Actual Actual Forecast Forecast Forecast Outturn Plan

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

OPERATINGIncome

Clinical Income -113,694 -113,483 -211 -12,583 -12,593 -12,409 -12,883 -12,475 -12,460 -12,927 -12,924 -12,440 -12,814 -12,663 -12,715 -151,886 -151,474

Other NHS Income -3,456 -3,696 240 -361 -384 -406 -333 -379 -450 -396 -360 -387 -398 -397 -398 -4,649 -4,947

Education and Training -653 -629 -24 -76 -108 -78 -70 -70 -75 -117 15 -74 -62 -63 -70 -848 -839

Other Income -2,366 -2,210 -156 -237 -215 -249 -254 -224 -274 -395 -215 -303 -263 -262 -278 -3,169 -2,969

INCOME TOTAL -120,169 -120,018 -151 -13,257 -13,300 -13,142 -13,540 -13,148 -13,259 -13,835 -13,484 -13,204 -13,537 -13,385 -13,461 -160,552 -160,229

Operating ExpensesEmployee Benefit Expenses 83,479 83,450 29 9,233 9,328 9,413 9,259 9,220 9,249 9,317 9,235 9,225 9,247 9,395 9,345 111,466 110,992

Drugs 701 645 56 46 226 56 58 63 53 43 58 98 58 58 58 875 940

Clinical Supplies and Services 5,991 5,559 432 490 546 502 652 640 596 1,047 763 755 679 680 680 8,030 7,277

Other Costs 24,320 24,139 181 2,741 2,497 2,527 2,676 2,652 2,670 3,011 2,779 2,767 2,730 2,677 2,617 32,344 33,188

OPERATING EXPENSES TOTAL 114,491 113,793 698 12,510 12,597 12,498 12,645 12,575 12,568 13,418 12,835 12,845 12,714 12,810 12,700 152,715 152,397

OPERATING (PROFIT) / LOSS EBITDA -5,678 -6,225 547 -747 -703 -644 -895 -573 -691 -417 -649 -359 -823 -575 -761 -7,837 -7,832

NON OPERATINGLoss / (Profit) on Asset Disposal 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1

Impairment of non-current assets 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Depreciation / Amortisation 2,847 2,841 6 320 319 319 315 315 315 315 314 315 313 314 313 3,787 3,782

Interest (Receivable) / Payable -38 -37 -1 -3 -6 -3 -5 -5 -4 -4 -4 -4 -4 -4 -4 -50 -50

Public Dividend Capital 1,769 1,875 -106 208 208 208 208 208 208 105 208 208 208 209 314 2,500 2,500

NON OPERATING TOTAL 4,578 4,679 -101 525 521 524 518 518 519 416 518 519 517 519 623 6,237 6,232

RETAINED (SURPLUS) / DEFICIT -1,100 -1,546 446 -222 -182 -120 -377 -55 -172 -1 -131 160 -306 -56 -138 -1,600 -1,600

ADJUSTMENTS TO RETAINED SURPLUS

Donated Asset Income (41) 0 (41) 0 0 0 0 0 0 0 0 (41) (20) 0 0 (61) 0

Donated Asset Depreciation 95 (0) 95 10 10 11 10 10 11 11 11 11 10 10 10 125 0

Impairment of non-current assets 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL ADJUSTMENTS 54 (0) 54 10 10 11 10 10 11 11 11 (30) (10) 10 10 64 0

ADJUSTED RETAINED (SURPLUS) / DEFICIT (1,046) (1,546) 500 (212) (172) (109) (367) (45) (161) 10 (120) 130 (316) (46) (128) (1,536) (1,600)

STATEMENT OF INCOME & EXPENDITUREDECEMBER 2014

Category

Year to Date Monthly Actual / Forecast

As at 31 December 2014


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Appendix 2

Plan £'000Plan % of

Annual ActualActual % of

Annual Risk RatingPlan £'000

Out-turn Actual Risk Rating FYE Forecast FYE Plan

Total CIP 14/15 4,934 67.4% 4,287 58.5% -648 -13% 7,324 6,097 -1227 -17% 6,622 8,709

Total PMO 1,529 63.6% 794 33.1% -734 -48% 2,403 1,299 -1104 -47% 1,690 3486

Total Transactional 3,406 69.2% 3,021 61.4% -384 -11% 4,921 4,134 -787 -16% 4,255 5223

Total Mitigation 0 - 471 - 471 0% 0 664 664 0 678 0

Programme Project Programme Lead PlanPlan % of

Annual Actual PlanOut-turn

Actual FYE Forecast FYE Plan

£'000 £'000 £'000 £'000 % £'000 £'000 £'000 % £'000 £'000Clinical Environments

Amber Valley Service Remodelling Mark Roberts 23 50.0% 2 3.7% -21 -93% 45 7 -38 -85% 14 90Clinical Environments

Consolidation of OPMH Beds Patrick Murphy 30 17.9% 30 17.9% 0 0% 168 30 -138 -82% 0 672Clinical Environments

LD Service Review Sue Ryan 6 25.0% 0 0.0% -6 -100% 25 0 -25 -100% 0 74Clinical Environments

Amber Valley IFM savings Maggie Barratt 12 50.0% 0 0.0% -12 -100% 24 12 -12 -50% 48 48Clinical Environments

NED Transformational Change Kim Ashall 0 0.0% 0 0.0% 0 0% 11 0 -11 -100% 0 45

HWBI Contraceptive and sexual health service review Paula Newbert 92 75.0% 83 68.0% -9 -9% 122 122 0 0% 122 122

HWBI Health Promotion Review Maddie Robinson 88 50.0% 70 39.8% -18 -20% 175 159 -16 -9% 350 350

Planned Care SLT Service Review Lisa Salton 56 68.6% 52 62.9% -5 -8% 82 77 -5 -6% 102 112

Planned Care Planned Care contract reviews Brenda Page 122 75.0% 122 75.0% 0 0% 162 162 0 0% 162 162

Planned Care I&E Staff and non pay Brenda Page 68 75.0% 42 46.2% -26 -38% 91 91 0 0% 91 91

IFM Catering cost reduction Richard Lyne 31 57.0% 37 67.4% 6 18% 55 62 7 13% 62 55

IFM Hotel services cost reduction Richard Lyne 85 52.6% 81 50.0% -4 -5% 162 113 -49 -30% 113 162

IFM IFM Staffing Management Review Richard Lyne 91 69.0% 94 71.1% 3 3% 132 139 7 5% 139 132

IFM IFM Non Pay Review Richard Lyne 6 25.0% 10 40.8% 4 63% 24 24 0 0% 24 24

IFM IFM Income Generation Richard Lyne 53 75.0% 0 0.0% -53 -100% 71 0 -71 -100% 0 71

IFM IFM Other Richard Lyne 21 75.0% 0 0.0% -21 -100% 29 0 -29 -100% 0 132

Corporate Administration Review Executives 404 75.0% 17 3.2% -387 -96% 539 17 -522 -97% 17 539

POE Review of Medical Contracts Jo Furley 233 70.0% 156 46.9% -77 -33% 333 284 -49 -15% 446 400

POE E Rostering Nicola Myronko 107 70.0% 0 0.0% -107 -100% 153 0 -153 -100% 0 205

Total PMO 1,529 63.6% 794 33.1% -734 -48% 2,403 1,299 -1104 -46% 1,690 3486



Annual PlanOut-turn

Actual FYE Forecast FYE Plan £'000 £'000 £'000 £'000 % £'000 £'000 £'000 % £'000 £'000

HWBI Health promotion (non pay relocation vacation of Coney Green ) Maddie Robinson 176 75.0% 176 75.0% 0 0% 235 235 0 0% 235 235

HWBI Psychology - change in staffing profile complete Matt Eves 8 75.0% 3 34.0% -4 -55% 10 5 -5 -50% 10 10

HWBI Management team review Jayne Needham 62 75.0% 62 75.2% 0 0% 83 83 0 0% 83 83

HWBI Childrens Services Reconfiguration Gill Levick 63 51.5% 63 51.5% 0 0% 122 122 0 0% 236 236

HWBI HWBI staffing and non pay review Jayne Needham 58 75.0% 58 75.5% 0 0% 77 77 0 0% 77 77

Planned Care Dental consolidation reduction in staff following site reduction. Richard Lyne 41 75.0% 42 75.5% 0 1% 55 55 0 0% 55 55

Planned Care Leicester Lab Manager move to external contractor Alison Wainwright 10 50.0% 10 50.5% 0 1% 19 19 0 0% 38 38

IFM IFM Staffing structure review Richard Lyne 237 75.0% 237 75.0% 0 0% 316 316 0 0% 316 316Clinical Environments

Contractual Efficiencies Jo Furley 150 75.0% 150 75.0% 0 0% 200 200 0 0% 200 200Clinical Environments

Management review Jo Furley 181 65.5% 130 47.0% -51 -28% 276 196 -80 -29% 314 394Clinical Environments

Bolsover/NED/ Chesterfield Management review CVA/Co-ords redesign

Jo Furley 53 66.7% 0 0.0% -53 -100% 80 0 -80 -100% 0 107Clinical Environments

Bolsover/NED/ Chesterfield Management review Therapy inpatient redesign

Jo Furley 21 56.0% 19 50.9% -2 -9% 37 28 -9 -26% 63 63Clinical Environments

OPMH/LD Medical Contract Jo Furley 13 50.0% 0 0.0% -13 -100% 25 25 0 0% 50 50Clinical Environments

High Peak and Dales Therapy remodelling Jonathan Sanderson 7 50.0% 3 21.3% -4 -57% 13 7 -6 -47% 26 26Clinical Environments

High Peak and Dales Diabetes Jonathan Sanderson 20 75.0% 14 50.7% 0 0% 27 14 -13 -49% 14 27Clinical Environments

ICBS Therapy services review Jo Furley 275 75.0% 202 55.0% -73 -27% 367 202 -165 -45% 80 367Clinical Environments

ICBS Non-Clincial vacancy review Jo Furley 210 75.0% 210 75.0% 0 0% 280 280 0 0% 280 280

Corporate Corporate CIP target Various 501 66.9% 479 63.9% -22 -4% 750 753 3 0% 750 750

Corporate Overheads Release Chris Sands 150 75.0% 112 56.0% -38 -25% 200 131 -69 -35% 131 200

Corporate Non Pay Efficiencies Chris Sands 375 75.0% 375 75.0% 0 0% 500 500 0 0% 500 500

Corporate Non clinical income efficiences Chris Sands 75 75.0% 75 75.0% 0 0% 100 100 0 0% 100 100

Estates Staff vacant posts Peter West 93 75.0% 93 75.0% 0 0% 124 124 0 0% 124 124

Procurement Standardisation on products in Nhs supply chain Brian Summerfield 26 75.0% 26 75.0% 0 0% 35 35 0 0% 35 35

Procurement Day to day value for money on requisitions Brian Summerfield 113 75.0% 113 75.0% 0 0% 150 150 0 0% 150 150

Procurement Travel and hotel booking Brian Summerfield 8 75.0% 8 75.0% 0 0% 11 11 0 0% 11 11

Procurement BOC Brian Summerfield 3 75.0% 3 75.0% 0 0% 4 4 0 0% 4 4

Procurement Room bookings and hospitality Brian Summerfield 8 75.0% 8 75.0% 0 0% 10 10 0 0% 10 10

Procurement Continence home delivery contract Brian Summerfield 48 70.0% 0 0.0% -48 -100% 69 0 -69 -100% 0 82

Procurement Laundry tender Brian Summerfield 0 0.0% 0 0.0% 0 0% 15 16 1 7% 39 20

Trust wide MARS scheme Chris Sands 177 72.7% 95 38.9% -82 -46% 243 130 -113 -47% 124 266

Trust wide Review of Non Pay Chris Sands 0 0.0% 0 0.0% 0 0% 193 0 -193 -100% 0 207

Trust wide Review of Capital Charges Chris Sands 150 75.0% 150 75.0% 0 0% 200 200 0 0% 200 200

Trust wide Non Recurrent release of reserves Chris Sands 95 100.0% 107 112.6% 12 13% 95 107 12 13% 0 0

Total Trans 3,406 69.2% 3,021 61.4% -378 -11% 4,921 4,134 -787 -16% 4,255 5223



Annual PlanOut-turn

Actual FYE Forecast FYE Plan

£'000 £'000 £'000 £'000 % £'000 £'000 £'000 % £'000 £'000Clinical Environments

MIU - 8-8 Jo Furley 0 - 0 - 0 0% 0 27 27 0% 56 0Clinical Environments

Bd 7 Physio vacancy held for 6 mths from Oct Jo Furley 0 - 0 - 0 0% 0 19 19 0% 0 0Clinical Environments

ERE / AV - SLA Reduction Jo Furley 0 - 9 - 9 0% 0 15 15 0% 10 0Clinical Environments

SDD / AV - Mitigations Jo Furley 0 - 18 - 18 0% 0 35 35 0% 12 0Clinical Environments

ICBS Mitigations - Additional Income - Contract Adjust Jo Furley 0 - 66 - 66 0% 0 88 88 0% 88 0Clinical Environments

NED - Mitigations Jo Furley 0 - 11 - 11 0% 0 18 18 0% 11 0Clinical Environments

HP&D - Mitigations Jo Furley 0 - 16 - 16 0% 0 27 27 0% 8 0

HWBI Slippage on tender Timescaless Jayne Needham 0 - 95 - 95 0% 0 95 95 0% 0 0

Reserves Release of Unutilised Reserves Chris Sands 0 - 257 - 257 0% 0 342 342 0% 493 0-

Total Mitigation 0 - 471 - 471 0% 0 664 664 0 678 0

Variance

Risk Rating

Variance

Risk Rating

Year to Date Annual

Mitigations 2014/15

PMO and Transactional CIP Monitoring 2014/15 December 2014

Summary of Overall CIP Monitoring 2014/15

PMO CIP Monitoring 2014/15

Transactional CIP Monitoring 2014/15

Actual % of Annual

Variance

Risk Rating

Variance

Risk Rating

Variance Variance

Year to Date Annual

Risk RatingRisk Rating

Year to Date Annual

Variance Variance


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Appendix 3

1 2 3 4 5 6 7 8 9 10 11 122013-14 Annual Annual

Year Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Outturn PlanEnd Actual Plan Variance Actual Actual Actual Actual Actual Actual Actual Actual Actual Forecast Forecast Forecast Outturn

£'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s

ASSETSNon Current

Tangible Assets 79,643 79,630 80,443 (813) 79,339 79,200 79,286 79,394 79,181 79,507 79,242 79,458 79,630 79,944 80,340 80,487 79,944

Intangible Assets 1,355 1,260 1,230 30 1,328 1,301 1,274 1,248 1,222 1,195 1,175 1,149 1,260 1,233 1,205 1,986 1,254

Total Non Current Assets 80,998 80,890 81,673 (783) 80,667 80,501 80,560 80,642 80,403 80,702 80,417 80,607 80,890 81,177 81,545 82,473 81,198

CurrentInventories 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

NHS Trade Receivabes 5,273 1,372 1,865 (493) 2,465 3,199 2,383 2,217 1,734 1,097 12,427 1,192 1,372 1,315 1,154 1,405 1,605

Non NHS Trade Receivabes 624 593 344 249 1,237 1,352 1,229 472 424 1,268 1,326 679 593 565 557 532 316

Bad Debt Provision (132) (162) (114) (48) (129) (159) (137) (131) (125) (127) (152) (189) (162) (172) (185) (155) (108)

Capital Receivables 144 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Accrued Income 1,027 2,322 1,689 633 944 740 1,051 1,440 1,544 1,616 1,617 3,036 2,322 1,456 1,279 1,055 1,289

Prepayments 1,520 905 262 643 1,216 1,163 1,101 946 988 940 890 1,011 905 895 954 1,004 182

Other Receivables 1,312 504 497 7 1,371 1,561 1,365 1,329 660 520 528 554 504 529 526 535 478

Cash and Cash Equivalents 11,731 14,092 13,193 899 11,829 11,085 12,290 12,608 14,806 13,804 15,442 14,668 14,092 12,833 12,370 11,801 13,285

Total Current Assets 21,499 19,626 17,736 1,890 18,933 18,941 19,282 18,881 20,031 19,118 32,078 20,951 19,626 17,421 16,655 16,177 17,047

TOTAL ASSETS 102,497 100,516 99,409 1,107 99,600 99,442 99,842 99,523 100,434 99,820 112,495 101,558 100,516 98,598 98,200 98,650 98,245

LIABILITIESCurrent Liabilities

Trade Payables (8,566) (6,956) (5,969) (987) (4,983) (4,432) (4,379) (3,481) (2,823) (3,405) (3,885) (6,362) (6,956) (4,500) (3,555) (3,289) (6,371)

Other Payables (3,598) (3,334) (3,637) 303 (3,396) (3,412) (3,356) (3,305) (3,318) (3,316) (3,325) (3,395) (3,334) (3,342) (3,379) (3,405) (3,622)

Public Dividend Capital Payable 0 (522) (662) 140 (209) (417) (625) (833) (1,042) 0 (105) (314) (522) (730) (938) 0 0

Capital Payables (1,132) (672) 0 (672) (615) (665) (901) (231) (401) (206) (175) (596) (672) (507) (507) (620) 0

Accrued Expenditure (2,586) (1,412) (988) (424) (3,569) (3,508) (3,579) (4,243) (5,330) (5,230) (5,179) (3,051) (1,412) (1,679) (2,010) (2,600) (702)

Annual Leave Accrual (431) (431) (431) 0 (431) (431) (431) (431) (431) (431) (431) (431) (431) (431) (431) (401) (401)

Deferred Income, Current (49) (261) (12) (249) (58) (68) (48) (112) (155) (134) (12,263) (250) (261) (166) (83) 0 0

Provisions, Current (967) (516) (109) (407) (959) (957) (867) (864) (863) (842) (885) (618) (516) (515) (523) (531) (129)

Total Current Liabilities (17,329) (14,104) (11,808) (2,296) (14,220) (13,890) (14,186) (13,500) (14,363) (13,564) (26,248) (15,017) (14,104) (11,870) (11,426) (10,846) (11,225)

Non Current LiablilitiesDeferred Income, Non Current 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Provisions, Non Current 0 (20) 0 (20) 0 0 0 0 0 (20) (20) (20) (20) (20) (20) (30) 0

Total Non Current Liabilities 0 (20) 0 (20) 0 0 0 0 0 (20) (20) (20) (20) (20) (20) (30) 0

TOTAL LIABILITIES (17,329) (14,124) (11,808) (2,316) (14,220) (13,890) (14,186) (13,500) (14,363) (13,584) (26,268) (15,037) (14,124) (11,890) (11,446) (10,876) (11,225)

TOTAL ASSET EMPLOYED 85,168 86,392 87,601 (1,209) 85,380 85,553 85,657 86,023 86,071 86,236 86,227 86,521 86,392 86,708 86,754 87,774 87,020

TAXPAYERS EQUITYPublic Dividend Capital (172) 1 343 (342) (172) (172) (172) (172) (172) (172) (172) 1 1 1 1 147 758

Retained Earnings 67,296 68,347 69,514 (1,167) 67,508 67,681 67,785 68,151 68,199 68,364 68,355 68,476 68,347 68,663 68,709 68,837 67,962

Revaluation Reserve 18,044 18,044 17,744 300 18,044 18,044 18,044 18,044 18,044 18,044 18,044 18,044 18,044 18,044 18,044 18,790 18,300

TOTAL TAXPAYERS EQUITY 85,168 86,392 87,601 (1,209) 85,380 85,553 85,657 86,023 86,071 86,236 86,227 86,521 86,392 86,708 86,754 87,774 87,020

Year to DateAs at 31 December 2014

Monthly Actual / Forecast

STATEMENT OF FINANCIAL POSITION 2014-1531 DECEMBER 2014


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Appendix 41 2 3 4 5 6 7 8 9 10 11 12

Annual Annual Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Outturn Plan Apr May June July August Sept Oct Nov Dec

Actual Plan Variance Actual Actual Actual Actual Actual Actual Actual Actual Actual Forecast Forecast Forecast Forecast Outturn Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast£'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s

Surplus / (Deficit) 1,045 1,546 (502) 212 172 106 367 46 161 (10) 121 (130) 316 46 128 1,535 1,600 180 (248) 554 637 192 116 49 536 323

Non Operating Income / ExpenditureFinance Income / Charges (41) (37) (4) (3) (6) (3) (5) (5) (7) (4) (4) (4) (4) (4) (4) (53) (50) (4) (5) (5) (5) (6) (6) (5) (5) (6)

Depreciation and Amortisation 2,940 2,841 99 329 330 329 326 326 325 325 325 325 326 326 326 3,918 4,452 340 339 340 340 339 340 339 339 340

Impact of Legacy Balances 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

PDC Dividend Expense 1,772 1,875 (103) 209 209 208 208 209 208 105 208 208 208 208 312 2,500 2,604 218 218 218 218 218 218 218 218 218

Impairment Losses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Operating Cashflows before Movements in Working Capital 5,716 6,225 (510) 747 705 640 896 576 687 416 650 399 846 576 762 7,900 8,606 734 304 1,107 1,190 743 668 601 1,088 875

Increase / (Decrease) in working capitalInventories 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

NHS Trade Receivabes 3,909 3,408 501 2,808 (734) 814 165 490 638 (11,329) 11,237 (180) 57 161 (253) 3,874 3,674 25 (1) (22) 5 11 0 (6) (7) 14

Non NHS Trade Receivabes 61 262 (201) (616) (85) 101 751 42 (842) (33) 684 59 38 21 (5) 115 284 27 0 (1) 0 1 0 0 0 1

Accrued Income (1,295) (662) (633) 83 204 (311) (389) (104) (72) (1) (1,419) 714 865 176 224 (30) (262) 100 470 (300) 210 50 (450) (800) (175) 300

Prepayments 615 1,258 (643) 304 53 62 155 (42) 48 50 (121) 106 10 (59) (50) 516 1,338 200 300 (300) 150 (200) 250 (300) 50 (200)

Other Receivables 808 815 (7) (59) (190) 196 36 669 140 (8) (26) 50 (25) 3 (9) 777 834 155 (100) (284) 163 22 (243) 268 (97) (54)

Trade Payables (1,612) (2,597) 986 (3,583) (552) (54) (898) (658) 582 480 2,477 594 (2,457) (946) (268) (5,283) (2,195) (1,455) 6 (4) (3) 3 1 3 (4) (1)

Other Payables (264) 39 (303) (202) 16 (56) (51) 13 (2) 9 70 (61) 8 37 26 (193) 24 6 76 (45) 88 (55) 39 (63) (5) 47

Accrued Expenditure (1,173) (1,598) 425 983 (62) 72 664 1,087 (100) (51) (2,128) (1,638) 266 331 590 14 (1,884) 750 335 678 364 550 (1,228) 24 100 50

Annual Leave Accrual 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (30) (30) (30) 0 0 0 0 0 0 0 0 0

Deferred Income, Current & Non Current 212 (37) 249 9 10 (20) 64 43 (21) 12,129 (12,013) 11 (95) (83) (83) (49) (49) 0 0 0 0 0 0 0 0 0

Provisions, Current & Non Current (411) (858) 447 (8) (2) (90) (3) (1) (1) 43 (267) (82) (1) 8 18 (386) (838) 0 0 5 0 0 5 0 0 5

Increase / (Decrease) in working capital 851 30 821 (281) (1,342) 714 494 1,539 370 1,289 (1,506) (427) (1,334) (351) 160 (675) 896 (192) 1,086 (273) 977 382 (1,626) (874) (138) 162

Net Cashflow from Operations 6,566 6,255 311 466 (637) 1,354 1,390 2,115 1,057 1,705 (856) (28) (488) 225 922 7,225 9,502 542 1,390 834 2,167 1,125 (958) (273) 950 1,037

Investing ActivitiesProperty, Plant & Equipment Expenditure (2,853) (3,107) 254 2 (163) (388) (407) (92) (621) (40) (516) (628) (610) (692) (505) (4,660) (4,925) (282) 19 24 (597) 24 23 (926) (317) (296)

Proceeds on Disposal of Property, Plant & Equipment 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 339 0 0 0 0 0 2,959

(Increase) / Decrease in Capital Receivables 144 144 0 144 0 0 0 0 0 0 0 0 0 0 0 144 144 0 0 0 0 0 0 0 0 0

Increase / (Decrease) in Capital Payables (460) (1,132) 672 (517) 50 236 (670) 170 (195) (31) 421 76 (165) 0 113 (512) (1,132) 0 0 0 0 0 0 0 0 0

Net Cashflow from Investing Activities (3,169) (4,095) 926 (371) (113) (152) (1,077) 78 (816) (71) (95) (552) (775) (692) (392) (5,028) (5,913) (282) 19 363 (597) 24 23 (926) (317) 2,663

Financing ActivitiesPDC Dividends Paid (1,250) (1,250) 0 0 0 0 0 0 (1,250) 0 0 0 0 0 (1,249) (2,499) (2,500) 0 0 0 0 0 (1,307) 0 0 0

PDC Received 173 515 (342) 0 0 0 0 0 0 0 173 0 0 0 146 319 415 0 0 0 0 0 0 0 0 0

Interest Received on Cash and Cash Equivalents 41 37 4 3 6 3 5 5 7 4 4 4 4 4 4 53 50 4 5 5 5 6 6 5 5 6

Net Cashflow from Financing Activities (1,036) (698) (338) 3 6 3 5 5 (1,243) 4 177 4 4 4 (1,099) (2,127) (2,035) 4 5 5 5 6 (1,301) 5 5 6

NET CASH INFLOW / (OUTFLOW) 2,361 1,462 899 98 (744) 1,205 318 2,198 (1,002) 1,638 (774) (576) (1,259) (463) (569) 70 1,554 264 1,414 1,202 1,575 1,155 (2,236) (1,194) 638 3,706

Opening Cash Balance 11,731 11,731 0 11,731 11,829 11,085 12,290 12,608 14,806 13,804 15,442 14,668 14,092 12,833 12,370 11,731 11,731 11,801 12,065 13,479 14,681 16,256 17,411 15,175 13,981 14,619

Net Cash Inflow / (Outflow) 2,361 1,462 899 98 (744) 1,205 318 2,198 (1,002) 1,638 (774) (576) (1,259) (463) (569) 70 1,554 264 1,414 1,202 1,575 1,155 (2,236) (1,194) 638 3,706

Closing Cash Balance 14,092 13,193 899 11,829 11,085 12,290 12,608 14,806 13,804 15,442 14,668 14,092 12,833 12,370 11,801 11,801 13,285 12,065 13,479 14,681 16,256 17,411 15,175 13,981 14,619 18,325

2015-16

Monthly Forecast

12 MONTH ROLLING CASHFLOW STATEMENT31 DECEMBER 2014

As at 31 December 2014Monthly Actual / Forecast

2014-15

Year to Date


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Appendix 5

Capital Number

Scheme Description Category 2014/15 Plan

Month 1 Actual

Month 2 Actual

Month 3 Actual

Month 4 Actual

Month 5 Actual

Month 6 Actual

Month 7 Actual

Month 8 Actual

Month 9 Actual

Month 10 Forecast

Month 11 Forecast

Month 12 Forecast

Full Year Forecast

Plan v Forecast

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000A5028 Car Parking & Additional Spaces - Ilkeston Hospital Estates 16.0 0.1 15.9 16.0A5031 Site Development - Buxton Hospital Estates 7.2 1.4 -0.2 6.0 -1.0 6.2 1.0A5033 Business Intelligence System IM&T 60.0 48.5 5.6 13.9 5.4 -1.1 5.7 78.0 -18.0 A5034 Renovate Linacre & Peveril Wards - Walton Estates 638.2 8.3 -1.2 0.9 151.5 65.3 199.0 164.0 50.4 638.2A5035 Solar Panels - Walton Hospital Estates 88.0 67.2 13.4 1.5 5.9 88.0A5036 Eye Gaze Communication Aid Equipment Equipment 35.0 13.7 12.1 9.2 35.0A5038 Replace Auto Sensing Taps - Cavendish Hospital Estates 8.3 8.3 8.3A5039 Replace Auto Sensing Taps - Walton Hospital Estates 33.1 26.1 7.0 33.1A5042 Replace windows & external redecoration - Killamarsh Estates 30.0 33.2 33.2 -3.2 A5044 Redecoration under lease terms - Tennyson Avenue Estates 13.0 0.4 16.2 -10.4 6.8 13.0A5045 Bathroom Refurbishment - Orchard Cottage Estates 9.8 9.8 9.8A5046 Road re-surfacing & drainage - Walton Estates 15.0 15.2 15.2 -0.2 A5047 Site Development - Walton Hospital Estates 56.8 0.6 4.1 4.0 3.4 2.2 15.0 15.0 12.5 56.8A5049 General Anaesthetic Machine - Leicester Dental Equipment 20.0 18.0 18.0 2.0A5050 Site Development - Heanor Hospital Estates 36.0 7.2 -1.2 0.7 0.7 -0.2 3.0 25.8 36.0A5051 League of Friends Tea Bar - Ripley Hospital Estates 12.0 6.0 6.0 12.0A5052 Security System (Melbourne/Linacre) - Walton H Estates 15.2 1.0 1.4 1.5 11.3 15.2A5053 Podiatry Cutting Machine - Manor Store Equipment 7.7 0.9 6.8 7.7A5054 Endoscopy DTC Refurbishment - Ilkeston Hospital Estates 10.0 1.2 8.8 10.0A5055 Structural Works - Manor Store Estates 19.0 15.5 3.5 19.0A5056 Upgrade Podiatry Theatre - Buxton Hospital Estates 59.6 0.3 1.5 57.8 59.6A5057 Health Facilities - Belper Project Estates 10.0 10.0 10.0A5058 Zeacom Server - Long Eaton Health Centre Equipment 6.0 6.0 6.0A5059 QA4 Trolley - Whitworth Hospital Equipment 5.2 4.3 0.9 5.2A5060 Smart Mover - Newholme Hospital Equipment 7.2 7.2 7.2A5061 Bariatric Bed - St Oswalds Hospital Equipment 10.5 10.5 10.5A5062 OPG Machine - Coleman Street Dental Clinic Equipment 18.0 18.0 18.0A5063 Pedestrian Walkway & Handrail - Cavendish Hospital Estates 7.8 7.8 7.8A5064 Orthopaedic Kit - Ilkeston Hospital Equipment 25.0 25.0 25.0A5381 Stage 3 refurbishment - Whitworth Hospital Estates 1,200.0 8.4 145.4 180.5 171.5 171.5 67.7 108.3 274.7 1.8 70.2 1,200.0A5429 Remodelling of MIU reception - Ripley Hospital Estates 50.0 32.8 17.7 -0.5 50.0A5432 IM&T desktop renewal / windows 7 migration IM&T 370.0 65.2 21.6 22.2 50.1 -0.8 21.0 13.3 6.2 50.0 248.8 121.2A5433 IM&T system procurement IM&T 40.0 0.3 0.3 0.6 3.3 -3.4 10.1 28.8 40.0A5434 IM&T communications infrastructure IM&T 150.0 12.4 83.3 50.0 145.7 4.3A5435 IM&T PAS replacement IM&T 830.0 8.7 36.2 -97.7 398.4 -62.6 14.3 9.2 16.5 216.5 187.5 727.0 103.0A5455 Replacement UPVC windows - Ilkeston Hospital Estates 13.2 -8.7 20.4 1.1 -3.4 3.8 13.2A5473 IM&T mobile working IM&T 350.0 82.8 97.7 199.5 380.0 -30.0 A5476 Upgrade Boilers - Ripley Hospital Estates 160.0 39.8 86.4 28.9 5.5 -0.9 3.8 163.5 -3.5 Various Outstanding capital programme 2013/14 IM&T 2.0 -2.0 Various Outstanding capital programme 2013/14 Estates -10.9 2.5 -2.6 -12.3 -110.1 11.2 -8.0 -3.9 0.5 -133.6 133.6Various Outstanding capital programme 2013/14 Equipment 1.1 1.1 -1.1 N/A Not yet approved on capital programme 2014/15 Various 179.2 27.5 65.8 70.0 163.3 15.9

Capital Programme Expenditure 4,622.0 -0.8 163.7 388.1 408.0 87.3 624.1 39.9 515.3 267.6 606.6 691.8 505.4 4,297.0 325.0Purchase of 84 Whitecotes Lane Estates 303.0 300.0 3.0 303.0Donated assets acquired Various 61.0 41.0 41.0 20.0Gross Capital Expenditure 4,986.0 -0.8 163.7 388.1 408.0 87.3 624.1 39.9 515.3 608.6 609.6 691.8 505.4 4,641.0 345.0Donations from Charitable Funds/League of Friends -61.0 -41.0 -41.0 -20.0 Charge against Capital Resource Limit 4,925.0 -0.8 163.7 388.1 408.0 87.3 624.1 39.9 515.3 567.6 609.6 691.8 505.4 4,600.0 325.0

Estates 2,508.2 -1.1 147.7 266.0 260.9 148.9 130.0 107.8 453.2 146.5 387.7 185.0 147.9 2,380.5 127.70Equipment 134.6 13.7 1.1 0.9 36.9 4.3 0.9 50.9 25.0 133.7 0.90IM&T 1,800.0 0.3 2.3 121.0 146.2 -61.6 457.2 -67.9 57.8 120.2 140.5 416.0 287.5 1,619.5 180.50Various 179.2 27.5 65.8 70.0 163.3 15.90Total 4,622.0 -0.8 163.7 388.1 408.0 87.3 624.1 39.9 515.3 267.6 606.6 691.8 505.4 4,297.0 325.0

CAPITAL PROGRAMME 2014/1531st DECEMBER 2014


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TRUST BOARD

Document Title: Monitor Self-Certification – Quarter 3

Presenter/Title: Melanie Curd - Deputy Trust Secretary Chris Sands – Director of Finance, Performance and Information


Author/Title: Chief Executive’s and Finance Department


01773 525065




Information Decision X Assurance X

Purpose of Paper

The purpose of the paper is to provide assurance to enable the Board to approve the Self-certification return for Quarter 3.

Recommendations

The Board is asked to consider the Self-certification, discuss the issues and approve the Quarter 3 return.


4.2.1 - There is a risk to the organisation due to not meeting regulatory, contractual or legal obligations resulting in sanctions.

Financial Impact

The financial implications are detailed within the report.


DCHS became a Foundation Trust (FT) on the 1 November 2014 and as such we are required to provide in-year submissions to Monitor on a quarterly basis based upon the reporting requirements in Monitor’s Risk Assessment Framework (RAF). The RAF provides a framework to assess individual NHS foundation trusts’ compliance with two specific aspects of their work: ‘the continuity of services’ and ‘governance conditions in their provider licenses’ The RAF confirms that the Governance rating will be based on: • performance against selected national access and outcomes standards;

28�Monitor�Self-Certification�

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• CQC judgments on the quality of care provided; • relevant information from third parties; • a selection of information chosen to reflect quality governance at the organisation; • the degree of risk to continuity of services and other aspects of risk relating to financial governance; and • any other relevant information. Appendix 1 details what could give Monitor cause for concern and affect our Governance Rating. To comply with the governance conditions of our licence we are required to provide a statement (the Corporate Governance Statement) detailing:

Any risks to compliance with the governance condition

Actions taken or being taken to maintain future compliance The statement replaces the Board Statements that were previously required under the Compliance Framework. Appendix 2 details the Corporate Governance Statement, the sources of assurance and the Executive Lead for that area. It also cross references the Board Assurance Framework. DCHS must report to Monitor any in-year material, actual or prospective changes which may affect our ability to comply with any aspect of our licence. In addition, the Board is required to make a declaration: For Finance, that: The Board anticipates that the Trust will continue to maintain a Continuity of Service Risk Rating of at least 3 over the next 12 months. Based upon the evidence provided, it is proposed that the Board makes a positive submission against both statements, please see Appendix 3 and the Finance Report for more detail. For Governance, that: The Board is satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing targets (after the application of thresholds) as set out in Appendix A of the Risk Assessment Framework; and a commitment to comply with all known targets going forward. Based upon our internal assessment of the risks, it is likely that the Trust will be rated Amber. The Board will wish to consider that we have failed to meet the Older People’s Mental Health Delayed Transfers of Care target for Quarter 3 and in terms of ongoing compliance, there is a risk in achieving the Referral to Treatment target. For further detail please see the Performance Report. Otherwise: The Board confirms that there are no matters arising in the quarter requiring an exception report to Monitor (per the Risk Assessment Framework page 21, Diagram 6) which have not already been reported. The Board is asked to confirm whether there are any matters to be reported to Monitor as an exception, please see Appendix 4. The Board is asked to discuss the information in the paper and agree the Board declaration.


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The Governors will require the information to perform their statutory duties of holding the Board to account.

Are there Equality and Diversity implications? X


X

Risk Register




No


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APPENDIX 1 Indicators of Governance Concerns (Risk Assessment Framework, Page 39)


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APPENDIX 2

Corporate Governance Statement 2014/15

(Risk Assessment Framework, Appendix D)

Corporate Governance Statement Assurance Frequency BAF Ref:

Lead

1) The Board is satisfied that the NHS foundation trust applies those principles, systems and standards of good corporate governance which reasonably be regarded as appropriate for a supplier of heath care services to the NHS

BAF AGS External Assurance from Head of Internal Audit Opinion External Audit Governance Report Summary Report from AAC

Quarterly Annual Annual Annual Quarterly

4.1.1 Trust Secretary

2) The Board has regard to such guidance on good corporate governance as may be issued by Monitor from time to time

Reports to Board or delegated Committee

As issued by Monitor


3) The Board is satisfied that the NHS foundation trust implements:

(a) effective board and committee structures

Review of Terms of Reference and Committee structure

Annually 4.1.1 Trust Secretary

(b) clear responsibilities for its Board, for committees reporting to the Board and for staff reporting to the Board and those committees and;

(c) Clear reporting lines and accountabilities throughout its organisation

Terms of Reference Summary Reports Governance Structure

Annually After each meeting Annually


4) The Board is satisfied that the NHS foundation trust effectively implements systems and/or processes:

(a) to ensure compliance with the Licence holder’s duty to operate efficiently, economically and effectively;

Performance, Finance and Quality Reports

Monthly All sections

Director of Finance

(b) for timely and effective scrutiny and oversight by the Board of the Licence holder’s operations;

Performance and Quality Reports Monthly All sections

Director of Operations

(c) to ensure compliance with health care standards binding on the Licence holder including but not restricted to standards specified by the Secretary of State, the Care Quality Commission, the NHS Commissioning Board and Statutory regulators of health care professions;

Quality Report Summary Report from QSC

Monthly Monthly

Section 1.0

Chief Nurse

(d) for effective financial decision-making, management and control (including but not restricted to appropriate systems and/or processes to ensure the Licence holder’s ability to continue as a going concern);

Finance Report Summary Report from QBC Summary Report from AAC

Monthly Bi-monthly Quarterly

3.2.6 Director of Finance

(e) to obtain and disseminate accurate, comprehensive, timely and up to date

Board and Committee Forward Agendas

Quarterly 4.1.1 Trust Secretary


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information for Board and Committee decision-making;

(f) to identify and manage (including but not restricted to manage through forward plans) material risks to compliance with the conditions of its Licence;

Risk Report Summary Reports from the Sub-Committees

Monthly After each meeting

4.2.2 Chief Nurse

(g) to generate and monitor delivery of business plans (including any changes to such plans) and to receive internal and where appropriate external assurance on such plans and their delivery; and

Summary Reports from QBC Board Development Sessions

Bi-monthly As required

3.1.3 Director of Finance

(h) to ensure compliance with all applicable legal requirements.

Summary Report from AAC Quarterly 4.2.1 Trust Secretary

5) The Board is satisfied:

a) that there is sufficient capability at Board level to provide effective organisational leadership on the quality of care provided;

Outcome of Appraisal Report for Executive Team NED Appraisal Job Descriptions for Board members Succession plans

Annually 2.2.1 Chair

b) that the Board’s planning and decision-making processes take timely and appropriate account of quality of care considerations,

Quality Report Monthly 4.1.1 Chief Nurse

c) the collection of accurate, comprehensive, timely and up to date information on quality of care;

Quality Dashboard Business Information System

Ongoing 3.2.6 Director of Finance

d) that the Board receives and takes into account accurate, comprehensive, timely and up to date information on quality of care;

Quality Report Performance Report

Monthly Monthly

3.2.6 Chief Nurse

e) that the NHS foundation trust including its Board actively engages on quality of care with patients, staff and other relevant stakeholders and takes into account as appropriate views and information from these sources; and

Council of Governors Summary Report

Quarterly 1.3.2 Chair

f) that there is clear accountability for quality of care throughout the NHS foundation trust including but not restricted to systems and/or processes for escalating and resolving quality issues including escalating them to the Board where appropriate,

Risk Report Quality Assurance Framework Ward to Board Escalation Framework

Monthly 4.2.2

Chief Nurse

6) The Board of the NHS foundation trust effectively implements systems to ensure that it has in place personnel on the Board, reporting to the Board and within the rest of the Licence holder’s organisation who are sufficient in number and appropriately qualified to ensure compliance with the Conditions of this Licence.

Staffing for Quality Appraisal Essential Learning Summary report from QPC

Monthly Annually Annually Bi-monthly

Section 2.0

Director of People


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Key:

AAC Audit and Assurance Committee

AGS Annual Governance Statement

BAF Board Assurance Framework

NED Non-Executive Director

QBC Quality Business Committee

QPC Quality People Committee

QSC Quality Service Committee


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APPENDIX 3 Continuity of Service Risk Rating

Statement Evidence Conclusion

The Board anticipates that the trust will continue to maintain a Continuity of Services rating of at least 3 over the next 12 months

Long Term Financial Model

Annual Plan

Monthly Financial Report

PwC Review of Working Capital and Financial Reporting procedures

Future 2 year plan forecasts a CoS of 4.

The Board is satisfied that the trust shall at all times remain a going concern, as defined by the relevant accounting standard in force from time to time.

Long Term Financial Model

Annual Plan

Monthly Financial Report

Board Memorandum on Working Capital

Financial Viability Review

PwC Review of Working Capital and Financial Reporting procedures

Confirmation that the Trust will remain a going concern as defined by the relevant accounting standard in paper to April 2014 Audit and Assurance Committee. Rolling cashflow does not highlight any liquidity concerns. PwC review of Working Capital provides external assurance as to the trust’s view that it will remain a going concern for the foreseeable future

Based upon the evidence provided, it is proposed that the Board makes a positive submission against both statements.


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APPENDIX 4 Examples of Exception Reporting (Risk Assessment Framework, page 21)


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