new barnsley hospital nhs foundation trust please note:- … · 2020. 6. 3. · dr jenkins provided...

A MEETING OF THE BOARD OF DIRECTORS WILL TAKE PLACE ON THURSDAY 4 JUNE 2020 at 10:15 am

by Video-link BARNSLEY HOSPITAL NHS FOUNDATION TRUST

Please note:- due to the Covid-19 outbreak this meeting will not be held in public.

No Item

Sponsor Ref

1 Apologies and Welcome. Mr T Lake Chairman

2 To receive and review a patient’s story (ICU). Mrs J Murphy Director Nursing

& Quality

Verbal Information (10:15 am)

3 To receive any Declarations of Interest. To confirm that due to Covid 19 the Board meeting is not held in public and will be held by secure video-link.

Mr T Lake Chairman

Verbal Assurance

4 To approve the minutes of the meeting of the Board of Directors held in public on 7 May 2020.

20/06/04/04 Approve

5 To approve the action log in relation to progress to date and review any outstanding actions.

20/06/04/05 Approve

ASSURANCE 6 To receive the COVID-19 response update.

Dr R Jenkins

Chief Executive Verbal Assurance

7 To receive and approve the Chair’s Log for the Quality and Governance Committee (Q&G) held on 27 May 2020.

Ms R Moore Chair of Quality &

Governance Committee

To follow Assurance

8 To receive and approve the Chair’s Log for the People, Finance and Performance Committee (PFP) held on 28 May 2020.

Mrs K Firth Chair of People,

Finance & Performance Committee

20/06/04/08 Assurance

9 To receive and approve the Chair’s Log for the Audit Committee held on 13 May 2020.

Mr N Mapstone Chair of Audit

Committee


10 To receive the Chair’s Log for Barnsley Facilities Services (BFS).

Mr F Patton Non-Executive

Director


11 To receive and review the Chair’s Log on any escalation issues from the Executive Team (ET).

Dr R Jenkins Chief Executive

Verbal Assurance

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12 To review the monthly Integrated Performance Report (IPR) – Month 01.

Mr B Kirton Chief Delivery Officer/Deputy Chief Executive


13 To receive the Annual Infection Prevention and Control Report 2019/2020.

Mrs J Murphy Director of

Nursing & Quality


14 To receive the quarterly review of the Corporate Risk Register (CRR).

Ms M Saunders Director of Corporate

Governance


15 To receive the quarterly review of the Board Assurance Framework (BAF).

Ms M Saunders Director of Corporate

Governance


STRATEGY 16 To receive the Chair’s Log for the Barnsley

Integrated Care Partnership Group. Mr T Lake Chairman

Verbal Note

OTHER ITEMS 17 To receive and review the monthly report from

the Chairman including:-

Mr T Lake Chairman

Verbal

Note

18 To receive and review the monthly report from the Chief Executive including:- i For information - update on the South

Yorkshire and Bassetlaw Integrated Care System (ICS)

Dr R Jenkins Chief Executive

20/06/04/18

20/06/04/18i

Note

19 Date of next meeting:

Thursday 6 August 2020, 9.00 am, Lecture Theatre 1 & 2, Education Centre, BHNFT

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MINUTES OF A MEETING OF THE

BOARD OF DIRECTORS HELD ON THURSDAY 7 MAY 2020

BY VIDEO-CONFERENCE

Due to the current Covid-19 pandemic, the meeting was not held in public In the interest of maintaining transparency and openness during the Covid-19 lockdown

a recording of the meeting was placed on the Trust website for public access.

PRESENT:- Mr T Lake Chairman, Chair Dr R Jenkins Chief Executive Dr S Enright Medical Director Mr R Kirton Chief Delivery Officer & Deputy Chief Executive Mrs J Murphy Director of Nursing & Quality Mr C Thickett Director of Finance Mr S Ned Director of Workforce Mr T Davidson Director of ICT Ms E Parkes Director of Communications Mrs K Firth Non-Executive Director Ms R Moore Non-Executive Director Mrs S Ellis Non-Executive Director Mr F Patton Non-Executive Director Mr N Mapstone Non-Executive Director Mr P Hudson Non-Executive Director Mr K Clifford Associate Non-Executive Director Miss L J Watson Executive PA to CEO/Chairman (minute taker) OBSERVERS:- Mr A Higgins Lead Governor APOLOGIES:- Ms M Saunders Director of Corporate Governance 20/61 APOLOGIES & WELCOME

Mr Lake welcomed Executive/Non-Executive colleagues, along with Mr Higgins, Lead Governor, to the Board of Directors (BoD) meeting for May 2020. Due to Covid-19 the meeting was held by video conferencing to comply with government guidelines on social distancing and lockdown. For openness and transparency, a recording of the public session of the meeting will be available on the Trust’s website for a period of 2 week. Apologies noted as above. Mr Lake informed questions were requested in advance of the meeting from the Non-Executives and submitted to the Executive Directors to enable responses being available today due to busy schedules in coping with the extra demands in dealing with the preparations and planning for Covid-19.

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20/62 TO RECEIVE ANY DECLARATIONS OF INTEREST The standing declarations of interest were noted from Mrs Ellis and Mr Patton as Directors of Barnsley Facilities Services (BFS), Dr R Jenkins as Chief Executive Officer and Mr S Ned as Director of Workforce in their joint roles between Barnsley NHS Foundation Trust and The Rotherham NHS Foundation Trust. No declarations of interest were received in relation to agenda items for discussion today.

20/63 MINUTES OF THE LAST MEETING Subject to minor amendments, as per the advanced points which had been circulated prior to the meeting today, the minutes of the meeting held on 2 April 2020 were reviewed and accepted as an accurate record of events.

20/64 ACTION LOG All outstanding actions from the previous meetings were reviewed with updates noted accordingly.

20/65 COVID-19 REPONSE UPDATE Dr Jenkins provided a verbal Covid-19 response update for members of the Board. The Trust has concluded phase one and are now entering into phase two of the planning stages, detailed within Sir Simon Stevens (Chief Executive of NHS England) letter, included under Item 15 of the agenda. The first phase included planning of the predicted increase in capacity and implementation of restructuring internal workings of the hospital to enable the Trust to deal with the Covid and Non-Covid stream. The hospital is now starting to see a slow decline in numbers from the peak activity, (information from Public Health England suggests South Yorkshire peaked on 8 April 2020) a rapid fall has been seen in the Intensive Care work as opposed to ward work, which is predicted to fall depending on the ease of lock down restrictions. Following national publicity in shortages of personal protection equipment (PPE), at all times the hospital has had sufficient supplies allowing staff to comply with the Public Health England advice and guidance. There have been, on occasions, a few issues encountered with the supply chain, under these circumstances throughout the South Yorkshire and Bassetlaw system (SY&B), the Trust has received and given mutual aid to Trusts within the area. Contingency plans have been made by Barnsley Facilities Services (BFS) in terms of the procurement lines as well as in-house solutions, in particular, to the critical issues around gowns. The Trust has complied with all recommendations for staff and patient testing, however there were a number of days where the Trust had to be cautious in the use of staff testing due to a shortage of chemical testing agents from Sheffield. This was rapidly addressed and assurance has been provided that all staff have now been tested where there has been a specific need. Initially testing was limited to symptomatic patients, but testing is now in place for all non-elective admissions on admission and all care home residents on

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discharge. The volume of tests available to the Trust is sufficient to meet the demand. One key concern is the impact on patients with non-covid related illnesses; there has been a significant reduction noted in all forms of activity including Accident and Emergency (excluding maternity). Over the last few weeks there has been a progressive increase in activity within Accident and Emergency although figures are still reduced as compared to pre-covid activity. The provision of other work has been reduced in line with national recommendations, in particular people requiring cancer related treatment, noting the Trust has adopted the triaging and screening approach recommended at national level. One major constraint for the Trust and neighbouring Hospitals, to enable further surgical activity to be reinstated, is the very limited supply of sterile surgical gowns. There are a number of different types of gowns and previously the Trust struggled in the procurement of disposable gowns, the sterile surgical gowns are required for surgeons to safely operate on patients. Despite the help of the Integrated Care System (ICS) through the regional command and control structure procurement, the Trust is not supportive of routine surgery recommencing until further supplies are secured. Currently the Trust only has sufficient gowns to allow urgent surgery to take place. As mentioned at the meeting in April 2020, the Trust implemented the planned major incident response approach for phase one, the Silver Tactical Coordinating Group (TCG) and Gold Strategic Coordinating Group (SCG), which have now been stepped down to be held 3 mornings per week. The ICS have put in place a governance structure with a weekly Strategic Group implemented looking at coordination of the response by the ICS. The Trust has invested support for staff during these difficult times both in terms of training relating to the different ways of working as well as the physical and wellbeing aspects in dealing with the pandemic. As part of this support, weekly staff side meetings have been implemented, led by Mr Ned, Director of Workforce. Concerns have been raised, in lined with other organisations, following recent emerging evidence of increased risk for colleagues from a Black, Asian and Minority Ethnic (BAME) background., Following recent work with the ICS, a letter has been circulated to all staff with a recommendation for a revised risk assessment to be completed. In response to Sir Simon Stevens letter, the Trust is to commence planning for how the urgent activity is reinstated, back to pre-covid levels. Following a recovery workshop session attended by Executive colleagues recently, external support has been commissioned to help with the second phase of planning with structured facilitated workshops arranged. This includes, i Clinical Business Unit’s (CBUs) to think through what this looks like in terms of the response to the plateau and also through the covid decline phase. This will include discussions around capturing the beneficial changes of the new ways of working in dealing with the response to covid. In response to questions/comments circulated prior to Board:- 1 Would be possible for further information to be provided relating to clinical

trials that the Trust is currently involved with. (Mr Patton)

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The Trust is currently involved in 4 studies, some of which were originally developed in 2013 during previous pandemics and required a new pandemic to be re-activated. In terms of patient recruitment, the Trust was the highest recruiter of patients in the North & Yorkshire with a total number of 450 patients taking part in the trials. Further detailed information of the trials will be circulated to Board Members.

2 What is the plan for supporting people post Covid? (Mrs Firth)

Dr Jenkins informed following discussions during a time-out session held with the ICS, a few areas were identified which would benefit from additional support. It was recognised places within the ICS are to take an holistic approach and the Trust will be working on developing a holistic support package both within Barnsley place and across the ICS. This will involve mental health, physical and physiological support.

3 What will be the approach to harnessing the changes to enable transformation? (Mrs Firth)

The Trust has implemented innovative ways of working, e.g. video conferencing via zoom meetings, use of Microsoft teams for team briefings and also clinics via video link, in dealing with the response to Covid-19., This will be systematically worked through in the forthcoming workshops over the next few weeks.

Mr Lake, on behalf of the Board, formally thanked all colleagues at the Trust, the wider NHS and all supporting partners for the commitment and professionalism shown in dealing with what is hopefully only a once in a lifetime pandemic experience. The response, commitment and dedication from all those involved has been outstanding. Tragically there are a number of families within Barnsley who have sadly lost loved ones; the Board expressed their condolences and their thoughts are with the families at this difficult time. The Board noted and received the update.

SE

20/66 CHAIRS LOG - QUALITY & GOVERNANCE COMMITTEE (Q&G) Ms Moore as Chair of the Quality & Governance Committee presented the report to provide an update following the meeting held on 29 April 2020. The executive summary provided details of all items discussed with the chairs log providing highlights required for the attention of Board members. In response to questions/concerns circulated prior to Board:- 1 Mrs Ellis asked, for assurance, if an update could be provided regarding

the low use of a Perfect Ward. Mrs Murphy informed pathway changes were made in March this year as the Lead Nurses/Matrons were trying to undertake the perfect ward audit. The process has now been changed which is supported both by the Research Team and Matrons allowing the Lead Nurses to continue to develop critical patient care. A full suite of the perfect ward audit will be available in April 2020.

2 Mr Patton asked for an update on the changes and reconfiguration for

cancer services. Mr Kirton informed the Cancer Alliance Team are

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working comprehensively and have standardised their ways of working. In terms of changes, Multi-disciplinary Team (MDTs) are now being performed virtually via Microsoft Teams, with work on going looking into electronic document management changes, however at the moment due to unforeseen circumstances, the teams are currently working in the traditional ways. Due to the cessation of endoscopy services a number of services have significantly been impacted, including upper/lower GI (gastro-intestinal). However intense work has commenced in conjunction with the ICS to resolve these issues.

3 In response to a concern raised by Mr Clifford, Mr Kirton informed that

lower GI, almost nationally but certainly regionally, have agreed an approach but unfortunately there is no resolution for the upper GI issues.

The Board noted and received the report.

20/67 CHAIRS LOG - PEOPLE, FINANCE & PERFORMANCE COMMITTEE (PFP) Mrs Firth as Chair of the People, Finance & Performance Committee presented the report to provide an update following the meeting held on 30 April 2020, highlighting the following key points:- A strong position has been maintained on training and appraisal

compliance however the impact of Covid-19 has had an effect. Sickness is reported at 4.7%, noted to be a similar position to last month. Assurance has been provided the sickness figures will be separated into Covid and Non-Covid for the April 2020 data.

Assurance was provided that the Trust has introduced a number of measures to support staff during this pandemic.

Operational performance remains in a strong position. The Emergency access and patient flow performance decreased to 91% this month and although below target, the Trust is noted to be in the top ten performing Trusts.

The committee expressed thanks to members within the Information and Communications Team (ICT) who have facilitated the rapid technological move in implementing the Trust’s approach in the operational delivery due to Covid.

The committee received a report which provided assurance on the revised governance controls and associated risks in response to Covid-19.

The Trust has concluded the year with a consolidated year end surplus of £431k, as forecast, against a break-even position, an excellent outcome for the Trust. Revised arrangements are in place for finance with the traditional contracts being replaced with nationally issued block envelopes, with mechanisms in place to cover reasonable Covid related costs. For assurance, there is no significant financial risk to the Trust for the period April – July 2020.

The committee received and noted a paper setting out the new cash and capital regimes effective from 1 April 2020., The key change being converting existing cumulative loans into public dividend capital which will give additional interest costs for the Trust. If there is a significant impact of this in the future, this will be presented at PF&P and Board.

In response to questions/comments circulated prior to Board:- 1 Would it be possible for an update to be provided in relation to the Covid-

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19 Workforce paper? (Mrs Ellis)

Mr Ned provided an update on the issue on Black and Minority Ethnic Staff (BAME) and the apparent disproportionate impact of Covid-19 on the BAME community, and particularly BAME Health Care Workers. A coordinated a joint response with the ICS and Chief Executive Officers (CEOs) was provided, as the issue is facing every provider. Meetings have also been held with representatives of the Consultant body as a number of issues had been raised at the Consultant forum as well as through the British Associate of Physicians of Indian Origin (BAPIO). A letter has been circulated to all BAME staff with the recommendation for a further risk assessment to be completed. The Trust is working to provide adequate support to the vulnerable staff groups but also recognising the need to maintain services. The nationally stated objective of all vulnerable staff groups is to ensure the individuals are kept safe and well whilst at work. This is an ongoing process which includes potential redeployment of staff, working from home if possible and will be addressed with the Clinical Business Units (CBUs).

Following recent agreements with The Nightingale Unit at Harrogate, Barnsley Hospital NHS Foundation Trust staff previously identified to be deployed to the Unit have formally been stood down as the Intensive Care capacity has been contained within local hospitals. This will be reviewed on a regular basis particularly if there is a second peak.

There has been a national compensation scheme implemented providing £65,000 to families of staff who have sadly lost lives. The criteria of this is yet to be identified but essentially this is applicable to front line workers who contracted Covid-19 in the preceding 14 days. As a provider, there is a national notification process to report any staff deaths that do occur if the Trust finds themselves in this unfortunate position.

2 Staff turnover in Allied Health Professions (AHP) and Healthcare Science

(HCS) - Are they are any gaps that might impact our ability to meeting our post- Covid recovery or impact performance and quality? (Ms Moore)

Mr Ned confirmed the turnover rates are related to an issue of limited career progression. There is a provision within Agenda for Change for career development progression posts, to appoint staff on a Band 5 who can now automatically transition onto Band 6 upon qualification.

On behalf of the Board, Mr Lake formally noted the outstanding performance for the Trust in terms of financial and performance targets for the financial year 2019/2020. The Board noted and received the report.

20/68 CHAIRS LOG - BARNSLY FACILITIES SERVICES (BFS) Mr Patton presented the Chair’s Log from the Barnsley Facilities Services (BFS) Board Meeting held on 20 April 2020. The key points to note:- For assurance to Board, the BFS Business Plan for 2019/20 was noted to

have been delivered, however there were a few delays due to Covid-19, these have been incorporated into the 2020/21 plan.

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The BFS Strategic Business Plan for 2020 – 2025 is currently under development. Upon completion this will be presented to Trust Board for sign off. Following discussion, agreement was made for the plan to be presented at one of the forthcoming Strategic Focus Meetings. Mr Lake informed confirmation of dates will be circulated once finalised.

On behalf of the Board, Mr Lake thanked BFS colleagues for the support provided to the Trust during very challenging and unprecedented times. The Board noted and received the report.

LJW TL

20/69 APPOINTMENT OF BARNSLEY FACILIITIES SERVICES (BFS) Board members noted and ratified the appointments and resignations of the BFS Board Directors as stated within the report.

20/70 CHAIRS LOG - EXECUTIVE TEAM Dr Jenkins provided a verbal update from the Executive Team. Following the recent suspension of Medway System C, a number of options were presented to the Executive Team which included a revised go live date of either 11 July or 3 October 2020. Due to the reduced levels of activity within the Trust due to Covid-19, it was deemed an appropriate time for the new system to be managed effectively. Therefore, the recommendation of the go live date of Saturday 11 July 2020 was approved by the Executive Team, who delegated authority for final confirmation and plans to the Medway Steering Group which is to be held on Monday 11 May 2020. In response to a question raised by Ms Moore regarding an extension of the current licence for Lorenzo if implementation wasn’t able to progress in July, Dr Jenkins informed that unfortunately an extension was not an option. This would cause a financial challenge for the Trust with additional costs incurred after October 2020, circa £1m. The Board noted and received the update.

20/71 INTEGRATED PERFORMANCE REPORT (IPR) - Month 12 Mr Kirton informed members the Integrated Performance Report for Month 12 was included for information, noting for assurance that the report has been discussed in the respective committees. The impact of Covid-19 has started to affect performance figures from the end of March 2020. Overall the Trust achieved the vast majority of the national waiting standards including cancelled operations, diagnostics, 31 days to first treatment, 62 days from GP referral to treatment. Unfortunately, the target for two-week wait was narrowly missed by 2%, reported 98.2%. In response to concerns/questions circulated prior to Board:- 1 Are we taking any steps to pay suppliers, especially local suppliers more

promptly to help protect employment? (Mr Mapstone)

Mr Thickett informed processes have been put in place and the Trust is

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paying the majority of suppliers quicker than usual. However, a pragmatic review is being taken in terms as to whether the process can accommodate the payment schedule taking into account cashflow forecasts. This will be detailed within the report for next month through PF&P in terms of creditor days.

2 Following discussions at PF&P, it would be useful have a total figure of sickness broken down into “normal” sickness, staff self-isolating and staff who have Covid-19. (Ms Moore/Mr Patton)

Mr Ned confirmed the reported figures for next month will be separated into the three categories as listed above.

3 Workforce issues covered by the committee action log –re targets deferred

due to Covid 19-is there a revised proposal/ schedule yet? (Mrs Ellis)

The targets for mandatory training and staff appraisals were suspended at the start of the preparations for Covid-19. Due to a decrease in activity, some managers are undertaking staff appraisals. Through the Covid-19 recovery meetings the targets and timescales will be discussed and reset as deemed appropriate.

4 Is it possible to have an update on Covid headcount? How many early graduation and Pandemic Re-registrants have we recruited? (Mr Clifford)

A number of nursing and medical students have been recruited within the Trust. Forty third year nursing students have commenced work as part of the Covid-19 response with a further sixty second year nursing students planned in the near future. There was a national initiative for retired staff to be recruited back into work; nine colleagues have returned through the bring back staff scheme. Dr Enright informed 25 Doctors are commencing mid May as Foundation Year 1 (FY1) Doctors, in additional 25 senior medical students are working in the Trust as volunteers and 2 re-registrant doctors. In addition, there are a number of doctors brought in from other areas into the acute sector.

5 A request for more detailed information regarding the 550 episodes of stress, anxiety or depression reported. (Mr Clifford)

Mr Ned will provide information to Mr Clifford outside the meeting. This will also be presented at the People, Finance and Performance Committee in May 2020.

6 What is the impact of tele-care on out-patient performance, activity and DNA’s? (Ms Moore)

Mr Kirton informed at least 50% less activity in terms of outpatient clinics is being performed. Tele-conferencing and video consultations also being held for a number of clinic appointments. A breakdown of figures will be available in due course. DNAs remain around 6%, same as pre-covid.

7 GP streaming has dropped significantly, is this due to covid arrangements? (Ms Moore)

The front door arrangements were changed as the Covid-19 situation escalated. The number of attendances within the Emergency Department

SN SN

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(ED) significantly reduced during this time and from 1 April 2020 the GP Federation primary care streaming was stopped, with resources being utilised off- site in a “hot clinic” at Oaks Park, Kendray, Barnsley.

8 RTT – this has obviously been impacted by Covid-19 measures; however, seeking continuing assurance regarding the management of those with high risk? (Ms Moore)

The Trust is currently working to a strict nationally led prioritisation basis based on a number of categories: - i Category 1 - throughout Covid-19 all emergency patients have been

seen (categorised as patients at highest risk and in need of immediate treatment) either in Hospital or a tertiary centre.

ii Category 2 - urgent patients requiring treatment within 4 weeks; within the last 3 weeks activity has noted to have increased.

iii Category 3 - patients requiring treatment within 3 month - treatment is now being planned. However, the limiting factor to this is access to Personal Protection Equipment (PPE), particularly in terms of sterile surgical gowns. The Trust has secured independent sector capacity nationally and as a region, this will be utilised so that the maximum number of operations that can be performed.

9 Positive to see the number of falls reduce, is there a reason for

improvement in February/March and is this related to the different types of patients seen within the Trust due to Covid-19? (Mr Patton)

Mrs Murphy confirmed following the appointment of a Falls Prevention Nurse and as a result of quality improvement measures, falls during February had decreased. Throughout March a different cohort of patients were seen in hospital which were much more bed bound as well as a lower number of patients. Unfortunately, April has seen an increase in falls due to the difficulty in providing enhanced care as a result of restrictions with social distancing.

Mr Lake raised a query relating the numbers for staff appraisals year to date and year end forecast figures. This is to be addressed outside the meeting. The Board noted and received the updates.

BK

20/72 CHAIRS LOG - BARNSLEY INTEGRATED CARE PARTNERSHIP (ICP) Mr Lake provided a verbal update in relation to the Barnsley Integrated Care Partnership. Following discussions with Mr J Budd, Director of Commissioning, Barnsley Clinical Commissioning Group and Ms A Monaghan, Chair, South West Yorkshire Partnership agreement has been made to reinstate the meetings. A proposal to reinstate the meetings of the ICP with a scoping/information sharing meeting to l be held on Thursday 28 May 2020, will be communicated the members of the partnership group. The Board noted and received the report.

TL

20/73 CELEBRATING OUR PEOPLE Mrs Parkes informed the Board of the report for May 2020 focussed on the

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overwhelming support received by staff colleagues, volunteers and patients in the Trust’s response in dealing with Covid-19. As a result of Covid-19 the Brilliant Awards have currently been temporarily suspended. As part of the celebrations for the International Midwives Day 5 May 2020 and the International Nurses Day 12 May 2020, arrangements have been made for the hospital to be lit up in blue. In response to questions circulated prior to Board:- 1 Following discussions, members felt it might be a nice idea for the Trust to

consider having a commemorative book to remember those who have died as a result of Covid-19 and also to reflect on how the Hospital dealt with the pandemic. Ms Parkes also informed a painting has kindly been donated by a member of the public which will be displayed within the Trust along with looking at ways as to how other information can be displayed throughout the Hospital.

2 Ms Moore commented the widespread rainbow used as a generic symbol

for the NHS during the Covid-19 pandemic is also used by the Trust as the symbol for Lesbian Bisexual, Gay and Transgender (LGBT) community. This has been noted by the Communications Department and work is on going as to how this can be addressed and communicated.

On behalf of the Board, Mr Lake praised Ms Parkes and the Communications, Marketing and Charity Team for their performance throughout the year, particularly during Covid-19, in delivering the very effective wide ranging styles of information for staff/public awareness and in supporting staff colleagues through the Covid-19 Charity funds The Board noted and received the report.

0/74 MONTHLY REPORT FROM THE CHAIRMAN Mr Lake informed there were no matters arising to inform Board members. As agreed, as part of the Board Development Workshop and Well led review feedback, the Board report from the Chairman going forward will be presented as a verbal report only bringing to Board’s attention any items of local, regional or national interest not reported elsewhere on the agenda. A full detailed report of the Chair’s activities will be presented at the Council of Governors Meetings as a separate document. The Board noted and received the update.

20/75 MONTHLY REPORT FROM THE CHIEF EXECUTIVE Dr Jenkins provided an overview of recent meetings and events that have recently been undertaken on behalf of the Trust which was noted and received by the Board. Appendices to the report:- i Update on South Yorkshire and Bassetlaw Integrated Care System SY&B

ICS) – to note for information.

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ii Letter from Simon Stevens, Chief Executive England – The Trust will undertake a gap analysis against the recommendations within the letter and will ensure the local next phased planning will take the recommendations into account. This will be reported through the respective committees for assurance.

iii Ethics Committee Terms of Reference (ToR) – to note for information.

Over the next few months the ToR will be revised. Members of the Board were asked to forward any comments onto Dr Enright for inclusion into the review.

In response to questions circulated prior to Board:- 1 Learning Disability/Autism update – Very welcome but could we have more

information on how we are supporting these particular vulnerable groups. (Mr Clifford)

There is a Learning Disability Nurse Specialist who works closely with all services users - to date 11 services users during the covid period. The Hospital passport has been used for each user along with an easy read manual (shared with the Community Teams involved in users care plans) to ensure all pathways are adhered to. The Communications Team have also provided support in relaying messages to all in-patients during this time, the use of the Hospital’s Facebook page as well as a dedicated contact line to contact the Learning Disability Nurse Specialist. In terms autism, there has only been one service user during this time where an alternative pathway has been delivered.

2 The CEO report describes transfer of children’s emergency surgery to

Sheffield Children’s Hospital. Do the executives think that this arrangement may become embedded in the post-covid world? If so, what are the implications? (Mr Mapstone)

The Trust has been very explicit that this a temporary arrangement as it was anticipated to allocate all available anaesthetist’s time in looking after and treating critically ill adults with covid. There maybe some sense in this being revised within a few months, if a patient presents to Barnsley directly with a surgical problem, a patient centred pragmatic decision is being made as to whether to treat the patient at Barnsley or to arrange transfer to the Children’s Hospital. This item will be kept under review.

3 Please explain more about the re-examination of the engineering aspects

of design and any lessons learned? (Ms Moore)

Dr Jenkins will obtain further information from BFS colleagues detailing the key points on the engineering aspects of the Trust. This will be circulated to Board members for information.

4 How well has the ICS worked particularly the SHCG & IMT and transformation teams? Can you give a bit more information? (Mr Patton)

Dr Jenkins informed the ICS report describes the National Incident Command and Control System which has been noted to have worked extremely well for the Trust during the last few weeks. The cells, working

RJ

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groups within the area, have adequate representative’s looking into testing, PPE etc and are noted to be working extremely well. Mr Kirton added there is now a consistent approach across the South Yorkshire region in terms of procurement and having the ICS in place has been extremely helpful in the Covid-19 preparations and planning.

5 Any arrangements for people with diagnosis of dementia? (Ms Moore)

Mrs Murphy provided assurance that individual plans of care are being developed for patients admitted with dementia and as mentioned previously, ensuring family members are present wherever possible to help provide care for their loved ones by being actively involved in the care plan. The Trust initially saw a decline in patients being admitted however this number is starting to gradually increase. There is also a dedicated Dementia Nurse Specialist working closely will the groups

6 Would the Ethics Committee benefit from a patient or lay representative?

(Ms Moore)

Dr Enright informed that the Ethics Committee is an ongoing working group currently meeting on a fortnightly basis as part of Trust’s rapid response to Covid-19. The group is currently under development and the possibility of having a patient/lay representative in the future will be considered. As previously mentioned, the ToR are to be reviewed within a few weeks. Mr Hudson added after reviewing the ToR there are a number of issues which he will forwarded onto Dr Enright as requested above.

The Board noted and received the update.

20/76 DATE AND TIME OF NEXT MEETING Prior to the meeting, a statement was made on the website inviting questions from members of the public to be submitted electronically, on checking this morning, no questions had been received. Mr Lake informed that Mr Higgins, as Lead Governor, had been invited to observe the meeting and invited any questions. On behalf of the Council of Governors, Trust Members and Constituents, Mr Higgins expressed sincere gratitude to all staff, volunteers and members of Barnsley Facility Services for all the hard work and dedication during very difficult and unsettling times in the response to dealing with the rapid onset of the Covid pandemic. In response to a query relating to decommissioning facilities escalated to deal with Covid, Dr Jenkins informed this will be discussed in the next phase of capacity planning however it is noted there are a number of constraints, in particular adequate personal protection equipment to allow theatres and clinical work to be re-instated. On behalf of the Executives and Non-Executives, Mr Lake thanked Mr Higgins for the extremely positive feedback provided today. The next meeting of the Trust Board is scheduled for Thursday 4 June 2020, 10. 15 – 1.00 pm via secure video link (Zoom).

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REPORT TO THE BOARD OF DIRECTORS

REF: BoD: 20/06/04/05

SUBJECT: BOARD ACTION LOG – PUBLIC

DATE: JUNE 2020 Private & Confidential

PURPOSE:

Tick as applicable

Tick as applicable

For decision/approval Assurance For review Governance For information Strategy

PREPARED BY: Margaret Saunders, Director of Corporate Governance

SPONSORED BY: Trevor Lake, Chairman

PRESENTED BY: Trevor Lake, Chairman

STRATEGIC CONTEXT

To ensure that actions emerging from Board meetings are progressed and reported to Board in a timely manner.

EXECUTIVE SUMMARY

Current action log arising from Public Board meetings as attached.

RECOMMENDATION The Board of Directors is asked to: a) note and approve reported progress and any verbal updates and b) review any outstanding actions

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Key to RAG statusRed Action overdue or no update providedAmber Update Provided but action not completeGreen Update provided and action complete

Subject: Board Action Log Ref: BoD: 20/06/04/05 ACTIONS ON AGENDA: Table 1 Minute

ref Meeting

date Item Action Owner Due date Done Date Progress report

RAG status

20/65 07.05.20 Covid-19 Response

update Clinical trials overview briefing to be circulated to Board members.

SE 04.06.20 29.05.20 Complete – information circulated Green

20/68 07.05.20 Chairs Log – Barnsley

Facilities Services (BFS)

BFS Strategic Business Plan 2020 – 2025 to be presented at a Board Strategic Focus Meeting.

LJW

04.06.20

Item has been added to the forward plan for a future Board

Strategic Focus Meeting. Green

Dates to be circulated once finalised.

TL 04.06.20

20/71 07.05.20 Integrated

Performance Report

Information to be circulated regarding the 550 episodes of sickness relating to stress, anxiety & depression. The information also to be presented at PFP in May 2020. Mr Ned confirmed the reported sickness figures for next month will be separated into the three categories

SN

SN

04.06.20 04.06.20

Further information in relation to the 550 episodes of sickness

absence related to stress, anxiety and depression circulated to Board

members on 29th May, 2020.

Sickness figures separated in the Workforce insights report and

Covid dashboard – to be incorporated into IPR from June

2020

Amber

Staff appraisals year:date and year end forecast figures to be reviewed.

BK 04.06.20

20/72

07.05.20

Chairs Log – Barnsley Integrated Care

Partnership

Meeting to be re-instated for Thursday 28 May 2020

TL 04.06.20 04.06.20 Complete – meeting was held on

Thursday 28.05.20 Green

20/75 07.05.20 Monthly report from the Chief Executive

Detailed information to be circulated to Board members detailing the key points on the value engineering aspects of thecurrent paediatric/CAU build project.

RJ 04.06.20

Pack page 16


ACTIONS COMPLETED & CLOSED SINCE LAST MEETING: Table 2 – N/A Minute

ref Meeting

date Item Action Owner Due date Done Date Progress report

RAG status

20/50 02.04.20 Covid-19 Emergency Preparedness Update

The temporary suspension ofgovernance arrangements for a number of sub groups and meetings will be discussed in further detail at the Audit, Quality & Governance (Q&G) and People, Finance & Performance (P, F & P) Committees in April 2020.

MS 07.05.20 09.04.20

Complete – item Audit, Q&G and P, F & P Committee agendas on 22.04.20, 29.04.20 and 30.04.20

respectively.

Green

Mr Patton to provide a written brief to members of the Governors People, Finance and Performance (P, F & P) sub group due to the cancellation of the meeting on 8 April 2020.

FP 07.05.20 09.04.20 Complete Green

Fortnightly updates to be provided Governors due to meetings temporarily suspended

TL 07.05.20 09.04.20 Complete and ongoing Green

Additional Charity Committee meeting to be arranged to ensure appropriate governance is in place.

TL 07.05.20 07.04.20 Meeting held on 7 April 2002. Green

The South Yorkshire and Bassetlaw (SY&B) Strategic Health Coordination Group Terms of Reference (ToR) to becirculated for information.

MS 07.05.20 02.04.20 Complete. Green

ROLLING TRACKER OF OUTSTANDING ACTIONS: Table 3 red = overdue Minute

ref Meeting

date Item Action Owner Due date Done Date Progress report RAG status

20/52 02.04.20

Chairs Log – People, Finance and Performance Committee –

Organisational Strategy (OD)

Ms Moore had raised a number of concerns relating to the ODStrategy prior to approval and would liaise with Mr Ned via email or telephone to discuss.

SN/RM 07.05.20 30.04.20 A meeting has been arranged

between Ms Moore and Mr Ned to review the OD strategy.

Amber

Pack page 17


20/52 (cont)

The Organisational Development Strategy (OD) to be re-presented to P,F&P following the necessary amendments at an appropriate time and if necessary, re-present to Trust Board at a later date.

SN 07.05.20 30.04.20

The revised OD strategy will be presented to the People, Finance

and Performance meeting following the meeting detailed above.

Amber

20/36 05.03.20 Bi-annual approval of the use of the Trust’s

Seal Register to be signed by Mr Lake. TL May 2020

To be completed once Government self- isolation restrictions relaxed.

Amber

20/22 06.02.20 Questions from the

public

Mr Higgins also sought views of the Board regarding Trust governance in relation to the work of the ICS. Mr Lake will respond to Mr Higgins, as Lead Governor, either via letter or at the next CoG meeting scheduled for 18 March 2020.

TL 05.03.20

28.02.20 - An update meeting with the lead governor and agreed to raise concerns with the ICS. 05.03.20 – Mr Lake has met with Mr Higgins, Lead Governor and will raise these issues at the ICS meeting on 6 April 2020. 02.04.20 – Mr Lake will note this item for discussion following Covid-19, when normal working has been reinstated.

Amber

Pack page 18

1


REF: BoD: 20/06/04/07

SUBJECT: QUALITY AND GOVERNANCE ASSURANCE REPORT

DATE: June 2020

PURPOSE:

Tick as applicable Tick as

applicable


PREPARED BY: Rosalyn Moore, Non Executive Director/Committee Chair SPONSORED BY: Rosalyn Moore, Non Executive Director/Committee ChairPRESENTED BY: Rosalyn Moore, Non Executive Director/Committee Chair

STRATEGIC CONTEXT

The Quality & Governance Committee (Q&G) is one of the key committees of the Board responsible for Governance. Its purpose is to provide detailed scrutiny of quality and safety across the Trust in order to provide assurance and raise concerns (if appropriate) to the Board of Directors and to make recommendations, as appropriate, on quality and safety matters to the Board of Directors.

EXECUTIVE SUMMARY

This report provides information to assist the Board on obtaining assurance about the quality of care and rigour of governance. From the Q&G Committee Meeting on the 27th May 2020, the following papers were received and reviewed:

COVID 19 Quality Exception Report Board Assurance Framework (BAF) and Corporate Risk Register (CRR) COVID 19 – Update on Trust Governance Arrangements April 2020 IPR COVID 19 Information Dashboard Learning from Experience Quarterly Report Annual Complaints Report Mortality Report including Crude Mortality SHMI and HSMR figures, Learning from Deaths

Report and brief narrative summary of ICU mortality Infection Prevention and Control (IPC) Annual Report and Surgical Site Infection SSI)

Surveillance Report Nursing, Midwifery and Medical Staffing Reports

There was further discussion concerning the submission date of submission for this year’s Quality Account. The Committee also considered changes to the forward plan and proposals for handling the annual review of the Q&G Committee and Sub Committees. For the purpose of assurance, the items noted in the log below highlights items for the attention of the Board.

RECOMMENDATION(S)

The Board is asked to receive and review the attached Log.

Pack page 19

2

Subject: QUALITY AND GOVERNANCE ASSURANCE REPORT Ref: BoD: 20/06/04/07

CHAIR’S LOG: Chair’s Key Issues and Assurance Model Committee / Group: Quality and Governance Committee (Q&G) Date: 27th May 2020 Chair: Rosalyn Moore

Ref Agenda Item Issue and Lead Officer

Receiving Body, i.e. Board or

Committee

Recommendation / Assurance/ mandate to

receiving body

1. Quality Exception Report

The Committee received a report providing assurance that the Trust continues to pursue the Quality Goals during the COVID 19 pandemic. Noting the increase in falls in Ward 35 (the Hot Triage ward for COVID) there was assurance that these (and other falls) were fully investigated and preventative measures implemented. Similarly, the incidence of PU’s in ICU arising from the clinical requirement for proning of COVID 19 patients. Datix and Serious Incident (SI) investigation continued with no COVID related SI's resulting in moderate or high harm. Assurance that the Trust continued to fulfil its safeguarding duties and had taken steps to mitigate the safeguarding risks arising from pandemic stress and social distancing measures. The committee noted that 19 (out of 24) Perfect Ward Audits had taken place, a significant increase on last month. The report offered assurance on several areas of experience including end of life and spiritual care.

Board of Directors

For assurance

2.

BAF and CRR The BAF and CRR for Quarter four 2019/20 was reviewed by the Committee. Updates and changes were recommended.

Board of Directors

For assurance

3. COVID Dashboard The Dashboard was reviewed. The committee recommended the addition of latest hospital deaths with cumulative totals.

Board of Directors

For information

4. IPR

During the review of the IPR for April 2020 the Committee noted a case of hospital acquired MRSA Bacteraemia Infection. Assurance was received that the case had subject to an RCA and that there was no evidence of a lapse in care.

Board of Directors

For information and assurance.

Pack page 20

3



Committee


receiving body

4. Quarterly Learning from Experience Report (LfE) and Annual Complaints Reports

The LfE January to March 2020 was reviewed with data on complaints, PALs, FFT, volunteering and Interpreter services provided. Assurance was provided that the Trust and CBUs had continued to act on patient feedback from various sources to make improvements. The 2019/20 Annual Complaints Report provided assurance that the Trust has continued to comply with national reporting requirements. However, with Quarter 4 2019/20 reporting suspended, there were some gaps in year on year comparative and benchmarking data. The top theme for complaints continues to concern clinical treatment. The Committee noted that further improvements had taken place in the quality of complaint management and improvement priorities for 2020/21.

Board of Directors

For assurance

5

Infection Control and Prevention IPC) Committee Log, Minutes, Annual Report 2019/20. SSI Surveillance Report.

The Committee papers demonstrated the vital contribution he DIPC and IPC Team had made to the Trusts response to the COVID 19 Pandemic and provided assurance that routine surveillance of other organisms and pathogens continued along with measures to improve IPC locally. As required in the H&SC Act and Hygiene Code (2015) the Committee received the Annual IPC Report prior to presentation at the Board and subsequent public release. The reports provided assurance that the Trust had continued with the Saving Lives Programme, meeting targets for MRSA but failing to meet the CDiff target for the second consecutive year. An external review had been commissioned in year with recommendations incorporated into the IPC action plan. Some clarifications were required in the data prior to presentation at the Board. Assurance was provided that the surveillance of SSI in orthopaedic surgery, large bowel surgery, and caesarean Section had continued in year. The Trust remains below the national average in operations for hip replacement and repair neck of femur but above for Knee replacement surgery. Further annual reductions in infections related to large bowel surgery were noted

Board of Directors

For assurance

Pack page 21

4



Committee


receiving body

but an increase in the number of infections following caesarean section. Assurance was provided that all cases were investigated and strategy for improvement developed.

6. Nursing, Midwifery and Medical Staffing Reports

Assurance was provided regarding redeployment of staff to cover COVID arrangements and also that Junior Doctors and other early entrants to the workforce were being provided with training and supervision.

Board of Directors

For assurance

7. Quality Account Arrangements

Clarification concerning arrangements for the submission on the Quality Account arrangements were discussed by the Committee.

Board of Directors

For assurance and information

Pack page 22


REF: BoD: 20/06/04/08

SUBJECT: PEOPLE, FINANCE AND PERFORMANCE ASSURANCE REPORT

DATE: JUNE 2020

PURPOSE:

Tick as applicable

Tick as applicable

For decision/approval x Assurance For review Governance For information Strategy

PREPARED BY: Keely Firth, Non-Executive Director, Chair People, Finance & Performance Committee

SPONSORED BY: Keely Firth, Non-Executive Director, Chair People, Finance & Performance Committee

PRESENTED BY: Keely Firth, Non-Executive Director, Chair People, Finance & Performance Committee

STRATEGIC CONTEXT

The People, Finance & Performance Committee (P,F&P) is one of the key committees of the Board responsible for Governance. Its purpose is to provide detailed scrutiny of financial matters, operational performance and indicators relating to our people in order to provide assurance and raise concerns (if appropriate) and to make recommendations, as appropriate, on people, financial and performance matters to the Board of Directors.

EXECUTIVE SUMMARY KEY: £k = thousands £m = millions

This report provides information to assist the Board to obtain assurance regarding the people, finance and operational performance and appropriate rigour of governance. The following papers were received at the meeting on the 28 May 2020:

Action log

Workforce report and dashboard

Integrated performance report (IPR)

Covid-19 information dashboard

Monthly ICT report

Annual information governance report

Board assurance framework (BAF) quarterly update

Corporate Risk Register (CRR) quarterly update

Covid-19 Trust governance arrangements

P, F & P Terms of Reference

Consolidated finance report & ICS finance report

Chairs’ logs from operational groups.

RECOMMENDATIONS

Board members are asked to receive and review the attached log.

Pack page 23

Subject: People, Finance and Performance Committee Assurance Report Ref: BoD: 20/06/04/08

CHAIR’S LOG: Chair’s Key Issues and Assurance Model

Committee / Group Date 28 May 2020 Chair People, Finance and Performance Committee April 2020 Keely Firth, Non Executive Director KEY: FTE: Full Time Equivalent; £k = thousands; £m = millions

Log Ref

Agenda Item Issue and Lead Officer


Committee

Recommendation / Assurance / mandate to

receiving body

1. Workforce Insight Report

The committee considered in depth the report which provides analysis of the issues facing the Trust from a workforce perspective. The key points to be highlighted are as follows: -

‐ Sickness Absence and Wellbeing: overall the Committee received assurance that there is to be renewed focus on sickness management and support with a revised sickness absence management policy being presented to the people and engagement group in June 2020.

‐ Sickness absence has increased from 4.7% to 5.4% across both long term and short term sickness with confirmed sickness for Covid-19 accounting for 1% and the remaining 4.5% due to other reasons.

The cumulative figure is 4.45%. National benchmarking figures available are for December 2019 with the NHS sickness rate on average at 4.86% which is below the Trust rate in the same month of 5%.

‐ Headcount & FTE: The headcount for the month is 4,152 (3,932 excluding bank). The actual FTE is recorded as 3,389 which when compared to funded establishment of 3,479 gives a variance of 90.

‐ Staff Turnover: The turnover rate is at 10.47% and above the target range of between 7–10%.

The areas with higher turnover rates continue to be (i) Prof and Tech at 14%; (ii) AHPs at 17.8%; and (iii) Nurses & Midwives at 12.7%. The committee was assured that some measures are already in place for example improved career paths and stay discussions with more focus and actions planned.

There were 28 leavers in the month with the top reason classified as “Voluntary Resignation Promotion”. There were 2 people who retired and returned to work in these numbers.

‐ Mandatory Training: Mandatory Training is at 85.8% (a decrease of 3% from last month).

Following a discussion regarding the impact of Covid-19 on training it was noted that traditional methods of delivery have been limited due to social distancing and staff capacity. Additional training has been introduced for mask-fit testing and limited class sizes for resuscitation.

‐ Appraisals: The appraisal season will formally re-commence from 1st June 2020 and will extend to 31st August 2020.

Board

For information, assurance and to note the increased risk to training compliance.

2. Integrated Performance Report

The committee reviewed the IPR focusing on the key performance indicators around patient access, people and finance and wish to highlight to the Baord the risk to delivery of the targets in 2020/2021. ‐ Emergency access & Patient Flow:

Performance against the four-hour standard increased in April to 95.3% from 91% which was one of eighteen nationally to achieve the target. ED attendances continue to steadily rise.

‐ RTT: A compliant position of 93.2% was achieved across 2019/20 and for most months the Trust was

Board

For information, assurance and to note the increased risk to delivery of access targets. Pack page 24

Log Ref



Committee


receiving body in the top five nationally. Covid-19 affected the position in March with a sharp reduction in elective activity and consequent performance at 88.7% with April dropping to 80%.

‐ Cancer: The Trust was compliant in March with the standards relating to two-week wait referrals and 31 days and 62-day from GP referral to treatment. For 2019/20 the 31 day and 62 day standards were achieved with the 2 week wait narrowly missed at 92.8%.

‐ Diagnostic Waits: Diagnostic access performance deteriorated in April due to Covid-19 with the 6 weeks’ target not achieved at 64%. There are plans to improve this with GI endoscopy and non urgent imaging activity resuming within the appropriate safety restrictions.

3. COVID-19 Information Dashboard

The committee received an update of the Covid-19 position at a fixed point in May. Members were assured that key information is being recorded and reported as requested within the appropriate definitions.

Board For information and assurance

4. ICT Report

The committee wishes to acknowledge the team members who continue to work hard under pressure to facilitate the significant shift in our approach to operational delivery. ‐ System C Medway EPR project – the committee received assurance that a robust plan is in place

and being progressed for the revised go live date of July 11th. Members were encouraged to learn that enhancements and fixes planned for later have now been implemented and training has commenced. A “dress rehearsal” is planned for the 13th June.

‐ Measures introduced due to COVID-19 - the committee received assurance that there have been no changes to the system, governance controls or risks during the delivery of the Covid-19 requirements. The work so far has been scaling the existing solutions.

‐ Future arrangements – Executive Team colleagues are currently reviewing areas where the changes can continue whilst considering and managing system, governance and risk controls and processes.

‐ Open referrals data quality –colleagues have validated 12,457 records - the project is expected to be completed by the end of August 2020.


5. Trust Covid-19 Governance

Assurance was provided to Committee regarding the Covid-19 governance arrangements in particular the maintenance of a robust COVID-19 risk register. Assurance was provided that despite significant challenges, the Trust has responded positively to the requirements set out in the letter from Simon Stevens on 29 April 2020 with capacity and PPE areas of concern as the Trust increases its services to accommodate more planned care.


6. Finance

The committee received assurance that national measures are in place to support the Trust during the April – July 2020 period with the ability to retrospectively claim via the NHSE top up process. Consequently the Trust has a consolidated breakeven position for the month after accruing an additional £0.077m top-up from NHS England (NHSE). The committee were assured that there is a robust strategy in place for managing the cash position which at the end of the month was £32.6m. Capital expenditure as at Month 1 is £0.423m, of which £0.408m relates to COVID-19 schemes.


Pack page 25

Log Ref



Committee


receiving body

7. BFS Performance Chair’s Log

The committee received assurance that the Trust manages the contract with BFS appropriately whilst valuing the pace at which BFS staff are able to respond to Covid-19.


8. Capital Monitoring Group

The committee received an update on the capital issues for 2020/2021 and supported the plan for the year which reflects the prioritisation of key developments. With regard to the ED/Childrens’ Assessment Unit, assurance was received that the pause for the Covid-19 measures had allowed for reductions in planned costs and support was given to the proposal to increase investment in the roof structure as a result of recommendations following the Grenfell fire report. As a result of slippage, due to the contractors not being on site since March 2020 and expected social distancing measures being required as they come back on site, it is now likely that the revised completion dates will be February 2021 for phase 2 and May 2021 for phase 3, resulting in a potential for £0.35m slippage into 2021/22.


Pack page 26

BoD 6 February 2020


REF: BoD:20/06/04/09

SUBJECT: AUDIT COMMITTEE CHAIR’S LOG


PURPOSE:

Tick as applicable

Tick as applicable


PREPARED BY: Nick Mapstone, Chair of the Audit Committee

SPONSORED BY: Nick Mapstone

PRESENTED BY: Nick Mapstone

STRATEGIC CONTEXT

This report is part of the Trust's governance and assurance arrangements. It shows how significant matters raised at the Audit Committee have been addressed.

EXECUTIVE SUMMARY

The Committee:

agreed the Trust Annual Report, subject to minor changes;

agreed the Annual Governance Statement;

approved the draft accounts and BFS, which are currently being audited;

noted the draft Head of Internal Audit Opinion, which gives Significant Assurance on the effectiveness of the Trust’s arrangements to manage risk.

The Committee noted that both Board Assurance Framework and Corporate Risk Register will need to be revised to reflect the challenges posed by the covid19 pandemic and associated recovery actions.

RECOMMENDATION

The Board of Directors is to review and endorse the log.

Pack page 27

BoD 6 February 2020

Subject: AUDIT COMMITTEE ASSURANCE REPORT Ref: BoD: 20/06/04/09

CHAIR’S LOG: Key Issues and Assurance Committee / Group Date ChairAudit Committee 13 May 2020 Nick Mapstone

Agenda Item Issue Receiving Body,

i.e. Board or Committee

Recommendation/ Assurance/ mandate to

receiving body

4, 8.3 and 8.4

Action Log

Previous meetings have discussed the merit in adopting a formal statement of risk appetite and a proposal to review the Board Assurance Framework and the Corporate Risk Register. These matters are to be subsumed into a wider review of the Trust’s risk management strategy, which is to be considered at the Audit Committee in July 2020.

The Committee noted that both BAF and CRR will need to be revised to reflect the challenges posed by the covid19 pandemic and associated recovery actions.

Board Assurance

6.1

Annual report

The Committee approved the Trust’s annual report, subject to minor corrections.

Board Assurance

6.2

Draft Annual Governance Statement

The Committee approved the AGS, subject to including more detail on the use of clinical audit as a source of assurance

Board Assurance

Pack page 28

BoD 4 June 2020 Page 2 of 5




receiving body

6.3

Draft accounts

The Committee approved the draft accounts and financial statements subject to the inclusion of a number of notes to the accounts, explaining the differences between the Trust accounts and Group accounts. The accounts are currently being audited with a deadline of 25 June. The Committee noted the current additional cost to date of the covid 19 pandemic of £877,000, which is fully underwritten by the DH and hence will not affect the Trust’s going concern position.

Board Assurance

6.4

BFS Accounts

The draft accounts were approved and are now to be considered by the BFS Board.

Board Assurance

6.5

Head of Internal Audit Opinion

The draft HOIAO provides a Significant Assurance opinion on the effectiveness of the Trust’s arrangements to manage organisational risk; however, the Head of Internal Audit is concerned that the Trust had not yet implemented recommendations to strengthen the Board Assurance Framework.

Board Assurance

Quality Account

NHS Improvement has notified trusts that the Quality Accounts deadline has been extended to 15 December 2020.

QGC Assurance

External Audit Board Assurance Pack page 29





receiving body 7.1

The audit of the Trust’s accounts has started. The valuation of land and buildings is likely to be an Emphasis of Matter. The audit is being conducted remotely so it has not been possible to undertake a stock check for BFS stores, which will be a limitation of scope in the audit.

7.2 a

Internal audit progress report

The completion of the data security and accounts payable has been delayed due to the covid19 pandemic. It is likely that Limited Assurance opinions will be issued but the Committee was reassured that the gaps identified will be addressed.

Board

Assurance

7.2b

Internal audit plan 2020/21

The Committee approved the plan subject to further discussions with the Executive Team.

ET

Assurance

8.6

Register of Directors’ interests

The Committee noted the register and asked for the register of gifts and hospitality to be brought to the July Audit Committee.

Board

Assurance

9

Invitation of Tenders for External Audit Services

The External Auditor’s contract end on 31 August 2020. The Committee discussed arrangements to invite tenders for the service for three years from 1 September 2020. The DoF stated that it should be possible to award a contract by that date. If this is not possible, the current external auditors said

Board

Assurance

Pack page 30





receiving body that they may be able to extend their contract for a short time, if the regulations state that a Foundation trust must have an appointed auditor at all times. (The Director of Corporate Governance is to check the regulations).

Pack page 31

REPORT TO THE BOARD OF DIRECTORS (BHNFT)

REF: BoD:20/06/04/10

SUBJECT: BARNSLEY FACILITIES SERVICES LIMITED (BFS).

DATE: JUNE 2020 PRIVATE AND CONFIDENTIAL

PURPOSE:

Tick as applicable

Tick as applicable


PREPARED BY: Francis Patton, Chair BFS & Non-Executive Director BHNFT

SPONSORED BY: Francis Patton, Chair, BFS & Non-Executive Director BHNFT

PRESENTED BY: Francis Patton, Chair BFS & Non-Executive Director BHNFT

STRATEGIC CONTEXT

Barnsley Facilities Services Ltd (BFS), (formerly Barnsley Hospital Support Services Limited BHSS), was established in 2012 as a wholly owned subsidiary of BHNFT and became operational from January 2013. It is intended as a vehicle for the Trust to explore and expand commercial opportunities and enhance income streams for the benefit of patient services.

EXECUTIVE SUMMARY

The aim of this report is to provide the Trust’s Board of Directors with a regular update on the activities of BFS and to flag any risks or concerns.

The Board discussed the Annual Report and Accounts which will be signed off at the June Board subject to the audit report.

In terms of performance BFS achieved all key performance indicators apart from some within estates maintenance which were missed due to Covid-19 priorities.

Productive meetings were held with IT, Communications, Marketing & Design and Outpatients Pharmacy.

From an HR perspective sickness is at 2.85% and training is at 89.6%.

RECOMMENDATION

BFS Board recommends that:

The Board of BHNFT notes the attached report and take assurance that the wholly owned Operated Healthcare Facility is performing to plan and budget.

The Board of BHNFT notes the ongoing development of a 5-year strategic plan and budget.

Pack page 32

REPORT TO THE BOARD OF DIRECTORS AND F&P - BFS (BHSS) Chair’s Log

REF: BoD: 20/06/04/10

CHAIR’S LOG: Chair’s Key Issues and Assurance Model Committee / Group: BFS Board Meeting Date: 18th May 2020 Chair: Francis Patton

Item Issue Receiving Body, i.e. Board

or Committee Recommendation/ Assurance/

mandate to receiving body

1. Annual Report and Accounts.

These are in the process of being prepared and have been reviewed by two Directors - M Betts and L Christopher of BFS who have recommended some preliminary amends primarily to the ‘directors report’ and ‘strategic report’.

The accounts continue to be produced according to FRS 101 accounting standards, a significant change this year is the requirement to disclose a ‘Section 172 statement’ within the strategic report. The external auditors Grant Thornton are in receipt of the and have commenced auditing the accounts for material items. Grant Thornton are yet to produce an external audit plan for BFS though have confirmed they have appointed an engagement lead. The remaining process to finalise the audited accounts is to be confirmed which will be dependent upon full Board review and the timings when Grant Thornton complete their audit enquiries.

2. Performance Report

Key highlights from the performance report include:

1. BFS achieved all KPIs across all service areas in March 2020, apart from within Estates Maintenance due to prioritisation of urgent Covid-19 related works.

2. No material performance issues or variances to report against BFS performance measures set by BHNFT. BFS Business Activity

3. Capital works –

- I&G (ED/CAU Scheme) suspended activity during March 2020, returning on the 20 April 2020; however, this is under

Trust Board For Information and Assurance

Pack page 33

BoD May 2020 BFS_Chairs Log




an extended programme due to reduced capacity and safe working practices, so work will remain behind schedule. Programme and cost evaluation being undertaken.

- Jarvale (O-Block Scheme) suspended activity during March 2020, returning on the 18 May 2020, it is anticipated that this will be at a depleted capacity, so work will remain behind schedule. Programme and cost evaluations being undertaken.

- LED Lighting – LED scheme due to return to site June 2020 although some areas may not be accessible to complete all works due to Covid-19 considerations.

- Full review of 2020/21 Capital impact to be undertaken.

3. Reverse SLA’s

Meetings were held with IT, Communications, Marketing & Design and Outpatient Pharmacy.

Key points for consideration included the following: - All IT operational issues dealt with the exception of

action required to allow correct functioning of Emergency Lighting system, (this is to be actioned immediately).

- Worked jointly on securing contractor to light up the hospital blue as part of celebration for ‘Year of the Nurse’.

- Great support from team on Covid-19 related items and support on social media for contractors supporting BFS and the Trust e.g. Thank You Rainbows at entrances

- Administration rights to BFS web-site issued.

- Trust Chief Pharmacist to advise BFS on all governance aspects relating to a potential change to electronic prescribing

- All vacancies filled for Pharmacy roles, and therefore full service is being offered.


Pack page 34

BoD May 2020 BFS_Chairs Log




4. People

From a HR perspective Key points to note are:

• The cumulative turnover rate was 7.39%. There was one leaver and six new starters during April.

• The sickness rate at the end of April is 2.85% which is a decrease of 0.64% from a figure of 3.49% in March.

• There are a number of employees being managed under a formal sickness management process, however most absence is Covid–19 related.

• The people impact of Covid-19 continues to be managed. There have been 81 isolations in BFS due to Covid-19, including 19 staff who are shielding. 60 staff have returned. • Training compliance is 89.6%. Emphasis in May will be on ensuring those out of date are identified and training undertaken where practical. Some mandatory training is currently unavailable due to Covid-19 change in working practices.

• There are a number of vacancies at various stages of the recruitment process. We have adopted a ‘fast track’ recruitment process to recruit key workers.


Pack page 35

REPORT TO THE BOARD OF DIRECTORS REF: BoD: 20/06/04/12

SUBJECT: Integrated Performance Report: April 2020

DATE: JUNE 2020

PURPOSE:


applicable


PREPARED BY: Andrew Potts – Deputy Director of Operations

SPONSORED BY: Bob Kirton – Deputy Chief Executive/Chief Delivery Officer

PRESENTED BY: Bob Kirton – Deputy Chief Executive/Chief Delivery Officer

STRATEGIC CONTEXT

Strategic Objective 1 – Patients will experience safe care Strategic Objective 3 – People will be proud to work for us Strategic Objective 4 – Performance Matters

EXECUTIVE SUMMARY 1. Patient Access:

Emergency access & Patient Flow: Performance against the Emergency Department 4 hour standard in April was 95.3% compared with 91.0% in March. The Trust was one of only 18 nationally which achieved the target. The coronavirus outbreak has resulted in a marked reduction in ED attendances but has also disrupted the organisation of the emergency care system. RTT: For the 2019/20 year as a whole, performance was strong with 93.2% of pathways completed within 18 weeks compared with the standard of 92%. For most months of the year the Trust was one of the top five performing Trusts nationally. Covid caused a sharp reduction in elective activity in March and consequent deterioration in RTT performance with 88.7% of patients treated within 18 weeks. March was the first month in which compliance was not achieved. The loss of elective surgery capacity also resulted in six breaches of the 52 week standard in April. Cancer: Despite Covid related disruption, national standards were attained in March for 2 week waits from referral, 31 days for first treatment, and 62 days from GP referral to treatment. The target for symptomatic breast referrals was achieved but not the target for inter-provider transfers. For the 2019/20 year as a whole the 31 day and 62 day standards were achieved but the 2 week standard was narrowly missed with 92.8% of appointments provided within 2 weeks. Diagnostic Waits: Covid caused a substantial loss of capacity for non-urgent diagnostic investigations in April. There was a resultant deterioration in performance with 36.2% of investigations breaching the 6 week standard.

2. Quality of Care:

2.1 Patient Safety: Pressure Ulcers

There were 10 Category Two hospital acquired pressure ulcers reported in April with 7 resulting from lapses in care, primarily lack of 25 point skin inspections. Perfect Ward audits are still being completed but the schedule has been disrupted by Covid related staff absence and ward moves. Pack page 36

There were 10 hospital acquired medical device related pressure ulcers, 6 of which were due to lapses of care. Most of the lapses in care were in ICU, particularly involving prone positioning of patients with Covid. Documentation regarding prone positioning and preventative measures are being reviewed by ICU and the tissue viability team.

Incidents:

There was one reported incident resulting in severe harm, an inpatient fall causing bilateral skull fractures. A fall root cause analysis is being undertaken.

Two serious incidents were reported, one obstetric incident involving a delay in recognising complications of treatment and the other a medication incident also involving delay in recognising complications of treatment.

One never event was reported in which wrong site surgery was almost performed.

Falls: In April there were 54 inpatient falls compared to 55 in March. The relatively low number of falls is likely attributable to the reduced number of inpatients. There were again a relatively high number of falls on Ward 35 which was a newly opened ward to help manage the Covid workload.

2.2 Patient Experience: During April the Trust received 9 new complaints. The primary theme was clinical care and treatment. All complaints closed in April were within the agreed timeframe. The average number of working days to investigate complaints was 52 days. Of the complaints closed, 74% were upheld or partially upheld.

3. People: Sickness: Sickness – The sickness absence rate in April was 5.43%, higher than the equivalent month the previous year when the rate was 4.12%. The non-Covid sickness absence rate in April was 4.44%. There were 108 staff absent due to Covid related sickness in April. Occupational Health contact staff on a weekly basis who are absent due to Covid related illness. There were 140 staff working from home or shielding at home in April because of vulnerability to Covid. Mandatory Training: Mandatory training compliance remains below the 90% target in April as a result of a limited number of training opportunities being provided during the Covid-19 pandemic. A proposal for resuming the training program will be presented to the People and Engagement Group and Executive Team in May. Staff Appraisal Rate: The 2020/21 appraisal window remains postponed due to Covid. A proposal for resuming appraisals will be presented to the People and Engagement Group and Executive Team in May. Staff Turnover: The staff groups with the highest turnover remains Allied Health at 17.7% with Scientific & Technical second at 14.14%. Career development progression for some Allied Health and Professional & Technical staff was introduced from April 2020 to improve staff retention.

4. Finance: In line with the NHS’s new financial flow arrangements for the early part of the year, the Trust had a consolidated break even position for Month 1. Total income was £0.23m adverse to plan in April. Clinical Income is funded via a block contract at present but Other Income was £0.263 below plan principally because of reduction of car parking income and recharges due to Covid. Capital expenditure for the year is £0.423m almost all of which is Covid related expenditure.

RECOMMENDATIONS The Executive Team is asked to receive and endorse the latest IPR and to note that new targets for 2020/21 have been agreed by the executive directors but that forecasts have not been included for Month 1 due to uncertainties arising from the impact of Covid.

Pack page 37

Created by: Healthcare Information and Insight Service

Title of report: Integrated Performance Report

Executive Lead: Bob Kirton

`

April 2020

Pack page 38

Exe

cuti

ve S

um

mar

y

1. Purpose of the Report:

The purpose of this report is to inform the Trust Board and sub-committees of the latest position against key performance indicators, including operational and

quality requirements mandated nationally, metrics detailed in the NHSi oversight model and those identified within the BHNFT Operational Plan for 2020/21. In

addition, it provides Trust Board with information relating to activity delivered and finance, which are key drivers for sustainability.

This report details the latest validated information available.

A high level view of the Trust’s performance is available in the at a glance summary. Further details on the domains of quality, people, patient access and finance

are available in more depth as part of the wider document.

2. Background and Introduction:

The well-led framework used by NHSi identifies effective oversight by Trust Boards as essential to ensuring Trusts consistently deliver safe, sustainable and high

quality care for patients.

BHNFT provides an integrated performance report to Trust Board each month for assurance. The report outlines key performance against a number of quality,

operational, financial and activity based indicators. The purpose of the report is to ensure Trust Board has timely and robust oversight of performance in key

areas along with actions being taken to address required improvements.

Executive Summary April 2020

Pack page 39

1 2 3 9 10 16 17 18 19 20 21

Capital Plan

Total activity in-month is down on plan across all points of delivery, except other, due to focusing activity on business critical areas in response to COVID-19. Other activity is above plan due to a large increase in telephone consultations partly

offset by other elements of activity.

Total income is £0.230m adverse to plan for the month. The majority of clinical income (£18.221m) is subject to block arrangements as part of the new financial flows introduced for the early part of 20/21. There is a small overall total

variance of £0.044m below plan which is mainly due to an under performance on activity with other Trusts which are not covered by the block arrangements. Other income is £0.263m below plan mainly due to reductions in car parking

income and recharges out as a consequence of COVID-19.

In line with the new financial flow arrangements in place across the NHS for the early part of the 20/21 financial year, the Trust has a consolidated break-even position for the month. This is after accruing an additional £0.077m income top-up

from NHS England (NHSE).

Cash balances have increased during the month to £32.629m mainly as a consequence of NHSE and CCGs paying two months block payments in April to help Trusts cash positions during the COVID-19 outbreak, partly offset by a reduction in

revenue and capital creditors.

Capital expenditure for the year is £0.423m of which £0.408m relates to COVID-19 schemes.

Is higher than last month and this time last year when it was at 4.12%. Confirmed Covid-19 sickness in April 2020 accounts for 0.99% (108 staff ), with the remaining 4.44% due to other sickness reasons. There were 121 episodes of stress in

month (1,958 FTE days lost) compared to 76 stress episodes in April 2019 (1,035 FTE days lost). Occ Health have held wellbeing calls with 47 staff off sick with stress/anxiety due to Covid in April, and approx. 50 staff have accessed the Wobble

Room. Occ Health are also contacting weekly all staff with Covid related sickness post isolation period, for up to a period of 28 days (181 staff contacted so far) All CBUs remain in red with the exception of Corporate and BFS. There are 140

staff shielding /working from home from Covid-19. 57 Covid-19 risk assessments to support vulnerable workers to continue in work have been received. Plans are underway to publicise a longer term psychological well-being support package

for health/care staff affected by Covid-19 in Barnsley, with signposting to various resources and providers.

Continues to drop below the 90% target due to an approved restricted mandatory training programme of 5 priority e-learning training topics in place during the coronavirus crisis. An options paper to lift the restriction is to be presented to the

People & Engagement Group/Executive Team in May for approval.

The 2020/21 appraisal window which was due to open on 1 April remains postponed due to the coronavirus crisis. An update offering remote and home working solutions to propose opening the appraisal window is due to be presented to the

People & Engagement Group/Executive Team in May for approval.

Highest staff group turnover remains Allied Health Professionals at 17.77% , followed by Scientific & Technical staff at 14.14%. 5 OTs, 5 Physios and 3 Dietetics posts have been put into the budget this year from April as band 5 to band 6

career development progression posts (using AfC T&Cs Annex 21). Recruitment to these posts now needs to happen to see the real effect. A proposal paper to recommend a similar career progression route for Pharmacists is currently in

development.

Referral To Treatment (18 weeks)

Pat

ien

t A

cce

ssP

eo

ple

Fin

ance

Emergency Access

Planned Cash Position

Planned Financial Position

Income

Cost Improvement Programme

Cancer

Diagnostic Waits

Sickness Absence

Mandatory Training

Staff Turnover

Staff Appraisal Rates

Emergency Access – Performance against the Emergency Department 4 hour standard in April was 95.3% compared with 91.0% in March. The Trust was one of only 18 trusts in the country to achieve the target in April. The

coronavirus outbreak has resulted in a marked reduction in ED attendances but has also disrupted the organisation of the emergency care system.

RTT – The need to manage Covid resulted in a sharp reduction in elective activity in March with consequent deterioration in performance against the 18 week standard. During March 88.7% of patients were treated within 18

weeks compared with the standard of 92%. March was the first month in which compliance was not achieved. The Trust’s performance was the 12thg best nationally.

Cancer – Despite Covid related disruption to cancer services, national standards were attained in March for 2 week waits from referral , 31 days for first treatment, and 62 days from GP referral to treatment. The target for

symptomatic breast referrals was achieved but not the target for inter-provider transfers.

Diagnostics - Covid caused a substantial loss of capacity for non-urgent diagnostic investigations in April. There was a resultant deterioration in performance with 36.2% of investigations breaching the 6 week standard

Patients Partnerships People Performance

BHNFT At-a-Glance April 2020

Pack page 40

1 2 9 10 16 17 18 19 20 21Q

ual

ity

Patient

Experience

Clinical

Effectiveness

SHMI - Latest data Jan 19-Dec19 - 102

HSMR Rolling 12 month March 19 - February 2020 - 95.90

Complaints

During April the Trust received 9 new complaints. The complaints were allocated as follows: CBU 1 – 4, CBU 2 – 4, CBU 3 – 1 and Corporate Services - 0. The primary theme was clinical care and treatment. The percentage of cases closed within

agreed timeframe or agreed extension for the month was 100%. The average number of working days to investigate complaints was 52 days. 74% of complaints closed within April were upheld or partly upheld. The PA&C Team dealt with 94

concerns and 87 general enquiries (total 181) during the month.

FFT

Due to the current circumstances regarding the Covid-19 pandemic, NHS England has advised that reporting on the Friends and Family Test is suspended until further notice.’ Collection of Friends and Family data has also been put on hold.

Incidents

One incidents resulting in severe harm

• Inpatient fall on ward 35 resulting in bilateral skull fractures (Falls RCA is underway)

No incidents resulting in death

Two serious incidents reported in the month

• 2020/6529 – Obstetric incident: delayed diagnosis of complication of treatment (incident occurred in December 2019)

• 2020/7792 – Medication incident: delay in recognising complication of treatment (incident occurred in March 2020)

One never event reported in the month (also reported as a serious incident)

• 2020/6670 – Wrong site surgery in ophthalmology (incident occurred in March 2020)

I have reviewed the ED attendances and bed occupancy in April 2020 against the number of incidents reported in April 2020 and compared this with April 2019 figures. There is no evidence that the rate of incident reporting in the Trust has

reduced, the numbers appear to have reduced proportionately when considered alongside ED attendances and bed occupancy.

Pressure Ulcers

There have been 10 category 2 hospital acquired pressure ulcers reported this month. Of these, 7 were found to have lapses in care. This was mainly due to lack of 25 point skin inspections. Lack of react to red.

Perfect ward audits are still being completed when they can.

There has been 10 hospital acquired medical device related pressure ulcers, six of which were due to lapses in care. Of the 5, 4 were attributable to ICU and were related to prone lying of patients with COVID 19. Device checklists not being

completed, inconsistent evidence regarding repositioning of the patients head. Pressure relieving measures being put in place to the ET tube ties after pressure ulcers occur.

Documentation regarding prone positioning and preventative measures are not being looked at by the ICU department and tissue viability.

Falls

For this month there were 54 inpatient falls reported Trust wide, 16 were repeat falls. Whilst these are lower than usual monthly numbers of falls reported in the Trust, there were high numbers of falls reported on ward 35 which is has continued

from March 2020. A renewed focus on the best practice interventions such as; mobility aids within arm’s reach of patients, call bells with the patient and bed side handovers will monitored for assurance of being implemented.

Patient

Safety


BHNFT At-a-Glance April 2020

Pack page 41

2 3 4 6 7

Domain KPI StandardStandard(Month)

Set By Current Qtr. Year to DateYear-End

Forecast Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20

Falls 785 (<) 65 BHNFT 54 54 76 71 55 70 47 75 73 77 81 88 60 55 54

Repeat Falls n/a BHNFT 16 16 17 17 5 13 5 16 14 15 22 21 12 11 16

Falls resulting in moderate harm or above 15 (< =) 1 BHNFT 1 1 2 0 2 1 2 0 1 0 3 1 4 1 1

Hand washing 95% (>) National 98% 98% 94% 97% 97% 96% 99% 99% 97% 97% 96% 96% 96% 98% 98%

Pressure Ulcers category 2 (Lapses in care) G < 30, R >30 0 BHNFT 7 7 2 5 5 4 7 6 3 4 10 13 1 3 7

To eliminate pressure ulcers resulting from medical devices resulting in lapses of care. 6 6 4 3 0 2 0 0 1 3 1 1 0 1 6

Q - Hospital Acquired Clostridium Difficile 19 (<) 1 NHSI 1 1 1 1 2 2 4 3 2 1 1 2 3 0 1

Q- Hospital Acquired MRSA Bacteraemia 0 0 NHSE 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1

Q - Serious Incidents - NHSE 2 2 2 0 2 2 3 3 1 4 4 2 2 2 2

Q- Total Number of Incidents Resulting in Death 0 0 National 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0

Q-Total Number of Incidents Resulting in Severe Harm 0 0 National 1 1 1 0 2 3 0 0 1 1 4 0 3 2 1

Never Events 0 0 National 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1

Q- FFT Positivity Rates -StaffG >85%, A >=80%-85%, R <80% (>

)BHNFT 82.0% 84.0%

Complaints closed within target or agreed extension % G >90%, A >=70%-90%, R <70% (>) BHNFT 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Q- Single Sex Breaches 0 0 National 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Q - Duty of Candour Breaches 0 0 National 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Q - VTE Screening Compliance G>= 95%, R < 95% NHSE 96.2% 96.2% 98.1% 98.2% 98.5% 98.2% 98.5% 98.2% 97.4% 96.6% 98.4% 98.0% 97.0% 96.3% 96.2%

Q - Sepsis-Antibiotics given within Hour of diagnosis G >= 90%, R < 90% National - - 87.8% 85.5% 83.2% 85.8%

Q - HSMR (Rolling 12 months) Latest Data is February 2020 - - - - - 96.9 96.9 97.9 95.4 94.2 94.8 97.3 98.8 98.4 96.5 95.9

Crude Mortality (Number of Deaths) - - - 137 137 100 88 79 65 69 80 81 104 104 95 84 100 137

Crude Mortality (COVID19 Deaths) - - - 70 70 8 70

SHMI (Rolling 12 months) Latest Data is December 2019 - - - 101.0 99.4 102.0

RAG Description

RED Failed Target

AMBER Failed by <5% (This tolerance can only be applied to local targets)

GREEN Achieved Target

< Less Is Good

> More is good

Q KPI is in the Quality Schedule for 2019/20 to be defined and included in IPR from May 2019

Quality Performance Scorecard

Patient Safety

Patient Experience

Clinical

Effectiveness

Patients will experience safe care


5Pack page 42

People and Patient Access Scorecard

Domain KPI StandardStandard(Month)

Set By Current Qtr. Year to DateYear-End

Forecast Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20

People will be proud to work for us

Staff Turnover (Rolling 12 months) G <=10%, A >10%-10.5%, R >10.5% (<) BHNFT 10.5% 10.5% 9.3% 9.7% 10.1% 10% 10.4% 10.5% 10.8% 10.6% 10.5% 10.8% 10.9% 10.8% 10.5%

Staff Appraisal Rate G >90%, A >=85%-90%, R <85% (>) BHNFT 90.5% 90.5% 7.6% 31.4% 86.5% 91.2% 92.8% 93.0% 93.0% 93.2% 92.9% 92.6% 92.2% 91.9% 90.5%

Mandatory Training G >90%, A >=85%-90%, R <85% (>) BHNFT 85.8% 85.8% 90.9% 91.3% 91.2% 90.7% 90.3% 89.8% 90.4% 90.6% 91.2% 90.6% 90.0% 88.8% 85.8%

Sickness Absence (In Month)G <=3.75%, A >3.75%-4.25%, R >4.25%

(<)BHNFT 5.43% 5.43% 4.12% 4.10% 4.02% 4.31% 3.85% 3.97% 4.29% 4.50% 5.05% 5.16% 4.73% 4.72% 5.43%

Performance matters - Key Performance Indicators

RTT Incomplete Pathways (March 2020, Q4, 1920 YTD) 92% (>) National 91.2% 93.2% 95.0% 94.7% 94.3% 93.5% 93.3% 93.8% 93.6% 93.7% 92.7% 92.5% 92.1% 88.7%

RTT 52 Week Breaches 0 National 3 9 0 0 0 0 1 4 1 0 0 0 0 3

Diagnostic patients waiting more than 6 weeks 1 %(<=) National 36.15% 36.15% 0.13% 0.00% 0.07% 0.29% 0.10% 0.10% 0.00% 0.00% 0.29% 0.07% 0.18% 1.16% 36.15%

Q - Cancer 2 Week Waits 93% (>) National 96.1% 92.8% 93.4% 94.8% 85.8% 87.8% 93.3% 93.7% 91.9% 92.9% 92.9% 94.9% 96.5% 97.1%

Q - Symptomatic Breast 2 Week Waits 93% (>) National 95.1% 85.7% 92.1% 94.9% 48.4% 57.9% 82.8% 98.1% 94.6% 92.6% 94.1% 91.8% 97.3% 96.6%

Q - 31 Day - 1st Definitive Treatment 96% (>) National 97.2% 97.8% 95% 92% 97% 100% 97% 100% 100% 100% 100% 99% 98% 94%

Q - 31 Day - Subsequent Treatment (Surgery) 94% (>) National 79.3% 93.9% 100% 100% 100% 100% 100% 100% 100% 100% 100% 80% 75% 82%

Q - 31 Day - Subsequent Treatment (Chemotherapy) 98% (>) National 100.0% 98.5% 88% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Q - 38 Day - Inter-Provider Transfer 85% (>) BHNFT 55.2% 56.3% 63.2% 45.0% 70% 58.3% 44.0% 76.2% 61.1% 44.4% 68.8% 42.9% 70.6% 55.0%

Q - 62 Day - GP Referral to Treatment 85% (>) National 85.9% 85.2% 93.2% 78.0% 73.3% 88.8% 78.5% 93.5% 85.1% 87.0% 91.1% 82.4% 87.9% 88.6%

Q - 62 Day - Screening Referral to Treatment 90% (>) National 78.8% 88.7% 100% 79% 100% 100% 100% 100% 88% 94% 90% 86% 92% 64%

Q - 62 Day - Consultant Upgrade to Treatment 85% (>) National 89.7% 84.7% 100% 100% 75% 94% 100% 83% 80% 38% 89% 77% 100% 94%

Emergency % Patients Waiting <4 Hours 95% (>) National 95.3% 95.3% 96% 95.6% 95.6% 93.5% 91.3% 96.3% 95.2% 85.7% 80.7% 86.9% 91.4% 91.0% 95.3%

Average Length of Stay - Elective (Spell) G <=3.45, A >3.45-3.91, R >3.91 (<) BHNFT 0.88 0.88 2.65 2.20 2.94 3.00 2.67 2.56 2.41 1.79 2.13 2.04 2.15 2.20 0.88

Average Length of Stay - Non-Elective (Spell) G <=3.45, A >3.45-3.91, R >3.91 (<) BHNFT 3.57 3.57 3.07 3.16 3.06 3.04 3.07 3.09 3.18 3.18 3.48 3.67 3.55 3.80 3.57

Re-admissions % (Validated) 8% BHNFT 8.4% 8.5% 8.9% 8.3% 8.4% 7.2% 7.6% 8.7% 8.0% 8.5% 7.1% 6.8%

Cancelled Operations - Breaches of the 28 day rule 0 0 National 0 0 0 0 0 0 0 0 1 0 2 0 0 11 0

Cancelled Operations - Sitrep Reportable 0.8% BHNFT 0.0 0.0 0.5% 0.7% 0.4% 0.7% 0.5% 0.6% 0.4% 0.4% 1.0% 0.5% 0.6% 0.9% 0.0%

DNA Outpatient DNA Rates G <=6.9%, R >6.9% (<) 6.9% BHNFT 5.8% 5.8% 6.8% 6.9% 6.7% 6.6% 6.7% 7.1% 6.8% 6.5% 7.5% 7.5% 6.5% 7.1% 5.8%

RAG Description

RED Failed Target

AMBER Failed by <5% (This tolerance can only be applied to local targets)

GREEN Achieved Target

< Less Is Good

> More is good

Q KPI is in the Quality Schedule

NOTE: National Indicators are considered as being either Achieved or Failed. These are therefore RAG rated as Green or Red.

Local indicators can have amber tolerances set and these have been agreed with the services.

Operational

Efficiency

Workforce

Elective Access

Cancer


6Pack page 43

Performance Matters (KPIs)Operational Efficiency

The Trust failed to deliver the Emergency access standard in the month of January at 91.1%. Activity is now 14% above plan for emergency department attendances and 6% above plan for non-elective admissions. Year to date, delivery is at 94.7% with a organisational effort focusing on the delivery of the 95% standard at year end

Comments:

The outpatient did not attend (DNA) rate reduced to 6.8% in April, comfortably within the 7.2% target

level. This reflects the efforts made to ensure patients requiring urgent consultations, via tele-

consultation or in person attendance, received them despite the difficulties arising from the coronavirus

outbreak.

DN

A R

ates

Bre

ast

Sym

pto

mat

ic

During April the need to manage Covid resulted in elective operating being restricted to a limited number of very urgent operations. Consequently there were no

cancelled operations. There were also no breaches of the standard that patients whose operations are cancelled by the hospital are provided with another appointment

within 28 days. The previously very strong performance with regard to diagnostic waiting times was adversely affected by the need to restrict services to only urgent

investigations in response to the coronavirus outbreak.

The reporting of re-admissions is being reviewed to ensure consistency between the Trust and Barnsley CCG

and changes will be made as required following the review. An audit of re-admissions has been undertaken

and a report issued in draft form. Actions will be agreed between partners in response to the report and the

final report and action plan will be shared in due course.

Re-

adm

issi

on

s


6.8% 6.9% 6.7% 6.6% 6.7% 7.1% 6.8% 6.5% 7.5% 7.5%

6.5% 7.1% 5.8%

0%

5%

10%

% o

f D

NA

Rat

es

DNA Rates

New Follow Up Total Standard 2017/18

Cancelled Operations target is '0'

0.5%

0.7%

0.4%

0.7%

0.5% 0.6%

0.4% 0.4%

1.0%

0.5%

0.6%

0.9%

0.0%

-0.1%

0.1%

0.3%

0.5%

0.7%

0.9%

1.1%

1.3%

1.5%

% o

f C

ance

lled

Op

era

tio

ns

Cancelled Operations

28 Day Breaches % Cancelled Ops Standard

Cancelled Operations Target '0'

8.4% 8.5% 8.9% 8.3% 8.4% 7.2% 7.6%

8.7% 8.0% 8.5%

7.1% 6.8%

0.00%

5.00%

10.00%

Cumulative Validated Re-admissions

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1%

36%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

Pe

rce

nta

ge o

ver

6 w

ee

ks

Diagnostic Tests over 6 Weeks

Standard Actual % 20/21

7Pack page 44

Performance Matters (KPIs)


Emergency Access and Patient Flow (1)

Performance against the 4 hour standard in April was 95.3% compared with 91.0% in March. The Trust was one of only 18 trusts in the

country to achieve the target in April. The coronavirus outbreak has resulted in a marked reduction in ED attendances but has also

disrupted the organisation of the emergency care system with the need to establish separate “hot” and “cold” facilities and workflows.

Patient pathways have been reviewed and improved to ensure the time patients spend in the Emergency Department is minimised.

Early review by senior medical staff and expediting transfers to wards for admitted patients have contributed to improved

performance.

The recording of ambulance handover times has been adversely affected by the disruption within the service with the proportion of

unrecorded times increasing markedly in March and April. Almost all recorded handovers were within 30 minutes with an average

handover time of around 15 minutes.

Co

mm

enta

ryED

4 H

ou

r W

ait

95.97% 95.64% 95.56%

93.45%

91.26%

96.32% 95.20%

85.67%

80.72%

86.92%

91.43% 91.03%

95.28%

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

0

2000

4000

6000

8000

10000

12000

Within 4Hrs Total Activity Target 4h Emergency Access PerformanceStandard

8Pack page 45




A&E benchmarking

Acuity analysis shows an expected increase as measured by EWS scores above. This is reflected in increased bed occupancy and mitigated by the flexible use of inpatient capacity

Inp

atie

nt

Acu

ity

- R

ed

A&

E 4

Ho

ur

Wa

it -

Be

nch

mar

kin

g

Am

bu

lan

ce H

and

ove

rsIn

pat

ien

t A

cuit

y -

Am

ber

(EW

S sc

ore

5-6

)

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20

No. Ambulance Handover Times (Pre-validated YAS)

No. between 15 & 30 mins No. between 30 & 60 mins No. between 60 & 120 mins No. over 120 mins Not recorded

EWS = Amber only

0

5

10

15

20

25

Occ

up

ancy

(1

2p

m)

Red

0

5

10

15

20

25

30

Occ

up

ancy

(1

2p

m)

Amber

9Pack page 46




GP streaming was suspended from April 2020 due to Covid. The accommodation has been repurposed to enable separate “hot” and “cold” areas in the Emergency

Department. Patients are being assessed on arrival to the Department and those patients requiring primary care are being directed to their primary care provider.

Tru

st B

ed

Occ

up

ancy

(M

ed

ical

)The elective average length of stay reduced markedly in April as a result of

Covid. The limited amount of elective surgery performed was predominantly

urgent short stay operations such as breast procedures. The amount and scope

of urgent elective surgery planned for May is considerably higher.

Len

gth

of

Stay

(Sp

ell)

GP

Str

eam

ing

0

1

2

3

4

5

LoS

(Day

s)

EL_LOS NEL_LOS

100

200

300

400

10Pack page 47



Regulatory Performance - 18 Week Referral to Treatment

As stated

RTT 18 Week Performance - March 2020Validated Position

CommentsSpecialty <18 >18 Total %

CARDIOLOGY 391 8 399 97.99%DERMATOLOGY 689 79 768 89.71%E N T 929 78 1007 92.25%GASTROENTEROLOGY 850 6 856 99.30%GENERAL MEDICINE 174 2 176 98.86%GENERAL SURGERY 1575 364 1939 81.23%GERIATRIC MEDICINE 137 0 137 100.00%GYNAECOLOGY 871 57 928 93.86%OPHTHALMOLOGY 870 28 898 96.88%ORAL SURGERY 1033 289 1322 78.14%OTHERS 676 15 691 97.83%RESPIRATORY MEDICINE 283 4 287 98.61%RHEUMATOLOGY 208 18 226 92.04%TRAUMA AND ORTHOPAEDICS 960 248 1208 79.47%UROLOGY 647 109 756 85.58%Total 10293 1305 11598 88.75%

Incompletes - Standard 92%

• Performance deteriorated sharply in March because of Covid and the need to

restrict non-urgent surgery in order to conserve stocks of personal protective

equipment and redeploy Anaesthetics and Theatre staff to support Critical Care.

This resulted in a non-compliant position in March in addition to several breaches

of the 52 week standard. For the year as a whole RTT performance was very

strong with 93.2% of pathways completed within 18 weeks compared with the

standard of 92%. For most months over the year the Trust was one of the top five

performing Trusts nationally. Performance across the country deteriorated over

the year as growth in referrals tended to exceed growth in capacity. At Barnsley

Hospital substantial and ongoing capacity pressures were experienced in General

Surgery, Oral Surgery, and Orthopaedics while Dermatology and Urology

encountered challenges in meeting the standard at various times.

Co

nsu

ltan

t 1

8 W

eek

Re

ferr

al t

o

Tre

atm

en

t

90% 94.74% 94.27% 93.53% 93.35% 93.83% 93.57% 93.70% 92.66% 92.48% 92.15%

88.75%

80%82%84%86%88%90%92%94%96%98%

100%

Pe

rce

nta

ge P

osi

tivi

ty

Incomplete Pathways

Actual Standard

11Pack page 48



Regulatory Performance - Cancer

Two Week Wait

While activity levels remain consistent, the validated position for March exceeded recent months with a

complaint position of 97.1% against a national target of 93.0%. All tumour groups with the exception of Upper GI

we individually compliant with Haematology, Lung and Head & Neck achieving 100%.

22 breaches in total due to patient choice (x13), capacity issues (x8) or COVID-19 where patient was self-isolating

(x1). Of the capacity related breaches x1 where no appointment was available within 2 weeks and x7 where the

trust were unable to offer a further appointment within target.

For the year as a whole 92.8% of patients referred on a two week wait pathway had an appointment within two

weeks compared with the standard of 93%. Substantial and ongoing referral growth for suspected lower

gastrointestinal and breast cancer proved particularly challenging and resulted in a large proportion of breaches.

Additional capacity has now been commissioned which, along with the introduction of the lower GI straight to

test pathway, is expected to result in much improved performance.

Breast Symptomatic

March’s validated position was compliant at 96.6% against the national target of 93.0%. Three

breaches in total due to the trust not being able to offer an appointment within 2 weeks (x1),

the trust unable to offer a further appointment within target after the patient was unable to

attend the original allocated slot (x1) and patient choice (x1).

Inte

r p

rovi

de

r Tr

ansf

er

Bre

ast

Sym

pto

mat

ic

All

Can

cer

2 W

ee

k W

aits

40%

50%

60%

70%

80%

90%

100%

Pe

rce

nta

ge P

osi

tivi

ty

Actual Standard

75%

80%

85%

90%

95%

100%

Pe

rce

nta

ge P

osi

tivi

ty

Actual Standard

38 Day Inter-Provider Transfers March’s position of 55.0% against a target of 85% shows a similar trend to the previous month. 9 breaches in total due to varying reasons. Lung (x3), Lower GI (x1), Upper GI (x1), Urology (x2), Head & Neck (x1) and Skin (x1) - patient choice, capacity issue and complex pathways being the main reasons. Due to changes to the Cancer Alliance data request the parameters around calculation of the Inter Provider Transfer (IPT) have been adjusted. The compliance against 38 days IPT is now calculated on patients that have been treated ‘in month’. This has been back dated to April 2019 for consistency of approach.

12Pack page 49



Regulatory Performance - Cancer

Graph to follow from Cancer services

Graph to follow from Cancer services

62 Day GP Referral to Treatment

March performance for 62 day GP referral to treatment was compliant with 87.1% against a target of 85% with five tumour sites performing at 100% (Haematology, Skin, Breast, Upper GI and Gynaecology).

Of the 10 breaches, x1 were local and x5 were shared.

Local – Lower GI due to inadequate surgical capacity (treat day 70).

Shared – Urology (x3) due to provider initiated delays to diagnostic testing (x2) and an unexceptional pathway compounded by a COVID-19 related treatment change. Upper GI (x1) due to a complex diagnostic

pathway and Lung (x1) due to an unexceptional pathway led to IPT late in pathway (day 50).

For the year as a whole the standard was achieved with 85.2% of pathways completed within 62 days compared with the target of 85%. This was despite the challenges arising from considerable referral growth

in a number of specialties. The focus continues to be on improving patient pathways to reduce unnecessary waits with expansion in capacity where this is required to meet growing demand

62 Day Screening Referral to Treatment

The March validated position for 62 day screening was non-compliant at 64.3% against a target of 90%.

Breast and Gynaecology both achieved 100% while all 5 breaches were local Lower GI pathways due to

inadequate surgical capacity (x3) and inefficient pathway (x2).

62 Day Consultant Upgrade to Treatment

Performance for March Consultant Upgrades was compliant with 94.4%. One breached

pathway within Head & Neck due to patient having concurrent primary diagnosis with Lung

being treated first.

62

Day

Can

cer

Targ

ets

62

Day

Can

cer

Targ

ets

60%

65%

70%

75%

80%

85%

90%

95%

100%

Pe

rce

nta

ge P

osi

tivi

ty

62 Day - Urgent GP Referral to Treatment

Actual Standard

0%

20%

40%

60%

80%

100%

Pe

rce

nta

ge P

osi

tivi

ty

62 Day - Screening Programme

Actual Standard

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pe

rce

nta

ge P

osi

tivi

ty

62 Day - Consultant Upgrades

Actual Standard

13Pack page 50

High Level Summary Sickness - Is higher than last month and this time last year when it was at 4.12%. Confirmed Covid-19 sickness in April 2020 accounts for 0.99% (126 staff ), with the remaining 4.44% due to other sickness reasons. There were 121 episodes of stress in month (1,958 FTE days lost) compared to 76 stress episodes in April 2019 (1,035 FTE days lost). Occ Health have held wellbeing calls with 47 staff off sick with stress/anxiety due to Covid in April, and approx. 50 staff have accessed the Wobble Room. Occ Health are also contacting weekly all staff with Covid related sickness post isolation period, for up to a period of 28 days (181 staff contacted so far) All CBUs remain in red with the exception of Corporate and BFS. There are 140 staff shielding /working from home from Covid-19. 57 Covid-19 risk assessments to support vulnerable workers to continue in work have been received. Plans are underway to publicise a longer term psychological well-being support package for health/care staff affected by Covid-19 in Barnsley, with signposting to various resources and providers. Staff Turnover— Highest staff group turnover remains Allied Health Professionals at 17.77% , followed by Scientific & Technical staff at 14.14%. 5 OTs, 5 Physios and 3 Dietetics posts have been put into the budget this year from April as band 5 to band 6 career development progression posts (using AfC T&Cs Annex 21). Recruitment to these posts now needs to happen to see the real effect. A proposal paper to recommend a similar career progression route for Pharmacists is currently in development. Mandatory Training - Continues to drop below the 90% target due to an approved restricted mandatory training programme of 5 priority e-learning training topics in place during the coronavirus crisis. An options paper to lift the restriction is to be presented to the People & Engagement Group/Executive Team in May for approval. Staff Appraisal Rate - The 2020/21 appraisal window which was due to open on 1 April remains postponed due to the coronavirus crisis. An update offering remote and home working solutions to propose opening the appraisal window is due to be presented to the People & Engagement Group/Executive Team in May for approval.

14Pack page 51

People - Trend Analysis Si

ckn

ess

(Tru

st w

ide

)St

aff

Turn

ove

r (1

2 M

on

ths)


Please the latest Sickness absence benchmarking data is only available up to December 2018

15Pack page 52

Performance MattersActivity

19/20 20/21 20/21

Actual Plan Actual Variance %

Elective Daycases 2,356 2,382 306 -2076 -87%

Elective Inpatients 306 335 59 -276 -82%

Elective Total 2,662 2,717 365 -2352 -87%

Non Elective Total 3,682 3,627 2,022 -1605 -44%

Maternity Pathway Total 523 539 489 -50 -9%

A&E Total 8,725 8,618 4,304 -4314 -50%

Outpatients Total 29,511 28,587 8,060 -20527 -72%

* Please note excess bed days are not included in these figures. 2020/21Activity Plan

2020/21 Activity Actual

2020/21 Activity Plan 2020/21 Activity Plan

2020/21 Activity Actual 2020/21 Activity Actual

Act

ivit

y

Day

Cas

es

Obstetric outpatient attendances are excluded as they are covered by the Maternity Pathways

Ele

ctiv

e In

pat

ien

ts

No

n-E

lect

ive

Inp

atie

nts


16Pack page 53

Performance MattersActivity

2020/21 Activity Plan 2020/21 Activity Plan

2020/21 Activity Actual 2020/21 Activity Actual

Comments:

2020/21 Activity Plan

2020/21 Activity Actual

Ou

tpat

ien

ts

Due to the impact of Covid-19 all areas of activity are under plan.

Mat

ern

ity

Pat

hw

ay

ED A

tte

nd

ance

s


17Pack page 54

SUMMARY

Trust Ove

rall

dat

aset

sco

re

Eth

nic

cat

ego

ry

Gen

eral

Med

ical

Pra

ctic

e C

od

e

NH

S N

um

ber

Po

stco

de

of

Uu

sual

Ad

dre

ss

Sou

rce

of

Ref

erra

l fo

r A

& E

Ove

rall

dat

aset

sco

re

Trea

tmen

t Fu

nct

ion

Co

de

Ad

mis

sio

n M

eth

od

Dis

char

ge D

ate

Pri

mar

y D

iagn

osi

s (I

CD

)

Sou

rce

Of

Ad

mis

sio

n C

od

e

Ove

rall

dat

aset

sco

re

Trea

tmen

t Fu

nct

ion

Co

de

Mai

n S

pec

ialit

y C

od

e

Co

nsu

ltan

t C

od

e

Gen

der

Sou

rce

of

Ref

erra

l

National data item average - - 79.5 90.5 87.7 90.9 72.6 - 96.7 97.5 97.8 89.6 96.7 - 96.7 95.6 92.2 94.4 92.5

Barnsley NHS FT 97.6 99.4 96.5 98.4 99.3 100 100 96 100 100 100 98.3 100 98.9 100 100 93.5 100 95.3

The Rotherham NHS FT 92.1 88.8 99.8 100 99.5 100 0 97 100 100 100 94.8 100 99.8 100 100 100 100 99.8

Chesterfield Royal NHS FT 91.7 99.8 99.4 100 99.5 99.7 100 96.9 100 100 100 98.2 100 100 100 100 100 100 100

Sheffield Teaching NHS FT 96.6 99.6 97.3 100 99.1 99.9 100 99.8 100 100 100 99.1 100 99.5 100 100 97.5 100 100

Doncaster & Bassetlaw FT 99.6 99.2 96.1 99.5 97.1 99.9 100 99.7 100 100 100 98.2 100 99.6 100 100 99.7 100 100

Mid Yorks Hospital 94.3 99.6 100 99.8 99.2 100 97.6 96.8 100 100 100 98.7 100 98 100 100 82 100 100

Definitions

Ethnic category - as stated by the patient

General Medicine Practice code - the organisation code of the GP Practice that the patient is registered with

NHS number - unique patient identifier

Source of referral for A&E - the source of referral of each A & E episode

Treatment Function Code - recorded to report the specialised service within which the patient is treated.

Admission Method - The method of admission to a hospital provider spell. For example, elective, emergency, maternity.

Discharge Date - The date a patient was discharged from a hospital provider spell.

Primary Diagnosis (ICD) - the International Classification of Diseases (ICD) code used to identify the primary diagnosis.

Source Of Admission Code - to a Hospital Provider Spell or a Nursing Episode when the patient is in a Hospital Site or a Care Home.

Consultant Code - code uniquely identifying a consultant

Gender - patient's current gender.

Source of Referral for Outpatients - source of referral of each Consultant Out-Patient Episode

The Trust now has a well-established Data Quality Group that aims to ensure the Trust’s core electronic patient record system is up-to-date and accurate. This group comprises operational and ICT staff and

reports directly into senior operational groups on progress and ensures delivery of action plans associated with emergent and pre-existing data quality issues.

The Data Quality Maturity Index (DQMI) is a quarterly NHS Digital publication intended to highlight the importance of data quality in the NHS. The most recent data is August 2019.

Postcode of usual address - the postcode of the address nominated by the patient where the address association type is 'Main Permanent Residence' or 'Other Permanent Residence'

Main Speciality Code - the specialty in which the consultant is contracted or recognised. Main speciality classifies clinical work divisions more precisely for a limited number of specialties.

Comments - Barnsley is better than the national average across all areas of mandated data. Outpatient consultant codes will improve when we implement

Medway as Lorenzo allows none standardised consultant codes (J Codes).

DQ

MI

ED Admitted Patient Care Outpatients


18Pack page 55

Performance - "At a glance"

Performance - Financial Overview

Month

Plan

Month

ActualVariance Variance % Plan YTD Actual YTD Variance

Variance

%

Month

Plan

Month

ActualVariance Variance % Plan YTD

Actual

YTDVariance

Variance

%

ACTIVITY LEVELS (PROVISIONAL) Statement of Financial Position (SOFP) £'000 £'000 £'000 £'000 £'000 £'000

Elective inpatients 335 59 (276) -82.39% 335 59 (276) -82.39% Capital Spend 0 (423) (423) 0 (423) (423)

Day Cases 2,382 306 (2,076) -87.15% 2,382 306 (2,076) -87.15% Inventory 3,731 3,770 (39) 1.05%

Outpatients 28,352 7,845 (20,507) -72.33% 28,352 7,845 (20,507) -72.33% Receivables 14,877 14,966 (89) 0.60%

Non-elective inpatients 3,665 2,038 (1,627) -44.39% 3,665 2,038 (1,627) -44.39% Payables (inc. Accruals) (27,304) (27,252) (52) 0.19%

A&E 8,618 4,304 (4,314) -50.06% 8,618 4,304 (4,314) -50.06% Other Net Liabilities (22,493) (22,443) (50) 0.22%

Other (excludes direct access tests) 8,447 10,305 1,858 22.00% 8,447 10,305 1,858 22.00%

Total activity 51,799 24,857 (26,942) -52.01% 51,799 24,857 (26,942) -52.01% Cash & Loan Funding £'000 £'000 £'000

Cash 32,708 32,629 (79) -0.24%

INCOME £'000 £'000 £'000 £'000 £'000 £'000 Loan Funding (67,376) (67,376) 0 0.00%

Elective inpatients 970 83 (887) -91.47% 970 83 (887) -91.47%

Day Cases 1,488 152 (1,336) -89.81% 1,488 152 (1,336) -89.81% KPIs

Outpatients 2,929 806 (2,123) -72.48% 2,929 806 (2,123) -72.48% EBITDA % 3.17% 3.46% 0.29% 9.23% 3.17% 3.46% 0.29% 9.23%

Non-elective inpatients 7,014 4,535 (2,479) -35.35% 7,014 4,535 (2,479) -35.35% Surplus / (Deficit) % 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

A&E 1,232 657 (575) -46.67% 1,232 657 (575) -46.67% Receivable Days 18.1 18.4 -0.3 1.46%

Other Clinical 4,700 12,057 7,357 156.53% 4,700 12,057 7,357 156.53% Payable (excluding accruals) Days 36.1 31.7 -4.4 -12.23%

PSF, FRF, MRET & Top-Up 1,372 1,449 77 5.61% 1,372 1,449 77 5.61%

Other 1,605 1,342 (263) -16.38% 1,605 1,342 (263) -16.38%

Total income 21,310 21,080 (230) -1.08% 21,310 21,080 (230) -1.08%

OPERATING COSTS £'000 £'000 £'000 £'000 £'000 £'000

Pay (14,514) (15,135) (621) -4.28% (14,514) (15,135) (621) -4.28%

Drugs (1,375) (1,066) 309 22.48% (1,375) (1,066) 309 22.48%

Non-Pay (4,746) (4,150) 596 12.56% (4,746) (4,150) 596 12.56%

Total Costs (20,635) (20,351) 284 1.38% (20,635) (20,351) 284 1.38%

EBITDA 675 729 54 8.05% 675 729 54 8.05%

Depreciation (473) (512) (39) -8.24% (473) (512) (39) -8.24%

Non Operating Expenditure (202) (217) (15) -7.60% (202) (217) (15) -7.60%

Surplus / (Deficit) 0 (0) (0) 0 (0) (0)

Performance - Financial Overview


Page 19 of 20Pack page 56

Performance Matters - Finance

April 20 Summary

Summary Performance:


Commentary Key to RAG Rating The RAG rating applied to Variance % is based on the following criteria: • Green equating to 0% or greater • Amber behind plan by up to 5% • Red greater than 5% behind plan

The key points derived from this table are as follows: • In line with the new financial flow arrangements in place across the NHS for the early part of the 20/21 financial year, the Trust has a consolidated break-even position for the month. This is

after accruing an additional £0.077m income top-up from NHS England (NHSE).

• Total activity in-month is down on plan across all points of delivery, except other, due to focusing activity on business critical areas in response to COVID-19. Other activity is above plan due to a large increase in telephone consultations partly offset by other elements of activity.

• Total income is £0.230m adverse to plan for the month. The majority of clinical income (£18.221m) is subject to block arrangements as part of the new financial flows introduced for the early part of 20/21. There is a small overall total variance of £0.044m below plan which is mainly due to an under performance on activity with other Trusts which are not covered by the block arrangements. Other income is £0.263m below plan mainly due to reductions in car parking income and recharges out as a consequence of COVID-19.

• Operating costs are £0.284m favourable to plan in total. Pay is £0.621m adverse mainly due to agency spend and additional costs incurred as a consequence of COVID-19 to safely staff the service and backfill staff members in isolation. Non-pay costs are £0.905m favourable mainly due to lower activity as a result of COVID-19 in non critical business areas offsetting any additional costs incurred as a consequence of COVID-19.

• Capital expenditure for the year is £0.423m of which £0.408m relates to COVID-19 schemes.

• Cash balances have increased during the month to £32.629m mainly as a consequence of NHSE and CCGs paying two months block payments in April to help Trusts cash positions during the COVID-19 outbreak, partly offset by a reduction in revenue and capital creditors.

• As a consequence of the NHSE and CCG block prepayments along with Health Education England paying all of quarter 1's income in April, deferred income within "other net liabilities" increased in month by £21.007m.

• Payable days (excluding accruals) are 31.7 which is 4.4 days favourable to plan and continue to show the managed reduction in the creditors position. Payable days have been calculated excluding accruals, because whilst accruals include certainties in respect of future payments, the timing of these payments is uncertain. Expenditure has been calculated as operating costs, less pay, add back lead units and agency, and capex.

Page 20 of 20Pack page 57


REF: BoD: 20/06/04/13

SUBJECT: INFECTION PREVENTION AND CONTROL ANNUAL REPORT


PURPOSE:

Tick as applicable

Tick as applicable


PREPARED BY: Christine Fisher, Assistant Director of Infection Prevention and Control

SPONSORED BY: Jackie Murphy, Executive lead for Infection Prevention & Control

PRESENTED BY: Jackie Murphy, Executive lead for Infection Prevention & Control

STRATEGIC CONTEXT

This report provides an overview of the work of Infection Prevention and Control Group (IPCG). The overall purpose of the group is to monitor progress against the Trust’s IPC strategy; reviewing and monitoring the infection prevention and control arrangements and to meet and deliver the requirements of the Health and Social Care Act 2008 (Hygiene code DH 2015). The group works alongside the Clinical Effectiveness Group (CEG), Patient Experience Group (PEG), Health & Safety Group (H&S), and the Patient Safety and Harm Group (PSHG) and plays a key role in the Trust’s governance structure, having operational responsibility for reporting into the Quality and Governance Committee (Q&G) on matters pertaining to infection prevention and control. In addition, the Trust is legally required to produce and circulate publicly an Infection Prevention and Control annual report that identifies what has been achieved over the last year and what is proposed for the year ahead.

EXECUTIVE SUMMARY

The Infection Prevention and Control Group (IPCG) has delivered on its key duties and responsibilities as outlined in the terms of reference. All scheduled meetings have taken place and have been chaired appropriately by the DIPC or Director of Nursing and Quality (Deputy Chair). Each CBU has provided an exception report (see appendix 2); reporting on compliance with Saving Lives high impact interventions, hand hygiene, infection prevention and control mandatory training and overall compliance with the Hygiene Code. Actions associated with healthcare-associated infections and blood culture contaminants have also been fed back through this report. The IPCG has reviewed these submissions against local surveillance and national requirements.

Pack page 58

of 2

1. Orthopaedic Surgical Site Infection Group

The IPCG has continued to support the SSI group in addressing the infection rate in orthopaedics. The group continues to meet monthly and there is an on-going action plan in place.

2. Water Strategy Group The terms of reference for this group was reviewed and updated. Water safety plan was updated and roles and responsibilities re-defined.

3. PIR Group The group meets monthly to review RCAs relating to healthcare-associated infection. Actions are monitored through the IPCG

4. Antimicrobial Stewardship Group The IPCG continues to support the AMS Group in challenging the over use and incorrect use of antibiotics.

All issues for escalation from IPCG have been reported to the Quality and Governance Committee through the IPCG exception report. The Group has also received and reviewed regular reports on progress against: Pest control Water safety Domestic exception and quarterly report Monthly Clostridium difficile toxin; MRSA, MSSA and E.coli bacteraemia and hospital acquired MRSA figures Surgical site infection surveillance feedback; orthopaedic, large bowel, breast and caesarean section. Intensive care ventilator associated pneumonia records Blood culture contamination data RCA lessons learnt IPC programme update Audit results CBU exception reports Influenza Antibiotic reviews Policies Annual report/programme of work Ad hoc reports continue to be received and reviewed to ensure Trust-wide compliance and, where necessary, delivery of actions to address any gaps in compliance with recommendations derived from the findings of the report. The IPCG has received new and revised policies procedures and guidelines relevant to the work of the Group and has ensured that they are fully reviewed and endorsed prior to approval. RECOMMENDATION

The IPCG has fulfilled its role in monitoring progress against the Trust Infection Prevention and Control Strategy and provides the Board of assurances of controls to meet the Hygiene Code.

Pack page 59

Infection Prevention and Control Annual Report 2019/2020

And Objectives for 2020/2021

The Infection Prevention & Control Team 2019/2020

Dr J Rao Consultant Microbiologist/DIPCDr Y Pang Consultant MicrobiologistChristine Fisher Assistant Director of Infection Prevention and Control Melissa Jeffs Specialist NurseDiane Allender Specialist Nurse (Covers Community IP&C) Sharon Johnson Clinical Nurse SpecialistCaroline Challand Clinical Nurse SpecialistJennifer Grice Clinical Nurse Specialist Jos Vines Clinical Nurse Specialist (Covers Community IP&C)Aimee Turner Assistant PractitionerSimon Watson Data AnalystLouise Pooley Personal AssistantAndrew Cotton Bailey Clerical Officer (from January 2020)Nicole Clarke Administrative Apprentice / Clerical Officer (until Dec. 2019)Megan Ray Administrative Apprentice (from January 2020)

Pack page 60

2

Contents 1.0 Executive Summary ................................................................................................................... 4 2.0 Introduction ................................................................................................................................ 6 3.0 Infection Prevention and Control Arrangements ........................................................................ 6

3.1 Reporting Arrangements ........................................................................................................... 6 4.0 Saving Lives: A delivery programme to reduce Healthcare Associated Infection ...................... 7

Table 1: Saving Lives – Trust-wide compliance results ............................................................ 7 5.0 Policies and Procedures ............................................................................................................ 7 6.0 Visits, reports and projects ........................................................................................................ 8

6.1 The Clean your hands campaign – thirteenth year .................................................................... 8

6.2 Aseptic non touch technique (ANTT) ........................................................................................ 8

6.3 Clinical practice sharing ............................................................................................................ 9 Table 2: Areas visited for clinical practice sharing .................................................................... 9

6.4 Infection Control Software system ............................................................................................. 9 7.0 Antimicrobial stewardship ........................................................................................................ 10 8.0 Audits ...................................................................................................................................... 11 9.0 Surveillance ............................................................................................................................. 11

9.1 MRSA ...................................................................................................................................... 11 Chart 1: Number of District figures for new cases MRSA infection/colonisation by location ... 11 Chart 2: Number of new cases of MRSA infection/colonisation: District figures ..................... 12 Table 3: MRSA bacteraemia rate 100,000 bed days .............................................................. 12 Chart 3: Total number of MRSA bacteraemia (District figures) ............................................... 12 Chart 4: Trust MRSA Bacteraemia compared with regional data. ........................................... 13

9.2 Meticilin Sensitive Staphylococcus aureus (MSSA) Bacteraemia ........................................... 13 Table 4: Total MSSA bacteraemia surveillance ...................................................................... 13 Chart 5: Trust MSSA bacteraemia compared with regional data. ........................................... 14 Table 5: MSSA bacteraemia RCA findings. ............................................................................ 14

9.3 Clostridiodes difficile ............................................................................................................... 14 Table 6: Clostridioides difficile National Surveillance Figures (all age groups) ....................... 15 Chart 6: BHNFT Clostridioides difficile Performance 2019/2020 cumulative .......................... 15 Chart 7: Trust Clostridioides difficile cases compared with regional data ............................... 16

9.4 Glycopeptide Resistant Enterococci (GRE) ............................................................................ 16 Table 7: Total numbers of GRE cases by year ....................................................................... 16

9.5 Surveillance of Escherichia coli Bacteraemia .......................................................................... 16

9.6 Gram-negative blood steam infections: ................................................................................... 17 Table 8: Total numbers Escherichia coli bacteraemia by month ............................................. 17 Chart 8: Trust E.coli bacteraemia compared with regional data .............................................. 18

9.7 Surveillance of blood culture contaminants: ............................................................................ 18 Chart 9: Total blood culture contaminants by month ............................................................... 18

9.8 Surveillance of Carbapenemase – Producing Enterobacteriacae: .......................................... 19 Table 9: Total numbers of Carbapenemase Producing Enterobacteriacae............................. 19

10.0 Surgical Site Infections ............................................................................................................ 19

10.1Orthopaedic surgical site infection surveillance: ..................................................................... 19 Chart 10: Hip replacement trend analysis (inpatient/re-admission) ......................................... 19 Chart 11: Knee replacement trend analysis (inpatient/re-admission) ...................................... 20

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Chart 12: Repair neck of femur trend analysis (inpatient/re-admission) ................................. 20

10.2 Large bowel surgery surveillance .......................................................................................... 20 Chart 13: Large bowel surgery surveillance ............................................................................ 21

10.3 Caesarean section surveillance ............................................................................................. 21 Table 10: The number of caesarean section operations and infections 2011 to 2019. ........... 21 Chart 14: Demonstrates number of caesarean section wound infections ............................... 22

10.4 Alert organism and alert conditions surveillance .................................................................... 22 Chart 15: Total number of alert organisms .............................................................................. 22

11.0 Clusters/Outbreaks .................................................................................................................. 23 Table 11: Clusters and outbreak during 1 April 2019 to 31 March 2020 ................................. 23

12.0 Complaints ............................................................................................................................... 23 13.0 Serious incidents ..................................................................................................................... 23 14.0 Patient assessment ................................................................................................................. 23 15.0 IPC response to COVID-19 ..................................................................................................... 24 17.0 Health promotion (patient and public involvement/special projects) ........................................ 25 18.0 Capital schemes/estates/equipment ........................................................................................ 26 19.0 Decontamination ...................................................................................................................... 26 20.0 External Reviews ..................................................................................................................... 26 21.0 Summary ................................................................................................................................. 27 22.0 Annual effectiveness report for the infection prevention and control group. ............................ 28 23.0 Appendix 1 – Committee structure lines of communication and accountability as of March 2019

................................................................................................................................................ 30 24.0 Appendix 2 – Infection Control Assurance Framework ............................................................ 31 25.0 Appendix 3 – Surgical site infection surveillance ..................................................................... 34 26.0 Appendix 4 – Performance indicators ...................................................................................... 36 27.0 Appendix 5 – Training data ...................................................................................................... 38 28.0 Appendix 6 – 2020/2021 Infection Control programme/action plan ......................................... 39 29.0 Appendix 7 – Abbreviations ..................................................................................................... 49

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1.0 Executive Summary The Infection Prevention and Control (IP&C) Annual Report provides a summary of all the IP&C activities across the hospital for the year of 2019/20. The Health and Social Care Act of 2008 and associated Hygiene Code (updated 2015) require all NHS Boards to receive and acknowledge such annual reports prior to public release. The Infection Prevention and Control Team (IPCT) continue to undertake surveillance of surgical wound infections as part of the Public Health England surveillance scheme (orthopaedic and large bowel) and local surveillance (caesarean section). The Trust remains above the national average for orthopaedic surgery in relation to knee replacement but are below the national average for hips and repair neck of femur. Considerable work has been undertaken and is continuing to address the infection rates. Surgical site infection in patients undergoing large bowel surgery has dropped for a further consecutive year, the Trust is below the national benchmark in this speciality. The Trust continues to support the Saving Lives program. An awareness week has been held promoting infection prevention and control, hand hygiene awareness and antibiotic awareness. The annual PLACE inspection and bi-weekly PLACE light inspections indicate that the hospital continues to provide a clean and safe environment to deliver care. The IPCT continue to work closely with Barnsley Facilities Services (BFS) in relation to cleanliness, the environment and capital schemes. The Water Strategy Group continues to manage the prevention of Legionella and Pseudomonas aeruginosa control. The Decontamination Services department continues to monitor and maintain standards taking into account national and legal requirements and undergoes six monthly audits by the external auditor to maintain registration and compliance with the Medical Device Directive 93/42/EEC, ISO 9001:2008 and ISO 13485:2003. The Trust achieved its target of 0 MRSA bacteraemia; this is a continued improvement on the Trust achieving the MRSA bacteraemia target. The Trust failed to achieve its reduction objective for second consecutive year. An external review was undertaken into the practices and processes in the prevention of C. difficile. The report was favourable and recommendations were incorporated into the C. difficile reduction action plan. The IPC clinical nurse specialists have continued conducting ward based practical observations of clinical practice. Working alongside ward staff has facilitated closer working between the IPCT and ward staff and allowed direct observation and sharing of good clinical practice. The IPCT has worked closely with the CBU’s to ensure compliance with mandatory training. Final compliance with training was disappointing and affected to some degree by the challenges failed with COVID-19. The IPCT and CBUs however are committed to improving compliance to training and will review the training process. The IPCT continue to review in-patients with ‘alert organisms’ and ‘alert conditions’ 6,646 patient episodes concerning alert organisms have been alerted to clinical staff and verbal advice given. 2,105 individual bedside assessments have been undertaken. Cases of norovirus and influenza were promptly identified and managed effectively which supported minimal disruption to services and patient flow. There were zero ward closures due to infection and all clusters were quickly resolved.

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The Director of Infection Prevention and Control (DIPC) meets regularly with the Director of Nursing and Quality and is chair of the Trust’s Infection Prevention and Control Group (IPCG). The DIPC attends the Quality and Governance Committee and the Trust Board when required. The Assistant DIPC is a member of the patient Safety and Harm Group and attends in Senior Nurses Forum and Health and Safety Group. Jackie Murphy Director of Nursing Dr Jyothi Rao Director of Infection Prevention and Control Christine Fisher Assistant Director of Infection Prevention and Control

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2.0 Introduction The incidence and management of healthcare associated infections continue to be monitored nationally via the Care Quality Commission, with standards based on The Health and Social Care Act - Code of Practice on the prevention and control of healthcare associated infections and related guidance 2008. The Trust recognises the obligation placed upon it by the Health and Social Care Act (2008) to comply with the code of practice for health and adult social care on the prevention and control of infections and related guidance and has declared compliance with these standards The Trust supports the principle that infections should be prevented wherever possible, or where this is not possible, minimised to an irreducible level and that effective, systematic arrangements for the surveillance, prevention and control of infection are provided within the Trust. The infection prevention and control annual report 2019 -2020, quarterly updates to the Quality and Governance Committee, the infection prevention and control annual plan and assurance framework are the means by which the Trust Board assures itself that the prevention and control of infection risk is being managed effectively and that the Trust remains registered with the CQC without condition. The annual report seeks to assure the Trust Board that progress has been made against the annual plan and demonstrates that the priorities identified in the annual plan have been addressed.

3.0 Infection Prevention and Control Arrangements

The infection control service is provided by an IPCT. The Consultant Microbiologists continue to support South West Yorkshire Partnership Foundation Trust (SWYPFT) Community Services Unit & the CCG as the Infection Control Doctor (ICD). A contract to provide an IPC service to the BCCG and BMBC is also in place.

1. Consultant Microbiologist/DIPC/ICD 37.5 hours weekly2. Consultant Microbiologist 37.5 hours weekly3. Assistant DIPC 37.5 hours weekly4. Specialist Infection Control Nurses 75 hours weekly5. Clinical Nurse Specialists 82.5 hours weekly6. Data Analyst 37.5 hours weekly7. Assistant Practitioner 22.5 hours weekly8. Personal Assistant 22.5 hours weekly9. Clerical Officer 37.5 hours weekly10. Apprentice (administration) 37.5 hours weekly

3.1 Reporting Arrangements

The Trust Infection Prevention and Control Group (IPCG) meet bi monthly. The Matron and Clinical Director have been nominated as infection control leads within

each CBU. The CBU’s are required to report and provide evidence of compliance with the Hygiene Code which is reported via exception to the IP&C Group.

The infection control reduction objectives are reported monthly as part of the Trust’s Quality Account.

The Trust has a Water Safety Group which meets twice a year and reports to both IPCG and Health & Safety Group.

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Cases of MRSA bacteraemia and C.difficile are internally scrutinised via RCA’s and multidisciplinary meetings with the clinical team. These are then externally scrutinised via a review group with SWYPFT, Barnsley Clinical Commissioning Group (BCCG) and by Public Health.

Lines of accountability for infection prevention & control with the 2019/20 year are shown in Appendix 1.

4.0 Saving Lives: A delivery programme to reduce Healthcare Associated Infection

Implementing the Code of Practice for Prevention and Control of Healthcare Associated Infections is a legal requirement for acute hospitals and other care providers. The Code of Practice states that “effective prevention and control of HCAI has to be embedded into everyday practice and applied consistently to everyone”. Saving Lives: reducing infection, delivering clean and safe care provides the tools and resources for Trusts to achieve this. Results of these audits are fed in to the Governance structure via the Infection Prevention and Control Group and back to the ward staff, matrons and clinical leads, with exception reporting to the Trust Board via the Quality and Governance Committee. Table 1: Saving Lives – Trust-wide compliance results

Apr - Jun 19

Jul - Sept 19

Oct - Dec 19

Jan - Mar 20

Insertion 100% 98% 100% 100%

Ongoing 95% 97% 100% 100%

Insertion 99% 98% 96% 100%

Ongoing 92% 97% 98% 100%

Pre-operative No Obs No Obs No Obs No Obs

Intra-operative 100% 100% 100% 100%

100% 100% 100% 100%

Insertion 100% 100% 99% 100%

Ongoing 98% 92% 100% 100%

100% 90% 60% 70%

30% 40% 40% 40%High impact interventions to prevent infection in chronic wounds

Saving Lives - Compliance Results

High impact interventions to prevent catheter associated urinary tract infection

High impact interventions to prevent ventilator associated pneumonia

Enteral Feeding

Intervention

High impact interventions to prevent infection associated with central venous access devicesHigh impact interventions to prevent infection associated with peripheral vascular access devices

High impact interventions to prevent surgical site infection

5.0 Policies and Procedures

The team update the IP&C policies and procedures; these can be found on the Trust policy warehouse. The following policies and procedures have been introduced, reviewed and updated: New and updated policies, procedures and guidelines Decontamination policy Diarrhoea policy

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Safe handling and disposal of sharps policy Blood Borne Virus policy Guidelines for Care of Patients with Infectious Disease Meningococcal policy Assistance dogs and pets as therapy protocol Standard Infection Control Precautions Group A Streptococcus policy CJD policy Panton Valentine Leukocidon policy GRE policy Therapeutic kitchen procedure Blood and bodily fluid spillages procedure Principles of care with patients with multi-drug resistant organisms Clostridioides difficile policy

6.0 Visits, reports and projects

6.1 The Clean your hands campaign – thirteenth year Hand hygiene compliance is monitored weekly by direct observation of health-care workers delivering routine care, with matrons conducting at least 10% of the observations. Results are presented at the IPCG meeting and are displayed at ward and department level. Clean Your Hands champions continue to attend yearly update training with the IPCT and deliver hand hygiene training at local level as well as monitoring practice through direct observation. A quarterly newsletter is produced to ensure adequate communication between IPC and Champions, as well as emailing or telephoning the IPC team; champions can also contact the IPC team via the ‘ask the team a question’ feature on the intranet. Added support from IPCN’s visiting wards/departments with the UV light box is also provided. Education Events are planned bi-annually for champions to ensure they have the appropriate knowledge and are kept abreast of relevant current issues. The Trust continues to promote the “bare below the elbow” standard for all staff entering clinical environments which is facilitated by Clean Your Hands champions and through staff training. The Trust’s volunteer team have assisted with an audit undertaken with patients; questioning patients whether staff were seen to wash their hands, if staff were bare below the elbow and whether patients felt they could wash their hands when they wanted to. The results were encouraging and there are plans to repeat the audit if the situation allows. The importance of embedding efficient and effective hand hygiene into all elements of care delivery must be kept prominent within health care and will remain a priority for the Trust.

6.2 Aseptic non touch technique (ANTT)

Inefficient standards of aseptic technique are a significant cause of healthcare - associated infections (HAI). HAI is not considered an unpredictable ‘complication’, but rather a

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potentially preventable ‘adverse event’. The Health and Social Care Act 2008 requires healthcare providers to have a standardised aseptic technique. Aseptic Non Touch Technique (ANTT) training was developed using resources from the Association of Safe Aseptic Practice, and is delivered annually for all relevant clinical staff. This training is being delivered jointly by the IPCT and the Clinical Skills Educator to Clinical Skills Trainers. Compliance is assessed using questioning and direct observation of practice. Trainers deliver the training to other clinical members within their team.

6.3 Clinical practice sharing

The team have continued to work alongside staff on the wards observing if the principles of infection control are integrated into practice. Good practice is acknowledged and commended; any discrepancies are dealt with immediately and followed with a written report, which is sent to the lead nurse requesting a response, providing assurance that action has been taken to address identified issues. Table 2: Areas visited for clinical practice sharing

6.4 Infection Control Software system The system provides notifications of patients with positive alert organisms in order that appropriate patient care is initiated as quickly as possible thereby improving efficiency and reducing the risk of infection. The infection control patient record and documentation is completed on the system which is stored against the patient’s unit number for easy access. The system is currently been used by the IPC Teams from Barnsley Hospital NHS Foundation Trust (BHNFT) and SWYPFT. Consultant Microbiologists, Matrons and Lead Nurses at BHNFT also have access to the system. E-mail alerts advising system users of patients who have a positive result for MRSA or C.difficile toxin within their ward areas can be actioned, documented and monitored.

Location Date Visited Nurse Acorn Rehabilitation Unit 26/06/2019 & 06/09/2019 Sharon Johnson Elderly Care 19 08/08/2019 & 11/02/2020 Sharon Johnson Elderly Care 20/ASU 04/09/2019 Sharon Johnson GIW 03/04/2019 Sharon Johnson ITU 05/09/2019 & 25/11/19 Caroline ChallandWard 18 12/06/2019 & 11/09/2019 Sharon Johnson Ward 21 13/08/2019 & 23/10/19 Sharon Johnson Ward 22 01/05/2019 Sharon Johnson Ward 23 23/05/2019 Sharon Johnson Ward 24 24/02/2020 Jen Grice Ward 29 30/07/2019 Sharon Johnson Ward 31 01/10/2019 Sharon Johnson Ward 32 31/07/19 18/09/2019 Caroline Challand Ward 33 27/02/2020 Caroline Challand

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Further work still continues with the Data Analyst and the Software provider regarding development issues to improve the functionality of the system.

7.0 Antimicrobial stewardship Antimicrobial resistance has risen alarmingly over the last 40 years. Antibiotic prescribing and antibiotic resistance are inextricably linked. Overuse and incorrect use of antibiotics are major drivers of resistance, which are of increasing global concern. The number of new classes of antimicrobials coming to market has reduced during recent years and total antibiotic consumption has gone up considerably. The 2019/20 CQUIN included; 1. Achieving 90% of antibiotic prescriptions for lower UTI in older people meeting NICE

guidance for lower UTI (NG109) and PHE Diagnosis of UTI guidance in terms of diagnosis and treatment. Teaching material in the form of a poster was distributed amongst medical teams to clarify the requirements for the UTI CQUIN. Teaching sessions were delivered to various medical teams whenever possible in addition to face to face discussions with doctors on the wards during ward rounds etc. Data collection for the CQUIN was done by the Audit Department. All non-compliant cases were individually fed-back to the relevant medical teams. Despite this effort we were unable to meet the target.

2. Achieving 90% of antibiotic surgical prophylaxis prescriptions for elective colorectal surgery

being a single dose and prescribed in accordance to local antibiotic guidelines. Audit and feedback mechanism helped us to achieve this target.

a. Antifungals CQUIN

For 2019/20 the antifungal CQUIN was introduced as a baseline for the establishment of Antifungal Stewardship across the NHS. The indicators for the first year were to establish evidence based antifungal guidelines, identification of an antifungal stewardship team (AFS), diagnostics GAP analysis and regular audit of antifungal prescribing. It also introduced a Blueteq form for isavuconazole. In BHNFT, the antifungal guidelines for South Yorkshire and Bassetlaw were adapted. The AFS team was identified comprising of Microbiology Consultants and Antimicrobials Pharmacist. Auditing antifungal use started in quarter 4 however it was suspended due to the COVID-19 outbreak. The antimicrobial pharmacist identified patients who received antifungals using the pharmacy dispensing system (Ascribe) on a weekly basis. Patient notes were retrieved by the audit team and retrospective collection of data carried out using the audit template. Teaching about the new guidelines and the CQUIN requirements was delivered to the ITU team during a learning at lunch session. Also teaching to pharmacy staff was delivered by the antimicrobials pharmacist.

b. Ward rounds Antimicrobial ward rounds continued whenever possible and aim to review as many patients on antibiotics as possible. Overall, more prescribing of narrow spectrum antibiotics such as amoxicillin and doxycycline was noticed which may be attributed to the continued teaching on the ward rounds.

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c. Audit Ward level point prevalence antibiotic audit was carried out by the antimicrobials pharmacist after each case C. difficile and results were fed back to the team and any actions were monitored.

8.0 Audits

All audits have been fed back to clinical teams; actions have been monitored via CBU governance meetings and the Infection Prevention and Control Group. The Quality and Governance Committee have received the results via the Infection Prevention and Control Group Chair’s log.

9.0 Surveillance

The IPCT continues to give a high priority to surveillance. In addition to the mandatory national surveillance scheme a regular cycle of other surgical interventions is monitored. The IPCT also undertakes targeted and alert organism surveillance.

9.1 MRSA

Each patient with MRSA is reviewed and assessed by the IPCN’s. Patients who have previously had positive MRSA results are also reviewed. The IPCN’s advise on decolonisation regimes and supporting the patients, relatives and staff. All patients (elective and emergency) admitted to the Trust continue to be screened for MRSA. MRSA screening is monitored and non-compliance fed back to clinical teams. Since 2001 it has been mandatory for Trusts to report MRSA bacteraemia figures to the Department of Health. Results are published as MRSA bacteraemia per 100,000 occupied bed days. The Trust achieved its MRSA bacteraemia target of zero. Chart 1: Number of District figures for new cases MRSA infection/colonisation1 by location

1 Colonisation: Presence of MRSA without any signs of infection.

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Chart 2: Number of new cases of MRSA infection/colonisation: District figures

Table 3: MRSA bacteraemia rate 100,000 bed days

Chart 3: Total number of MRSA bacteraemia (District figures)

No of MRSA bacteraemia

BHNFT Community Target Rate per 100,000 bed days

(Trust Apportioned)

2007/08 12 6 6 12 4.6

2008/09 8 3 5 11 1.3

2009/10 2 1 1 8 0.7

2010/11 0 0 0 1 0.0

2011/12 1 0 1 0 0.0

2012/13 1 0 1 0 0.0

2013/14 3 0 3 0 0.0

2014/15 1 0 1 0 0.0

2015/16 1 (contaminate) 1

(contaminate)0 0 0.8

201617 1 0 1 0 0.0

2017/18 3 2 1 0 1.5

2018/19 3 0 3 0 0.0

2019/20 4 0 4 0 0.0

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Chart 4: Trust MRSA Bacteraemia compared with regional data.

9.2 Meticilin Sensitive Staphylococcus aureus (MSSA) Bacteraemia

Since January 2010 it has been a requirement to report nationally all MSSA bacteraemia. Out of 42 MSSA bacteraemia, 9 were hospital acquired (post 48 hour admission). The sources of these 9 bacteraemia are provided in table 5. Root cause analysis has been undertaken by the CBU’s.

Table 4: Total MSSA bacteraemia surveillance

Staphylococcus aureus Bacteraemia (MSSA) - Monthly

Surveillance 2019/2020

Month Total No. Hospital Community SWYPFTApril 1 0 1 0May 3 1 2 0June 5 1 4 0July 3 0 3 0August 1 0 1 0September 4 2 2 0October 1 0 1 0November 7 3 4 0December 5 1 4 0January 4 0 4 0February 3 1 2 0March 5 0 5 0

Total 42 9 33 0

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Chart 5: Trust MSSA bacteraemia compared with regional data.

Table 5: MSSA bacteraemia RCA findings.

Case Source 1 Unknown2 SSTI 3 Cannula Site infection4 PICC line infection 5 Urinary 6 Cannula Site infection7 SSI 8 ?UTI ? Pressure sore9 Cellulitis

9.3 Clostridiodes difficile

Since 2004 the reporting of C. difficile infection has been mandatory. All NHS Trusts are required to test diarrhoeal stool samples from patients over 65 years; reporting all positive results to Public Health England. Since 2007 this has been changed to report all positive C. difficile cases >2 years of age. Data is expressed as the rate per 100,000 bed days. The end of year 2019/20 position was 22 positive cases against a trajectory of 19 therefore reduction objectives were exceeded. All in-patients testing positive for C. difficile antigen and toxin and are symptomatic, have a regular review undertaken by the IPCT. Blood

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results, dietary and fluid intake, stool type and medications are reviewed and relevant actions taken to improve the clinical care of the patient.

Table 6: Clostridioides difficile National Surveillance Figures (all age groups) Chart 6: BHNFT Clostridioides difficile Performance 2019/2020 cumulative

Number of Cases (Trust

Apportioned)Rate per 100,000 bed days (Trust

Apportioned cases) 2007/08 148 96.9 2008/09 105 67.5 2009/10 52 33.5 2010/11 49 33.2 2011/12 28 17.6 2012/13 22 14.6 2013/14 20 13.5 2014/15 13 9.7 2015/16 13 10.3 2016/17 11 8.8 2017/18 13 9.9 2018/19 15 11.4 2019/20 22 N/A

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Chart 7: Trust Clostridioides difficile cases compared with regional data

RCA and multidisciplinary case review has been undertaken for all cases of C. difficile toxin by the IPCT or Matron and an exception report is produced, if 2 or more cases are identified in a particular ward within 28 days. An antibiotic audit is undertaken by the antimicrobial pharmacist; environmental audits and observations of practice are also undertaken following each case. Actions are taken based on the results of the RCA, exception reports and case review.

9.4 Glycopeptide Resistant Enterococci (GRE)

The IPCT also monitor the number of cases of GRE. There were 10 cases of GRE colonisation/infection identified in 2019/2020. Table 7: Total numbers of GRE cases by year

Year BHNFT Community MVH TOTAL2009/10 0 0 0 02010/11 0 0 0 02011/12 3 0 0 32012/13 0 0 0 02013/14 2 0 0 22014/15 2 0 0 22015/16 6 0 0 62016/17 2 0 0 22017/18 31 1 0 322018/19 7 0 0 72019/20 10 0 0 10

9.5 Surveillance of Escherichia coli Bacteraemia

Since April 2011, it has become mandatory to report all cases of E.coli bacteraemia into the national database. 26 hospital acquired E.coli bacteraemia were identified during surveillance period April 2019 to March 2020 (Table 8 Chart 7).

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9.6 Gram-negative blood steam infections: The infection control team has worked alongside colleagues from SWYPFT and BCCG to an agreed improvement plan. Further work is to be arranged through the South Yorkshire and Bassetlaw ICS. Enhanced root cause analysis of E.coli blood stream infections has been undertaken and the results and recommendations produced in a report. Initiatives regarding the promotion and prevention of urinary infections e.g. urinary catheter management within the Barnsley health community were identified. The ‘urinary catheter passport’ has been updated and further joint work is planned and the multi-disciplinary even, which included colleagues from SWYPFT and BCCG was held. As a result of root cause analysis undertaken at BHNFT, antibiotic prophylaxis guidance has been produced in relation to urinary catheter manipulations, ERCP and TURP.

Table 8: Total numbers Escherichia coli bacteraemia by month

E Coli Bacteraemia - Monthly Surveillance 2019/20.

Month Total No. Hospital Community SWYPFT ESBL April 12 2 10 0 1 May 18 4 13 1 4 June 19 2 17 0 3 July 11 5 6 0 2 August 17 4 13 0 5 September 9 1 8 0 1 October 13 2 11 0 1 November 20 3 17 0 3 December 15 1 14 0 3 January 11 0 11 0 3 February 7 1 6 0 2

March 15 1 14 0 1

Total 167 26 140 1 29

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Chart 8: Trust E.coli bacteraemia compared with regional data

9.7 Surveillance of blood culture contaminants: The monthly surveillance of blood culture contaminants continues. Where possible, the health professional who has taken the culture is identified and the results of the contaminant discussed. Additional training on ANTT and taking blood cultures is offered where required. The aim is to keep the contamination rate below 3.0%. Those areas who are consistently above 3% are requested to provide actions to the IPC group. Chart 9: Total blood culture contaminants by month

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9.8 Surveillance of Carbapenemase – Producing Enterobacteriacae: Carbapenemases are enzymes which destroy the carbapenem group of antibiotics conferring resistance to this group of antibiotics. Enterobacteriaceae (coliforms) carrying these enzymes which are usually resistant to other groups of antibiotics making the infection difficult to treat. These organisms can cause outbreaks in institutional settings with a number of clusters and outbreaks being reported nationally and internationally. Trust guidance incorporates recommendations made by DH for the early detection, management and control of CPE. Table 9: Total numbers of Carbapenemase Producing Enterobacteriacae

Period No of positive casesApril 2013 to March 2014 2 (not BHNFT acquired)April 2014 to March 2015 0April 2015 to March 2016 0April 2016 to March 2017 1 (not BHNFT acquired)April 2017 to March 2018 1 (not BHNFT acquired)April 2018 to March 2019 0April 2019 to March 2020 0

10.0 Surgical Site Infections

10.1 Orthopaedic surgical site infection surveillance: The Trust has been participating in the mandatory orthopaedic surgical site infection surveillance since 2001. Trusts are required only to collect data on one type of orthopaedic procedure for a 3 month period; however BHNFT has elected to undertake consistent surveillance of hip, knee and hip hemi-arthroplasty. An orthopaedic surgical site infection group meets monthly and there is an on-going action plan in place.

Post discharge surveillance continues for patients undergoing hip and knee replacement and hemi arthroplasty surgery.

Chart 10: Hip replacement trend analysis (inpatient/re-admission)

The percentage of surgical site infections for the last four periods for this category is 0.3% against the national benchmark of 0.4%

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Chart 11: Knee replacement trend analysis (inpatient/re-admission)

The percentage of surgical site infections for the last four periods for this category is 1.5% against the national benchmark of 0.3%

Chart 12: Repair neck of femur trend analysis (inpatient/re-admission)

The percentage of surgical site infections for the last four periods for this category is 0.8% against the national benchmark of 0.9%.

10.2 Large bowel surgery surveillance

There were zero Surgical Site Infections identified during this period out of 18 operations. The infection rate for this period is 0.0% which is a decrease from 2.9 from the previous surveillance quarter October to December 2018. More detailed results of this surveillance are shown in appendix 3.

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Chart 13: Large bowel surgery surveillance

10.3 Caesarean section surveillance Caesarean section wound surveillance (including post discharge surveillance) was carried out during two quarterly periods between April to September 2019. This information was collected for six months as part of Getting it Right First Time (GIRFT) surveillance. Results showed an increase in surgical site infections each quarter, giving a percentage of 15% in July – September 2019. All cases were classed as superficial infections. This was an increase of 6% from the previous surveillance period. A strategy for improvement has been developed by the obstetric team. Considerations are to focus on re-admissions, to improve on wound management information for patients, consider Aquacel® for those ladies with a BMI > 30 and to consider vaginal douching. Post discharge questionnaires are also to be sent to those ladies out of the area.

Table 10: The number of caesarean section operations and infections 2011 to 2019.

Apr - Jun

2011 Apr -

Jun 2012 Apr - Jun

2013 Mar - Jun

2014 Jan -

Mar 2015 Apr -

Jun 2015 Apr - Jun

2016 Apr -

Jun 2017 Jul - Sep

2018 Apr Jun

2019 Jul - Sep

2019

No. of operations 139 140 134 172 151 167 165 167 186 206 176

No. of SSI 22 20 21 24 12 8 10 13 17 19 27

% of SSI 16% 14% 16% 14% 8% 5% 6% 8% 9% 9% 15%

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Chart 14: Demonstrates number of caesarean section wound infections

10.4 Alert organism and alert conditions surveillance Chart 15 gives the number of laboratory confirmed alert organisms identified between April 2019 to March 2020 alert organisms are those organisms that have infection prevention and control implications (excluding MRSA and C. difficile).

Chart 15: Total number of alert organisms

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11.0 Clusters/Outbreaks

Table 11: Clusters and outbreak during 1 April 2019 to 31 March 2020 Several wards were monitored following reports of diarrhoea and/or vomiting. In one instance a bay was closed to admissions for 3 days.

12.0 Complaints

The department has not received any complaints during this financial year.

13.0 Serious incidents Zero serious incidents relating to IP&C have been reported.

14.0 Patient assessment The team continue to support patients with infections, providing on-going support for healthcare providers, carers, relatives and others. The team aim to visit all patients with alert conditions or alert organisms within two working days of notification, providing individual assessments on care management and control of infection as well as providing information to patients and relatives. If the patient is unable to communicate, the team leave a compliment slip advising of the visit and availability to relatives. Additionally the team conduct C. difficile ward rounds visiting patients with C. difficile associated disease (CDAD) evaluating and monitoring their progress. The consultant microbiologists conduct significant micro-organism isolate and antibiotic stewardship ward rounds in addition to daily visits to ITU. The control of infection relies on the prompt identification and management of infectious patients. Therefore the response times of the IPCT are a vital element in the process to controlling risks associated with the transmission of human pathogens. The IPCT have set the following 2 target indicators against which they are performance managed. Indicator 1 - Percentage of verbal advice within 30 minutes on notification of alert organism and alert conditions (Target 99% of in-patients).

Date Ward No. of days

closed

No. of patients affected

No. of staff

affected

Days monitored

Symptoms Organism

03.04.19 19 0 2 0 2 D+V None identified

18.04.19 23 X1 bay 3

days 2 0 5 D+V Norovirus

12.06.19 Ward 19 0 3 0 7 Diarrhoea None identified

13.06.19 Ward 23 0 1 0 D+V Campylobacter

24.09.19 Ward 20 0 3 0 3 D+V None identified

28.11.19 Ward 21 0 76

contacts 1

All at risk patients

given treatment

Skin irritation

Scabies

19.12.19 Ward 17 0 4 0 7 Flu like illness

Influenza A

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Indicator 1- 6649 in-patient episodes of alert organism have been notified by the IPCT to clinical staff and verbal advice has been given. In 99 % of cases this was achieved within 30 minutes. Indicator 2 – Percentage of visits to the area within 2 working days. (Target 98% of in-patients) Indicator 2- 2010 initial visits have been conducted, 99.6% of which were completed within 2 working days. The full report can be seen in appendix 4.

15.0 IPC response to COVID-19

15.1 Operational The team worked with the Emergency Department to devise a process of patient swabbing that was safe for our staff and patients, ensuring that practice was in line with IPC and PHE guidelines whilst maintaining ED pathways and protecting front line services. The team collaborated with the CBU’s to develop standard operating procedures including patient swabbing, staff screening, patient admission pathways and the safe discharge of patients and continue to work with the CBU’s to improve these processes an d update as guidance changes. Ensuring the availability of PPE and the safety of staff has been paramount. The team have worked alongside procurement to source alternative personal protective equipment and reviewed donated PPE to ensure the products are fit for purpose. The IPCN’s have also liaised with outside agencies to provide assistance with the mask fit testing programme. The team have liaised with the communications team to ensure that infection prevention and control advice is available to staff and with the mortuary staff regarding care of the deceased patient. Work with BFS was undertaken to source portable hand wash basins and place on the entrance/exit to several wards to improve hand hygiene following the removal of PPE. Additionally the team supported the rapid turnaround of a new intensive care unit to accommodate an increase in ICU beds maintaining compliance with infection prevention and control policies. A COVID-19 data base was established and maintained daily.

15.2 Clinical The IPCN’s and microbiologists have acted on all positive in-patient results, giving advice and support to staff on how to safety manage patient care and provided infection prevention and control advice to patients as required. A daily ward round by the IPCN and consultant microbiologist was undertaken on all wards with patients positive for COVID-19. Care homes and GP’s have been supported with advice and outbreak management in line with the current contract with BCCG and BMBC.

15.3 Training

The IPCN’s have provided training on the correct use of personal protective equipment to clinical and non-clinical staff and provided training on the correct process of donning and doffing PPE, working with the communications team to ensure on-line resources regarding training were available.

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The IPCN’s have also undertook mask fit testing of staff and increased the ‘train the trainer’ programme in relation to mask fit testing. Although we experienced some difficulty with the variety of masks being sent to the Trust in March we utilised innovation and support from partners to be able to deliver a fit test programme that ensured staff were safe.

16.0 Educational initiative

The on-going education of all staff remains a high priority for the team however; problems releasing staff continue to be experienced. The team have explored different methods of providing training and have developed a bespoke programme of training in several areas. It is vital that all staff have the necessary knowledge, understanding and skills in order to improve the overall safety and quality of patient care. Trust wide infection prevention and control induction has been updated, as have clinical and non-clinical mandatory training. Educational food hygiene training has been added to clinical and non-clinical updates.

The team participate in the induction programmes for new medical staff and medical students and have achieved 100% compliance with the provision of this service. The microbiologists continue to undertake targeted education of medical staff. The team participate in the mandatory training & induction programmes for all other staff and have achieved 100% compliance with provision of this service. Site specific mandatory training has also been delivered to assist in wards and departments reaching their respective training targets. An enhanced programme for FFP3 mask fit testing was instigated and has been successful for improving compliance rates amongst relevant staff.

ANTT training continues Bug of the month FFP3 mask fit testing The team have continued to train the clean your hands champions who in turn monitor and

check the hand washing technique at clinical level. The team participate in the IV additives training days Training delivered to the Intensive

Clinical Experience (ICE) students. Student training, including; dental student, physician associate students, ISS Hostess service IPC training Training on MRSA and CDT on the registered nurses preceptorship programme Environment co-ordinators study event Infection Prevention and Control Week Antibiotic awareness week Hand hygiene week PPE training COVID-19 training

17.0 Health promotion (patient and public involvement/special projects)

The IPCT recognise the importance of working with the public to reduce healthcare associated infections and have encouraged the public to see this as a partnership.

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The team have promoted the principles of infection control to the general public by: Items in the local press. Infection Control week highlighting hydration as a means of reducing gram negative

infections. Patient Hand hygiene cards produced for inpatients highlighting when to clean hands and

how to use a hand wipe. Updated patient information leaflets. Maintenance of a public display boards with seasonal related infection prevention health

promotion advice e.g. Flu and Norovirus, preventing food poisoning, using antibiotics wisely, urinary tract infections etc.

18.0 Capital schemes/estates/equipment

The Infection Prevention & Control Team’s advice must be sought by the Trust for all service development activity including capital/building schemes, work in the women’s and children’s block, replacement of the air handling units in theatres, replacement programme in the decontamination services department, development of outpatient pharmacy, equipment procurement and contracting for services, which have implications for infection control.

19.0 Decontamination

Following withdrawal of the Trusts external auditor for BFS Decontamination Services, the service was successfully transferred to BSI as the new notified body and are fully compliant. A new Sterrad NX100 was purchased by BFS Decontamination Services and is fully commissioned and validated. The Trust’s environmental and device cleaning products were successfully changed to Tristel. This change ensures a high level cleaning product is used as a minimum and does not have the potential safety issues associated with chlorine based products. A proactive programme of decontamination with Ultra V was implemented in clinical areas. Evaluation of the programme identified that due to demand, the proactive programme was not as successful as anticipated. Further work is required to explore the purchase of further machines.

20.0 External Reviews

The pathology department has retained UKAS accreditation. Decontamination Services has retained all the required standards and has successfully added the endoscopy decontamination unit to ISO 13485 2003 and is compliant with the medical devices directive 93/42/EEC. An external verification of the department’s data has confirmed the accuracy of local statistics. An independent review of practices and processes in the prevention of CDI was commissioned in September 2019 following an increase in CDI cases attributed to the Trust. The reviewer noted good practice and identified actions which may be of benefit. These were incorporated into the Trust’s CDI reduction action plan and in the most have been achieved. Recommendations such as electronic prescribing whilst not achieved during this financial year are on the Trusts programme of improvements.

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21.0 Summary The Infection Prevention and Control Team along with IP&C group members worked hard to deliver on 2019-20 IP&C programme. There is a robust governance structure in place. We are particularly proud of zero MRSA bacteraemia for the second year. A reduction in E.coli bacteraemia has been achieved alongside a reduction in hip and fracture neck of femur surgical site infections. We regret that we have not managed to meet the C.difficile target however each case has gone through a robust RCA. An external review was undertaken and the findings were favourable, with recommendations incorporated into the C.difficile reduction action plan. There was sustained compliance with hand hygiene and Saving Lives Audit. We also saw very few outbreaks this year again with minimal disruption. We had milder Flu season, however Covid 19 kept the team very busy in the later part of the year. Preparations for Covid 19 began at the end of January however as this was new disease and guidance were changing rapidly we had a challenging time .

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22.0 Annual effectiveness report for the infection prevention and control group.

Statement

Str

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Theme 1 – Group Focus I am clear about the objectives the group has set itself f o r e a c h y e a r .

3 4

I understand how the group wants to operate in terms of the level of information it would like to receive for each of the items on its annual work plan.

5 2

I have a full understanding of the Terms of Reference of the group.

4 3

Theme 2 – Group Team Working The group membership has the right balance of experience, knowledge and skills to fulfil the role described in its Terms of Reference.

5 2

The group has structured its agenda to ensure all elements of the annual work plan are covered.

5 2

The work-plan is revisited at the end of every meeting to ensure it is accurate and up to date.

4 3

I am clear with regards to the agenda items I am expected and required to contribute to.

5 2

I am clear with regards to the requirements for my attendance at the group.

5 2

Non-attendance by members is addressed by the Chair of the group.

3 3 1

It is clear to me why I am a member of this group and what information I am required to provide to the group.

5 2

I feel sufficiently comfortable within the group environment to be able to express my views, doubts and opinions.

5 2

Members are held to account for late or missing information.

3 2 2

When a decision has been made or action agreed I feel confident that it will be implemented as agreed and in line with the timescale set down.

3 4

Theme 3 – Group Effectiveness

The quality of group papers received allows me to perform my role effectively.

4 3

Members provide real and genuine discussion and challenge which is of benefit to the effectiveness of the group.

4 3

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Statement

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Comments/ actions

Debate is allowed to flow and conclusions reached without being cut short or stifled due to time constraints etc.

5 2

Each agenda item is 'closed off' appropriately so that I am clear what the conclusion is; who is doing what, when and how etc. and how it is being monitored.

4 3

At the end of each meeting we discuss the outcomes and reflect back on decisions made and what worked well, not so well etc.

2 5

The group provides a written summary report of its meetings to the Quality & Governance Committee.

4 3

There is a formal appraisal of the group's effectiveness each year which is evidence based and takes into account my views and external views.

4 3

The group actively challenges information providers during the year to gain a clear understanding of progress and achievement.

4 3

Theme 4 – Group Leadership The group Chair has a positive impact on the performance of the group.

6 1

Group meetings are chaired effectively and with clarity of purpose and outcome.

6 1

The group Chair allows debate to flow freely and does not assert his/her views too strongly.

5 2

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23.0 Appendix 1 – Committee structure lines of communication and accountability as of March 2019

Health Protection Board & CCG Health Board

BHNFT Board of Directors

Quality and Governance Committee

CCG & Public Health England

Infection Prevention & Control Group

Post Infection Review Group

Antibiotic Stewardship

Group

SSI Group Water Safety Group

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24.0 Appendix 2 – Infection Control Assurance Framework

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Pack page 91

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25.0 Appendix 3 – Surgical site infection surveillance

Hip Replacement Surveillance 2019 and previous periods.

BHNFT All Hospitals

Last Period Last 4 periods

Last 5 Years October – December 2018 January - December 2019

Risk Index No.

Operations No.

SSI’s %

InfectedNo.

OperationsNo.

SSI’s %

InfectedNo.

Operations No.

SSI’s %

Infected

0 56 0 0.0% 204 1 0.5% 250348 659 0.3% 1 20 0 0.0% 79 0 0.0% 72539 455 0.6% 2 5 0 0.0% 17 0 0.0% 10437 151 1.4% 3 0 0 0.0% 0 0 0.0% 79 0 0.0%

Unknown 0 0 0.0% 0 0 0.0% 9012 31 0.3% Total 81 0 0.0% 300 1 0.3% 342415 1296 0.4%

Knee Replacement Surveillance

2019 and previous periods

BHNFT All Hospitals



Risk Index No.

Operations No.

SSI’s %

InfectedNo.

OperationsNo.

SSI’s %

InfectedNo.

Operations No.

SSI’s %

Infected

0 71 2 2.8% 312 5 1.6% 281489 634 0.2% 1 19 1 5.3% 78 1 1.3% 75475 438 0.6% 2 6 0 0.0% 7 0 0.0% 6987 104 1.5% 3 0 0 0.0% 0 0 0.0% 53 0 0.0%

Unknown 0 0 0.0% 0 0 0.0% 9275 36 0.4% Total 96 3 3.1% 397 6 1.5% 373279 1212 0.3%

Repair of neck of femur Surveillance


BHNFT All Hospitals



Risk Index No.

Operations No.

SSI’s %

InfectedNo.

OperationsNo.

SSI’s %

InfectedNo.

Operations No.

SSI’s %

Infected

0 24 1 4.2% 64 1 1.6% 17449 95 0.5% 1 49 1 2.0% 179 1 0.6% 57162 534 0.9% 2 2 0 0.0% 9 0 0.0% 12478 202 1.6% 3 0 0 0.0% 0 0 0.0% 4 0 0.0%

Unknown 0 0 0.0% 3 0 0.0% 4463 37 0.8% Total 75 2 2.7% 255 2 0.8% 91556 868 0.9%

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Large Bowel Surgery


BHNFT All Hospitals

Last Period

Last 4 periods Last 5 Years October – December 2019

Risk Index No.

Operations No.

SSI’s %

InfectedNo.

OperationsNo.

SSI’s %

InfectedNo.

Operations No.

SSI’s %

Infected

0 4 0 0.0% 23 0 0.0% 4161 232 5.6% 1 9 0 0.0% 66 2 3.0% 7914 634 8.0% 2 5 0 0.0% 20 1 5.0% 3698 429 11.6% 3 0 0 0.0% 0 0 0.0% 469 84 17.9%

Unknown 0 0 0.0% 5 0 0.0% 942 62 6.6% Total 18 0 0.0% 114 3 2.6% 17184 1441 8.4%

Risk Index Definition A Risk Index comprising data obtained from three factors – ASA score, wound classification and duration of operation – is used to assign a risk score between 0 and 3 to each operation. Operations with a risk index score of 3 have a higher risk of developing SSI than those with a score of 0. This score is used to stratify operations and enable rates of SSI to be adjusted by these risk factors.

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26.0 Appendix 4 – Performance indicators

PERFORMANCE INDICATOR 1 – achieved 99% Percentage of verbal advice given within 30 minutes on notification of alert organism and alert conditions (Target 99% of in-patients). Breakdown of Total No. of referrals seen by Infection Control at BHNFT (Please note the table relates to original referral criteria not necessarily confirmed cases). 2019-20 2018-19

Month Number of

Assessments Total Within 30

Minutes Total Exceeding

30 MinutesPercentage Compliant

April 416 414 2 100%May 406 401 5 99%June 368 363 5 98.6%July 400 399 1 99.8%

August 376 372 4 98.9%September 450 444 6 98.7%

October 448 448 0 100.0%November 584 571 13 97.8%December 1062 1051 11 99.0%January 814 799 15 98.2%February 510 503 7 98.6%

March 812 805 7 99.1%

Total 6646 6570 76 99%

Month Number of


Minutes Total Exceeding

30 MinutesPercentage Compliant

April 235 233 2 99%May 284 275 9 97%June 279 278 1 99.6%July 332 327 5 98.5%

August 284 278 6 97.9%September 324 320 4 98.8%

October 315 309 6 98.1%November 306 305 1 99.7%December 361 356 5 98.6%January 801 796 5 99.4%February 529 525 4 99.2%

March 509 500 9 98.2%

Total 4559 4502 57 99%

The tables above show there was an increase of 2087, in the number of assessments undertaken from 2018-19 to 2019-20. PERFORMANCE INDICATOR 2 – achieved 100% Total number of referrals seen/not seen within 2 working days of notification by the Infection Prevention & Control.

2019-20 2018-19

Month Number of


Hours Total Exceeding

48 HoursPercentage Compliant

April 173 172 1 99%May 152 151 1 99%June 157 156 1 99%July 149 149 0 100%

August 173 173 0 100%September 201 199 2 99%

October 184 184 0 100%November 178 177 1 99%December 231 229 2 99%January 185 185 0 100%February 165 165 0 100%

March 157 157 0 100%

Total 2105 2097 8 99.6%

Month Number of


Hours Total Exceeding

48 HoursPercentage Compliant

April 139 139 0 100%May 150 150 0 100%June 143 142 1 99%July 150 150 0 100%

August 135 135 0 100%September 141 140 1 99%

October 163 163 0 100%November 154 154 0 100%December 186 186 0 100%January 260 260 0 100%February 197 196 1 99%

March 192 190 2 99%

Total 2010 2005 5 100%

The tables above show there was an increase of 95, in the number of assessments undertaken from 2018-19 to 2019-20.

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PERFORMANCE INDICATOR 2 Type of Organism Related to referral.

2019-20 2018-19

The tables above show there was an increase of 95, in the number of organisms related to referral.

2019-20 2018-19

The tables above shows an increase of 106 in the number of patients monitored with diarrhoea and an increase of 4 in the number of consultant lead diarrhoea ward rounds.

Infection: BHNFT April 19 – March 20

MRSA 1079Clostridioides difficile Toxin

212

Other 814

Total 2105

Infection: BHNFT April 18 – March 19

MRSA 1080Clostridioides difficile Toxin

179

Other 751

Total 2010

Additional Activity

April 19 – March 20

Number of patients monitored with diarrhoea (this does not reflect the number of actual follow up reviews)

343

Number of consultant lead diarrhoea ward round

41

Additional Activity

April 18 – March 19

Number of patients monitored with diarrhoea (this does not reflect the number of actual follow up reviews)

237

Number of consultant lead diarrhoea ward round

37

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27.0 Appendix 5 – Training data

Course title Number of

sessions

Number of

attendees

Infection control patient contact update

93 952

Infection control patient contact (clinical induction)

12 324

Infection control non patient contact

29 210

Hand hygiene (training by champions)

96 271

Hand hygiene: train the trainers

17 58

Mask fit testing

100 640

Mask fit testing‐ train the trainer

5 17

Mask fit checking 13 82

ANTT

12 28

Student Induction

3 37

Totals 382 2619

*Not in addition to the above training some staff will have undertaken mandatory training online

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28.0 Appendix 6 – 2020/2021 Infection Control programme/action plan

BARNSLEY HOSPITAL NHS FOUNDATION TRUST

2020/2021 YEARLY INFECTION CONTROL PROGRAMME/ACTION PLAN These are in addition to core infection control activities

OBJECTIVE ACTION LEAD TARGET

DATE

QUARTERLY UPDATE FOR

INFECTION CONTROL GROUP

1. Policies and Procedures to be updated or produced1.1 Policies and infection control

procedures/guidelines will be reviewed. Review and update policies as

required. Upload onto SharePoint. Raise awareness of contents. Produce policy on the care and

management of patients with COVID-19

IPCT March 2021 July 2021

2. Audit of Policies and Procedures 2.1

Procedure: Hand Washing Hand Washing Observational Audit All wards/clinical areas

Conduct weekly audits Feedback results Establish action plan to address non

compliance Liaise with Trust volunteers to

undertake patient experiences of hand hygiene.

Matrons/ IPCT/Heads of Dept.

March 2021 Quarterly update at IPCG

2.2

Policy: Decontamination, National cleaning standards

Audit the clinical environment and equipment

All equipment and environment will be thoroughly decontaminated and cleanliness maintained to the highest level in all clinical areas according to infection prevention and control policies and procedures

Organise and arrange audits Conduct audits as part of an

exception report. Collate results and feed back to CBUs.

Monitor cleanliness and conduct PLACE light inspections

Participate in the annual PLACE inspection.

Undertake ‘Perfect Ward’ Inspections.

IPCT/ Matrons/ BFS

March 2021 Quarterly update at IPCG

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DATE



2.3 Policy: MRSA and MRSA Screening

Audit compliance with MRSA decolonisation and screening

Conduct audit and feedback results Ensure MRSA patients are managed

in line with the policy Promote awareness of correct

procedure CBU to integrate actions into practise

as required in action plan CBU to report to IPCG progress via

exception report CBUs to identify quality improvement

initiatives.

IPCT CBU’s

September 2020

2.4 Policy: Antibiotic Antibiotic stewardship/ Audit compliance with the policy

Conduct daily ward rounds on ITU Review antibiotic use on patients with

C.difficile Restrict the use of certain antibiotics

as directed by the consultant microbiologist

Monitor antibiotic CQUIN, prophylaxis in bowel surgery and total reduction of antibiotics.

Chair the antimicrobial stewardship group; disseminating information/actions to the CBU’s as required.

Participate in relevant CQUIN’s with regard to antibiotic use. Results to CBU’s, IPCG and also to Q&G by exception.

Consultant microbiologist Antibiotic pharmacist

On-going Quarterly update at IPCG.

2.5 Policy: CPE and Candida auris Audit compliance with CPE policy

Conduct on-going audit on the care and management of patients

Provide prompt feedback to clinical area.

Datix to be completed when IPC team not informed of repatriation

Explore methods for improving screening for CPE/C auris.

IPCT March 2021 Quarterly update to IPCG

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DATE



2.6 Loose stools audit. Identify patients with type 6 and 7 stools

Undertake audit to identify whether patient managed in line with Trust policies.

Feedback audit to clinical teams monthly/quarterly

Maintain accurate stool chart. Isolate the patient according to policy.

Complete Datix if not able to isolate.


2.7 Audit into the safe use of PPE. Devise audit proforma. Disseminate to CBU’s Commence minimum weekly audit Results to be monitored by the PPE

action group. Actions agreed and monitored by the

PPE action group. Updates provided to IPCG

Corporate May 2020

2.8 Audit care of Clostridioides difficile patients including monitoring clinical care Policy: Care of Clostridioides difficile toxin positive patients

Conduct C.difficile ward rounds Collate information Feedback to clinical teams Identify and action any lapses in care IPC audit to be undertaken following

each case of CDI

IPCT/Matrons On-going Quarterly update to IPCG

2.9 Procedure: Administer Hydrex pre-operatively for patients undergoing hip and knee surgery.

Continue to advise patients on hour and when to apply Hydrex

Conduct audit and analyse results Disseminate results appropriately. Feedback results to IPCG and update

on any action

CBU 2 March 2021

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DATE



3. Education 3.1 Educate the patients and general public

providing up to date and relevant information.

Develop flyers for dissemination on preventing infections to be handed to the public

Display information around the Trust targeting the public

Review and update patient leaflets as required

Consult with staff and patients Develop new leaflets if required Develop patient information in relation

to COVID-19


3.2 Educate staff in the appropriate use of PPE, particularly in response to COVID-19.

Promote on-line video links in relation to donning and doffing.

Ensure staff have visual reminders of the correct PPE.

Ensure staff are aware of the different types of PPE and how to wear correctly.

IPCT Health & Safety Team CBU’s

On-going

3.3 Staff who are required to wear FFP3 masks to be mask fit tested.

Maintain database Manage a programme of train the

trainers Identify staff who require training. Review and evaluate training

IPCT CBU’s

On-going Quarterly update to IPG

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DATE



4. Projects 4.1

Maintain the saving lives programme

Continue to Incorporate High Impact interventions into appropriate procedures

Monitor and deliver Saving Lives programme

Present and discuss results at IPCG and Individual CBU meetings – CBU’s to identify action required and develop an action plan

Implement and monitor action plans arising from the audits

Matrons to provide exception reports for any areas not achieving targets.

IPCT/ Matrons

On-going Quarterly update to

IPCG.

4.2 Promote events Develop programme of promotional events to include hand hygiene, IPC week, antibiotic awareness week.

Plan and execute programme of activity to raise awareness

IPCT/Matron senior professional

May 2020 (hand hygiene) October 2020 (IPC week) November 2020 (Antibiotic awareness)

4.3 Ensure staff have adequate supplies of PPE.

Source alternatives to current PPE. Explore possible re-use of PPE. Liaise with communications team. Undertake risk assessments as

appropriate. Co-ordinate work streams with the

PPE action group.

BFS IPCT CBU’s

Quarterly update to IPCT from PPE group

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DATE



4.4 Review and evaluate point of care testing Evaluate success of point of care testing

Explore expansion of point of care testing

Review current guidelines and procedures; develop guidelines as appropriate.

IPCT December 2020.

5. Surveillance5.1 The routine surveillance of alert organisms,

alert conditions, antibiotic resistance patterns and monitoring of all positive isolates will continue.

Conduct surveillance daily Report all significant organisms to

clinicians. Monitor trends and increase in

incidence and take actions where appropriate

Maintain databases relating to alert organisms. (MRSA, C difficile, COVID-19, MDRO)

IPCT On-going Quarterly update to IPCG

5.2 MSSA Bacteraemia surveillance will be continued and RCA of all hospital acquired cases will be undertaken

Comply with mandatory surveillance and reporting

Conduct RCA and Implement shared learning and identify any lapses in care.

Feedback to clinical teams with a MDT meeting when appropriate

Monitor trends and take action where necessary.

Report via CBU exception report to IPCG.

IPCT On-going Quarterly update at IPCG.

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DATE



5.3

MRSA bacteraemia surveillance will continue with root cause analysis of all cases.

Comply with mandatory reporting arrangements.

Collate data collection Use RCA surveillance form to

robustly review cases ensuring compliance with reporting timescales and engagement of Consultants with the processes, escalating areas for action and lessons learnt.

Identify all MRSA’s that were avoidable

Develop comprehensive action plans Report to IP&CG PSQG + CCG Review all RCA and monitor trends

across the organisation To be reviewed and presented at the

PIR group

IPCT/ Matrons Matrons DIPC Matrons / Consultants DIPC

On-going Quarterly update at IPCG.

5.4 Surveillance of multi drug resistant organisms. E.g. CPE and GRE.

Comply with mandatory reporting arrangements.

Monitor the trend and investigate unusual trends

IPCT On-going Quarterly update at IPCG.

5.5 Targeted surveillance of hips knees and neck of femur repair, including post discharge surveillance

Conduct surveillance in line with national requirements.

Conduct a RCA of each infection with clinical teams

Hold regular SSI meetings Review action plan and report to

IPCG

IPCT/ CBU 2

July to September 2020 October-December 2020 December – March 2021

5.6

Conduct 3 months surveillance of Caesarean section infections including post discharge surveillance

Conduct surveillance and evaluate proforma

Discuss and organise post discharge surveillance with midwives

Feed back to clinical teams

IPCT /Matron October 2020

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DATE



5.7 Conduct 3 months surveillance of Large Bowel surgery infections, including post discharge surveillance

Conduct surveillance in line with national requirements. Feedback to clinical teams

IPCT February 2021

5.8 Continue surveillance of E.coli /Gram negative bacteraemia and undertake RCA

Comply with mandatory surveillance and reporting

Conduct RCA where indicated Implement shared learning and identify any lapses in care.

Feedback to clinical teams with a MDT meeting when appropriate

Monitor trends and increases in

incidence and take action where necessary.

Report via CBU exception report to IPCG

Work with colleagues in BCCG and SWYPT to reduce Gram negative bacteraemia

Work within the ICS to identify and action any work streams.

CBU/IPCT On-going Quarterly update IPCG.

5.9 The prevention and monitoring strategy for Clostridioides difficile will continue

Comply with mandatory reporting arrangements

Monitor trends feeding back to clinical staff and local Governance structure

Continue to monitor patients with diarrhoea reviewing blood results etc.

A root cause analysis will be completed on all C. difficile cases, including actions during a period of increased incidence or same ribotype.

RCA’s to be discussed at multidisciplinary post infection review group.

IPCT On-going update to IPCG

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DATE



6. Environment

6.1 Participate in new development and capital schemes

Review plans as required Participate in programme Agree equipment finishes etc. Agree process for providing onsite

laundry facilities. Review proposed ITU location and

reconfiguration in response to COVID-19.

IPCT/BFS March 2021

7. Decontamination7.1 Monitor compliance with the legionella policy

and Pseudomonas guidance

Monitor progress at the Water Strategy Group meeting.

Agree where ‘discretionary’ samples are to be taken from.

Continue to hold action meetings where readings are found to be above agreed levels. Consider updating policy should any new national guidance be issued.

IPCT/BFS Quarterly update to IPCG.

7.2 Continue monitoring programme for washer disinfectors including endoscopy dishwashers, washing machines etc.

Conduct weekly water sampling of endoscopy washers

Action results as appropriate Take regular readings of temperature

controls for internal washing machines

Apply the appropriate testing for specialist washers e.g. SSD RO Plant

BFS

On-going Quarterly update to IPCG

7.3 Produce cleaning report to provide board assurance

Continue to produce monthly reports. Assurance of cleaning given to the

Infection Prevention and Control Group

BFS


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DATE



7.4 Monitor and maintain standards within the Decontamination Services Department taking account of national and legal requirements

Monthly internal audits undertaken as part of the QA system.

Six monthly audits undertaken by the external Auditor to maintain registration and compliance with the Medical Device Directive 93/42/EEC, ISO 9001:2008 and ISO 13485:2003.

BFS


8. Performance Management 8.1 Ensure compliance with infection control

Programme and Hygiene Code at CBU level

CBU’s to compile and present their compliance to the core standards of the hygiene code via their exception reports presented to IPCG

Clinical Directors Associate Directors of Nursing and Matrons

Quarterly

MRSA Meticillin Resistant Staphylococcus aureus IPCT Infection Prevention and Control Team MSSA Meticillin Sensitive Staphylococcus aureus CD Clinical Director IPCG Infection Prevention & Control Group CBU Clinical Business Unit DIPC Director of Infection Prevention and Control PSQG Patient Safety and Quality GroupCQUIN Commissioning for Quality & Innovation HCAI Health Care Associated Infection CPE Carbapenemase-producing Enterobacteriaceae MDT Multi-Disciplinary Team CEO Chief Executive Officer ESBL Extended Spectrum Betalactamse RCA Root Cause Analysis GRE Glycopeptide Resistant EnterococciSSI Surgical Site Infection PLACE Patient Led Assessment of Care Environment BHNFT Barnsley Hospital NHS Foundation Trust PIR Post Infection Review COVID-19

Ensure updated guidance is implemented Escalate exceptions to silver/gold command Provide support and advice to the CBU’s Reduce the risk on on-going transmission within the organisation. Work with partners to provide care for patients suspected or confirmed as having COVID-19

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29.0 Appendix 7 – Abbreviations ANTT Aseptic Non-Touch TechniqueBHNFT Barnsley Hospital NHS Foundation Trust C. difficile Clostridioides difficileC.difficile Antigen Clostridioides difficile antigenCDT Clostridioides difficile toxinCCG Clinical Commissioning group CDAD Clostridioides difficile associated diarrhoea CE Chief Executive COSHH Control of Substances Hazardous to HealthCPE Carbapenemase-producing Enterobacteriacae CRE Carbapanamase resistant EnterobacteriaceaeCQC Care Quality CommissionCQUIN Commissioning for Quality and Innovation CBU Clinical Business UnitCVP Central Venous PressureDH Department of HealthDIPC Director of Infection Prevention & ControlESBL Extended Spectrum Beta LactamasesGDH Glutamase Dehydrogenase Enzyme Immunoassay HACCP Hazard Analysis and Critical Control PointHBV Hepatitis B VirusHCAI Health Care Associated InfectionICD Infection Control DoctorICN Infection Control NurseIP&C Infection Prevention & Control IPCG Infection Prevention & Control Group IPCT Infection Prevention & Control TeamITU Intensive Care UnitMDT Multi-Disciplinary TeamMRSA Meticillin Resistant Staphylococcus aureusNHSLA National Health Service Litigation Authority NNU Neonatal Unit PAS Patient Administration SystemPLACE Patient Led Assessment of the Care Environment PGD Patient Group DirectivePPE Personal Protective EquipmentPPQ Pre Purchase Questionnaire (for new equipment) RCA Root Cause AnalysisSHDU Surgical High Dependency UnitSSD Sterile Services Department SSI Surgical Site Infection SWYPFT South West Yorkshire Partnership Foundation Trust TB Tuberculosis bacilli

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EXECUTIVE SUMMARY

STRATEGIC CONTEXT

CONCLUSION/RECOMMENDATIONS

REPORT TO THE PUBLIC BOARD OF DIRECTORS

BoD: 20/06/04/14

SUBJECT: CORPORATE RISK REGISTER

DATE: June 2020

PURPOSE:


applicable


PREPARED BY: Kim Traynor, Risk Management Co-ordinator

SPONSORED BY: Margaret Saunders, Director of Corporate Governance

PRESENTED BY: Margaret Saunders, Director of Corporate Governance

The Board of Directors has delegated the quarterly review of the Corporate Risk Register (CRR) to the Audit Committee as part of the strategic approach to risk management of the Trust with the Quality and Governance (Q&G) and People, Finance and Performance (P, F& P) Committees receiving quarterly updates.

The appendix provides an overview of the current extreme risks on the CRR as at May 2020, the date the report was produced due to the demands of the pandemic. It is intended to re-adjust review timescales throughout the year to re-align to quarterly reporting. Work has been undertaken with all relevant Directors to update the CRR accordingly bringing together the strategic and high-level risks which if not addressed would compromise the ability of the Trust to achieve its corporate objectives. The appendix provides details of the extreme risks (risk rated 15-25) on the CRR.

The Board is asked to review this update of the CRR.

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Subject: CORPORATE RISK REGISTER Ref: BoD: 20/06/04/14

1. STRATEGIC CONTEXT

The Board of Directors has delegated the quarterly review of the Corporate Risk Register (CRR) to the Audit Committee as part of the strategic approach to risk management of the Trust with the Quality and Governance (Q&G) and People, Finance and Performance (P, F& P) Committees receiving quarterly updates.

2. INTRODUCTION

There have been reviews with all relevant Executive Leads to provide comprehensive updates on the risks held on the CRR.

2.1 There are 91 risks currently active on the CRR; 18 of which specifically relate the Covid-19 pandemic. Details of the Covid-19 risks are included in a separate report.

2.2 There are five risks graded as Extreme Risk (15+) and 26 graded as High Risk (8-12) out of the other 73 corporate risks. 21 of these risks are regarding counter fraud in line with a change in the counter fraud legislation (a requirement that the Trust hold all counter fraud risks on the corporate risk register).

2.3 All extreme risks (15+) are reported to the Board Committees on a quarterly basis.

2.4 The CRR has been reviewed in order to provide an update as of May 2020.

2.5 This review considered:

The need to re-score the current risks following an assessment of the controls in operation for the year to date and the operational delivery achieved as of May 2020.

The setting and monitoring of target risk scores going forward for the remainder of the financial year.

Identification of any known new risks. Identification of any strategic risks that may impact on the risk to achieving the Trust’s

objectives.

2.6 The Trust’s timeframes for reviewing risks are Extreme – monthly, high – bi-monthly, moderate – quarterly and Low – Six months. Since the last report, the following changes have been made:

Risks updated: See the table at the end of the report for progress of extreme risks. The updates for the high risks are as follows: Risk 2358 – Chief Delivery Officer Risk regarding mask fit testing April 2020 update – update from C Fisher The Trust has limited access to a quantitative fit test from South Yorkshire Fire and Rescue and we have two similar machines on order.

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Risk 2261 – Chief Delivery Officer Risk of waste water/sewage leak within the hospital All actions in the plan have been delivered. The Trust is taking all reasonable actions to avoid any further leaks. There is on-going surveillance of the issue and practices regarding waste disposal. Risk 1966 – Chief Delivery Officer Risk regarding high levels of non-elective activity The Trust continues to put in place best practice pathways and models to ensure improved management of elective patients. The Trust are working closely with partners to keep developing our approach ensuring it is in line with the Trust vision of outstanding and integrated care. This is managed via the Barnsley urgent and emergency care Board. Risk 2174 – Chief Delivery Officer Risk regarding lack of clinical lead for the cancer of unknown primary MDT Mitigation appears adequate.

Risk 2251– Chief Delivery Officer Risk regarding fire emergency bleep Phone bleep now in operation. Staff instructed to Datix any issues with receiving bleeps. Last issue was reported on the 18th March 2020. Risk 2357– Chief Delivery Officer Risk regarding duplication of handover May 2020 update – Risk approved by Director of Nursing following discussion at PSP on 30/03/20. Risk 1539 – Director of Finance Risk regarding some medical equipment not being replaced Risk reviewed score remains constant. Risk 2044 – Director of Finance Risk regarding MRI monitor Risk reviewed score remains constant Risk 1713 – Director of Finance Risk regarding 2019/20 financial plain including CIP programme Risk reviewed continues into 2020/21 Risk 1791 – Director of Finance Risk regarding insufficient cash funds to meet operational requirements Risk reviewed score remains constant Risk 1857– Director of Finance Risk regarding agency control target for 19/20 Risk reviewed continues into 2020/21 Risk 2223 – Director of Finance Risk regarding impact from Unison legal claims April 2020 update – initial court case successful on behalf of the claimant. Currently subject to challenge.

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Risk 2050 – Director of Finance Risk regarding the underlying financial deficit Risk reviewed score remains constant Risk 2222 – Director of Finance Risk regarding loans from the DHSC Risk reviewed and reduced pending conversion of loan to Public Dividend Capital (PDC). Risk 1201 – Director of Human Resources Risk regarding potential risk of non-recruitment April 2020 update – work underway led by Directors of Nursing within South Yorkshire and Bassetlaw to increase numbers of trained nurses. This includes increased placement places and overseas recruitment, plans developed subject to sign off of business case. Risk 2122 – Director of ICT Risk regarding cyber-security incident due to lack of external support April 2020 update – target risk amended following discussion Risk 2098 – Director of ICT Risk regarding risks from Lorenzo replacement, Medway April 2020 update – project postponed due to Covid-19 pandemic. Expected restart September 2020. No change in risk. Risk 1835 – Director of ICT Risk regarding performance issues with Lorenzo April 2020 update – Medway postponed; expected Go-live in September 2020. No change in risk. Risk 1865 – Director of ICT Risk regarding zero-day vulnerability April 2020 update – no change in risk. Risk 2164 – Medical Director Risk regarding adequate safety netting processes for incidental findings May 2020 - Mitigation updated. Completion of ICE filing was due May 20 this has been postponed due to the current covid situation and is due to be completed by the end of the called calendar year. Risk 2334 – Director of Nursing and Quality Risk regarding on-going recruitment to registered nurse vacancies April 2020 update – Recruiting third year students to support the nursing workforce. Changes made due to Covid-19 means there are less nursing staff shortages. All other recruitment continues. Risk 2335 – Director of Nursing and Quality Risk regarding Acute Response Team being made ward based April 2020 update – The ANPs are not being used to backfill wards. Continue to monitor. Risk 2362 – Director of Nursing and Quality Risk regarding enhanced care requirements April 2020 update – The paper with the recommendations is on hold during the current Covid-19 situation. There has been very little requirement for enhanced care during this

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4

period. Staff have been redeployed and therefore patients requiring additional supervision additional supervision can be supported. Risk 2323 – Director of Nursing and Quality Risk regarding safeguarding capacity April 2020 update – posts filled, including interim post. Risk 2195 – Director of Nursing and Quality Risk regarding the management of procedures and clinical guidelines April 2020 update – the work is on-going for TADs with no further risks. Risk 2401 – Director of Nursing and Quality Risk regarding safeguarding capacity Risk opened in April 2020. Risks added: There have been 41 risks added to the corporate risk register in the 19/20 financial year. These are allocated to the following risk registers

Apr-19

May-19

Jun-19

Jul-19

Aug-19

Sep-19

Oct-19

Nov-19

Dec-19

Jan-20

Feb-20

Mar-20 Total

Chief Delivery Officer 1 2 1 1 6 2 2 1 16Director of ICT 3 1 4Director of Finance 2 5 7Director of Human Resources 7 7Medical Director 1 1Nursing Director 1 1 3 1 6

Total 1 1 2 3 1 21 1 2 0 5 3 1 41

Risk removed/closed

Apr-19

May-19

Jun-19

Jul-19

Aug-19

Sep-19

Oct-19

Nov-19

Dec-19

Jan-20

Feb-20

Mar-20 Total

Chief Delivery Officer 1 1 1 1 3 7Director of ICT 1 1Director of Human Resources 1 3 4Medical Director 1 1Total 1 2 4 1 0 0 1 0 0 1 0 3 13

3. CONCLUSION

3.1 Each month all risks will be reviewed by the risk owners and updated as necessary. Work

will be needs to be undertaken to ensure consistency of approach and the briefing of risk owners in a timely way.

3.2 The Board is asked to note the updated version of the CRR as at May 2020.

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ID Opened

(date risk identified)

Description Mitigation Service Unit

Risk level (current)

Progress Notes

2375 09/03/2020 Covid 19 outbreak has the potential to impact on all business as usual across all domains of the organisation. This includes the operational, clinical and medical teams involved. Routine Trust activities will be reviewed in line with our Silver command approach to an outbreak incident. The Trust is following guidance from NHSI/E and DoH around specific actions. These are captured at the daily operational meeting.

Daily operational meeting Action logs to capture information Silver command in place 24/7 Executive team updated by Operational lead NHSI/ E returns collated as requested Robust on call arrangements in place Weekly update to on call staff to ensure operational teams are aware of the parameters set put by NHSE/I Gold command in place from Thursday 19 March 2020

Chief Delivery Officer

Extreme Risk (15-25)

March 2020 - The situation is escalating on a daily basis worldwide. The trust is ensuring that all staff, patients and visitors’ health and welfare are the priority as decisions are made/enacted. The Trust is working with system partners to national direction. (There is a separate risk register providing further detail ) May 2020 update: Position continues to be monitoring with recovery being implemented.

1025 10/04/2013 Risk identified of not meeting the 4 hours in ED/A&E: the details and impact are as follows: There is a risk of a sustained failure to deliver on the 4hr waiting times target.

Constant review of performance to support delivery of trajectory. The Trust has escalated its approach internally and externally with partners with regular updates on progress against agreed actions. Weekly meetings held with ED team and other key influencers of patient flow. Extra support put in ED on lates and overnight. Further support to Junior doctors working overnight to better handle peaks in activity. Delivery of ready together patient flow programme actions.



The Trust delivered over 91% for the year and have remained in the top quartile of all organisations.

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2205 10/06/2019 The Breast Imaging Service is at risk due to increased demand from symptomatic and breast screening services. There are 2 key contributing factors: one has been an increase in out of area referrals and the second is national workforce shortages. The Barnsley service runs with 1 main breast radiologist who has now given notice.

A number of actions are being taken to address this issue: -Permanent recruitment of a replacement -Recruitment of a locum consultant has been signed off. -Support to a second radiologist returning from mat leave who can cover some of the work. -Recruitment and training of further reporting radiographers. -Weekly review of forward demand and capacity to identify any staffing gaps and alert partners to gain support. -Support for a review of the regional service with the ICS -Consideration of further business cases that increase capacity in the breast service.



Currently in the department there are 2 part time Radiologists who are not screening radiologist. CBU2 and 3 are working together and meeting weekly to ensure there is sufficient capacity to meet the symptomatic demand. Pre COVID, BHNFT were negotiating an SLA agreement with TRFT to support us with 2 sessions a week. This is currently on hold due to COVID-19; however, TRFT is supporting the service virtually. It has been agreed that the assessment clinics can continuing with the Locum and TRFT will virtually support him. Routine screening has been stopped due to COVID-19.The Trust are working with the ICS on potential regional solutions for Breast Screening.

2033 17/11/2017 There is a Risk of: Loss of functionality of Pathology equipment which may lead to a delay in the production of patient pathology reports to support diagnosis and treatment with possible detrimental effect upon the patient in terms of clinical outcomes. Increased costs to support ageing equipment. Some equipment remaining outside of the existing MSC, with no support or replacement plan Increase pressure on staff Caused by: Inability to replace ageing equipment – Pause on MSC due to NHSI pathology directive Breakdown of ageing equipment. Increased downtime following breakdown - Equipment no longer being produced resulting in reduced availability of spare parts. Historically some equipment was not part of MSC (e.g. Immunology) Increased time spent on maintenance, responding to phone calls from users when testing delayed Resulting in: Inability to provide robust and timely test results which will impact on patient management and Trust targets. Additional cost of sending work to external sites for analysis where no in house back up is available Loss of reputation of the department resulting in issues recruiting and retaining staff Unable to develop service in line with new technologies. Increased sickness and difficulty retaining staff

The procurement process for the SYB ICS has commenced but the timescales don't address the immediate concerns for the BRILS service. Therefore all partners have agreed to BRILS arranging an extension on the existing contracts to mitigate risks and concerns. The Trust is awaiting a finalised delivery plan for this extension.



27/03/2020 - Reviewed by DF at request of BK. Following release of the project plan delaying the project, this was escalated with Siemens and a meeting convened on the 24th Jan 2020. Following the meeting, Siemens attended site to review the options available to deliver the equipment implementation earlier. Following a review of the options available, project plan v6.1 was accepted by the Trust which brought forward the planned Go Live at Rotherham to 10/04/20 and the Barnsley Go Live to 30/06/20, achieved by concurrent installation of Haematology analysers (Stago Star Max, Advia 2120s) and the Chemistry Analysers (Atellicas). Weekly meetings held with Siemens to monitor progress and to ensure adherence to the new project plan. w/c 23/03/2020- Notified of pause of project due to COVID-19. Awaiting call between Siemens and ADO to ascertain the impact on the current project timeline. Equipment remains unreliable.

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2344 27/01/2020 There is a risk that patients have not received follow up treatment and or monitoring which may have resulted in harm and or poor experience. 55,000 patient pathways with open referrals without further activity have been identified as part of the migration to Medway work in the last 2 years, in addition to this there are a further 70,000 that are older than 2 years that have no further activity. A series of reports and validation exercises have commenced but there is a significant risk of lost to follow up patients and the potential risk of 52 week breaches. 52 week breaches have already been found in Ophthalmology and more recently Urology. Lost to follow patients have been found in Ophthalmology, Dermatology and there are a number of potential lost to follow up's in other specialities that are currently being reviewed. The capacity of existing teams to validate this number of referrals is also a concern as this is additional workload on top of the day to day business. The Medway Steering Group have made a decision that any referrals that are still open with no further activity that they will be closed going into Medway, and a report of these patients will be kept. This presents a further risk of patient pathways not been validated in a timely manner increasing the clinical risk of any lost follow up's.

An external review has been commissioned with an approach and action plan developed from the findings. The plan is overseen by the data quality group with updates coming to ET and PFP.



April/May 2020 - ICT Data Quality Team have data quality validated 8660 records to date and have to date found no cases of any clinical harm due to the delay. We expect the entire list to be completed by End of August 2020. Any clinical validation via scheduled patient appointment in outpatient clinics. Further resource has been funded to speed up the data quality review and support ongoing RTT training needs.

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REPORT TO THE PUBLIC BOARD OF DIRECTORS

REF: BoD: 20/06/04/15

SUBJECT: BOARD ASSURANCE FRAMEWORK 2019/20 REPORT

DATE: June 2020

PURPOSE:

Tick as applicable

Tick as applicable


PREPARED BY: Margaret Saunders, Director of Corporate Governance

SPONSORED BY: Margaret Saunders, Director of Corporate Governance

PRESENTED BY: Margaret Saunders, Director of Corporate Governance

STRATEGIC CONTEXT

The Board Assurance Framework (BAF) enables the Board to monitor how the internal governance arrangements are supporting the achievement and delivery of the strategic objectives of the Trust and aids in identifying risks. Specifically, the BAF maps to the Trust’s Strategic Objectives as follows:

Strategic Objective 1 – Patients: will experience outstanding care Strategic Objective 2 – Partners: we will work with partners to deliver better, more

integrated care Strategic Objective 3 – People: will be proud to work for us Strategic Objective 4 (i) Operational & (ii) Finance – Performance: we will achieve our

goals sustainably

EXECUTIVE SUMMARY

The BAF has been reviewed and updated throughout January 2020 – to May 2020 following meetings with Executives and presentation to the Executive Team in May 2020 followed by the Audit, Quality and Governance (Q&G) and People, Finance and Performance (P, F & P) Committees. The reporting of the BAF has been slightly extended due to the demands of the pandemic and it is intended to re-adjust review timescales throughout the year to re-align to quarterly reporting. Risks added: None. Risks updated: 13 Risks removed: 6 Risks reduced: 1

RECOMMENDATIONS

The BAF has been reviewed and updated in accordance with agreed process. The Board is asked to note the updated BAF and make any proposed changes considered necessary.

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Subject: BOARD ASSURANCE FRAMEWORK 2019/20 Ref: BoD: 20/06/04/15

1. STRATEGIC CONTEXT

1.1 The BAF enables the Board of the Trust to monitor how the internal governance

arrangements are supporting the achievement and delivery of the Trust’s strategic objectives and aids in identifying risks.

1.2 The role of the BAF is to provide evidence and structure to support effective management of risk within the organisation. The BAF provides evidence to support the Annual Governance Statement.

2. INTRODUCTION

2.1 The BAF provides a level of assurance to the Trust and identifies which of the Trust’s

Strategic objectives are at risk of not being delivered. At the same time, it provides positive assurance where risks are being managed effectively and objectives are being delivered. This allows the Board to determine where to make most efficient use of their resources and address the issues identified in order to improve the quality and safety of care.

2.2 The BAF reports on strategic risks identified in the Trust’s business plan and provides

high level reporting to the Committees of the Board and the Board of the Trust to indicate where there are gaps in controls and assurances and how this impact on the risk to achieving that objective.

2.3 Each month the Corporate Risk Register (CRR) and BAF are reviewed with each lead Director to identify new risks, resolved risks and any additional gaps in control.

2.4 The BAF has been updated as at May 2020 and the following changes have been

made:

Risks added: None. Risks updated: Risk 1966 (Lead Director: Chief Delivery Officer) The Barnsley system is experiencing high levels of growth in non-elective activity this is impacting on the hospital being able to deliver consistently on access standards and challenging system finances. The CCG has previously explored the procurement of an integrated care model and is now reviewing approaches to reducing this non elective activity through a partnership approach including a financial risk share. The Trust continues to put in place best practice pathways and models to ensure improved management of no elective patients. The Trust are working closely with partners to keep developing our approach ensuring it is line with the Trust vision of outstanding and integrated care. The Trust continues to put in place best practice pathways and models to ensure improved management of no elective patients. The Trust are working closely with partners to keep developing our approach ensuring it is line with the Trust vision of outstanding and integrated care. This is managed via the Barnsley urgent and emergency care Board. (Risk rating: High 12) Risk 1868 (Lead Director: Medical Director)

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Risk identified regarding consultant provision for the Stroke Service due to vacancies. Locum Agencies are providing cover. The Service Manager is looking at a recruitment solution with the current locums in place. Consultant staffing remain under review. No issues raised as a result of the change over to the new HASU model. Unclear at this stage when review will take place, given current operational issues. (Risk rating: Moderate 6) Risk 2375 (Lead Director: Chief Delivery Officer) Risk identified Covid 19 outbreak has the potential to impact on all business as usual across all domains of the organisation. This includes the operational, clinical and medical teams involved. Routine Trust activities will be reviewed in line with our Silver command approach to an outbreak incident. The Trust is following guidance from NHSI/E and DoH around specific actions. These are captured at the daily operational meeting. (Risk rating: Extreme 20) Risk 1025 (Lead Director: Chief Delivery Officer) Risk identified there is a risk of a sustained failure to deliver on the ED waiting times target or not to achieve the 95% year end position, impacting on quality of service and organisation reputation. (Risk rating: Extreme 15). Risk 2205 (Lead Director: Chief Delivery Officer) Risk identified The Breast Imaging Service is at risk due to increased demand from symptomatic and breast screening services. There are 2 key contributing factors: one has been an increase in out of area referrals and the second is national workforce shortages. (Risk rating: Extreme 16). Risk 2344 (Lead Director: Chief Delivery Officer) Risk identified there is a risk that patients have not received follow up treatment and or monitoring which may have resulted in harm and or poor experience. 55,000 patient pathways with open referrals without further activity have been identified as part of the migration to Medway work in the last 2 years, in addition to this there are a further 70,000 that are older than 2 years that have no further activity. (Risk rating: Extreme 15). Risk 1835 (Lead Director: Director of ITC) Risk identified regarding the on-going Lorenzo performance issues impact on the following: 1. Patient Safety as it takes longer to input data into the systems that are critical for the patient flow through the organisation. 2. Organisational reputation - Increased negative media as appointments are missed. 3. Missed Activity and reduced income - Due to missed appointments and increased DNAs. (Risk rating: High 12). Risk 1865 (Lead Director: Director of ITC) Risk identified regarding zero-day (also known as zero-hour or 0-day) vulnerability; this is a disclosed computer-software vulnerability that hackers can exploit to adversely affect computer programs, data, additional computers or a network. It is known as a "zero-day" because once the flaw becomes known, the software's author has zero days in which to plan and advise any mitigation against its exploitation. (Risk rating Moderate 6). Risk 2098 (Lead Director: Director of ITC) Risk identified Lorenzo replacement Medway causes operational/financial/reputational and clinical safety risks during replacement. (Risk rating High 10).

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Risk 2122 (Lead Director: Director of ITC) Risk identified impact on operational services due to a cyber-security incident due to lack of external support for all computer systems. (Risk rating High 8). Risk 1943 (Lead Director: Director of Finance) Failure to develop recurrent CIP schemes impacting on the ability to deliver the overall Trust financial plan. (Risk rating Moderate 6). Risk 1791 (Lead Director: Director of Finance) Insufficient cash funds to meet the operational requirement of the Trust. (Risk rating Moderate 4). Risk 1713 (Lead Director: Director of Finance) Failure to deliver the financial plan including CIP programme and clinical activity in accordance with contractual agreements. Failure would adversely impact on the financial stability of the Trust, resulting in the need for further borrowing to support the continuity of services and failure to achieve PSF (cross references to Risks: 1025, 1832, 1849) (Risk rating High 8). Risk 2222 (Lead Director: Director of Finance) Trust currently has approximately £67M of loans from the DHSC, due for repayment within 2020/21. The Trust is unable to meet the repayment. (Risk rating Moderate 4). Risks reduced: Risk 2121 (Lead Director: Chief Delivery Officer) - The Local Resilience Forum (LRF) stood down Operation Yellowhammer planning and response prior to the 2019 Christmas period. The Trust will continue to adopt a ‘minimal hold position’ as expected nationally and stand down at a local level however work will continue nationally up to 31 December 2020. Further information will be provided in due course regarding the agreements made by the Department of Health and Social Care (DHSC) and central government. The Trust will continue with a Single Point of Contact (SPOC) and email address which will be used for any future questions/queries. Anny work nationally will continue to be aligned to the 7 work streams agreed within the published operational guidance with any individual work stream escalation information circulated via normal channels i.e. Procurement, Human Resources (HR), Medicine Management etc. Trusts are requested to retain any intelligence and organisational memory from previous arrangements. (Risk rating: High 12) Risk rating revised accordingly in that due to the run up to the final transition date in December 2020 all areas of the operational framework are to be dynamically risk assessed and managed. Medium term impacts are considered low. (Risk rating: Moderate 6) Risks removed: Following the Trust Risk Management Strategy review process the following risks have been removed as the mitigating actions to minimise the identified risk/s to the respective Strategic Objective/s are now complete.

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Strategic Objective

1 2130

Risk identified regarding the inability to recruit paediatric nurses into the vacancies on Ward 37

Strategic Objective

1

1931

Risk identified regarding ophthalmology staffing. Final confirmation of medical staff that would TUPE across from Rotherham FT has left Trust with number of vacancies.

Strategic Objective

1 2185

Risk identified regarding paediatric services – specifically regarding governance, leadership and relationships within the team and service. Risk de-escalated following December 2019 Q & G Committee

Strategic Objective

4

2210

Impact of HMRC changes for taxation structure concerning those with high incomes. Resultant impact is that certain groups who cross higher tax thresholds have a detrimental impact on their personal income. This issue to the Trust is a risk to the delivery of clinical services if senior medical and nursing staff were to be forced to reduce their commitments clinically. There is also a risk that the individual financial stability of a group of individuals could be adversely affected.

Strategic Objective

3 1200

Risk identified regarding the partnership working with staff;the details and impact are as follows: Lack of engagement with the workforce will lead to a failure to deliver cultural and behavioural change to support the 5 year plan.

Strategic Objective

4 1844

The Lord Carter Report 15 recommendations to improve efficiency failure to do this will result in efficiency opportunities being missed.

3. CONCLUSION The BAF has been reviewed and updated in accordance with agreed process. The Board is asked to note the updated BAF and make any proposed changes considered necessary.

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Barnsley Hospital NHS Foundation Trust

Board Assurance Framework 2019/20

Keys to Risk Rating

Scored Likelihood x Consequence

Consequence

Likelihood Negligible (1) Minor (2) Moderate (3) Major (4) Catastrophic (5)

Almost Certain (5)

Likely (4)

Possible (3)

Unlikely (2)

Rare (1)

Key to Assurance Rating

H Risk controls in place are rated as providing high assurance

M Risk controls in place are rated as providing medium assurance

L Risk controls in place are rated as providing low assurance

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Strategic Objective 1

Patients: will experience outstanding care

Director Lead

Medical Director & Director Nursing & Quality

Board

Committee Quality & Governance

Impact of failing to achieve the strategic objective

Patients may have a poor experience of care and may be at risk of avoidable harm

CRR Ref

Description of Risk

Director Lead

Alignment to

Committee

Nov 19

Dec 2019

May 2020

1868

Risk identified regarding consultant provision for the Stroke Service due to vacancies. March 2020 update consultant staffing remains under review. No issues raised as a result of the change over to the new HASU model. Unclear at this stage when review will take place given current operational issues.

Medical Director

Q&G 3x2

3x2

3x2

2167

Risk relating to compliance with NICE guideline 31 – Nutrition Support in Adults. Review identified gap at BHNFT and requirement for Nutrition Nurse. Business Case in development. Risk identified by CBU3 but applicable across Trust.

Director of Nursing and

Quality Q&G 3x2

3x2

3x2

Risk controls in place Assurance rating

2167

A business case is being developed in CBU3 with the assistance and input of the Deputy Associate Director of Nursing for surgery for a band 7 1.0 whole time equivalent (WTE) nutrition Nurse. If approved then this post would fulfil the requirements of this specialist role across the Trust and meet NICE guidance 32 for this parameter. In the interim the dietetic team are leading on ward staff training for MUST screening and are available Monday-Friday for tube troubleshooting. The gastroenterology team are also supporting ED and inpatient areas with nutritional issues and tubes. The business case has been approved at Nutrition Group and is awaiting CBU sign off, prior to ET. April 2020 Reviewing job description as B& recruitment was unsuccessful.

M M M

Gaps in Risk Control CRR Ref

Description of Gap Action to Address Gap in Risk Control Date

1868 Continuing difficulty providing locum cover. Service Manager working with the Clinical Lead to look at the service moving forward. March 2020 - Consultant staffing remain under review.

On-going

Source of Assurance

CRR Ref

Description of Assurance Date Received Positive or

Negative

Internal or

External

1868 Regular review at ET May 2018 Positive Internal

Narrative to support exception reporting

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Partners: we will work with partners to deliver better, more

integrated care

Director

Lead

Chief Delivery Officer & the Medical Director

Board

Committee

People, Finance & Performance


BHNFT will be unable to provide sustainable health and care services for the local population due to ineffective partnership working.

CRR Ref

Description of Risk

Director Lead

Alignment to

Committee

Nov 19

Dec 2019

May 2020

1966

The Barnsley system is experiencing high levels of growth in non-elective activity this is impacting on the hospital being able to deliver consistently on access standards and challenging system finances. The CCG has previously explored the procurement of an integrated care model and is now reviewing approaches to reducing this non elective activity through a partnership approach including a financial risk share.


P, F & P 3x3

3x3

3x3

2121

The risks to the Trust and BFS of a possible 'no deal' Brexit scenario and monitoring the Government's ongoing preparations should the UK leave the EU without any deal in March 2019. Based on a paper from the Secretary of State for H&SC dated 23rd August 2018 and a number of technical papers from Her Majesty's Government there are a number of issues highlighted that are possibly relevant to the Trust and BFS:

Continuity of supply (medicines, equipment, consumables)

Although unlikely - continuity of utility services (power/gas interconnectors)

Workforce planning - EU citizens - doctors/nurses exempt from cap - however it may impact on other staff categories.

Workplace rights - agency staff, WTD, TUPE, Equality Act

Financial services (banking & insurance)

Business VAT Student funding (EU and Erasmus+) Quality, safety of human tissue,

blood, blood products and organs R&D: Regulatory information and

trials on medicines and medical devices.


P, F & P 3x4

3x4

3x2

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4

2375

Covid 19 outbreak has the potential to impact on all business as usual across all domains of the organisation. This includes the operational, clinical and medical teams involved. Routine Trust activities will be reviewed in line with our Silver command approach to an outbreak incident. The Trust is following guidance from NHSE/I and DoH around specific actions. These are captured at the daily operational meeting.


P, F & P 3x5

3x5

5x4

1693

Risk identified surrounding adverse publicity to the Trust. Possible adverse publicity and reputational damage through different routes of exposure to the Trust. Impacting on patient choice and potential financial income and regulatory action.

Director of Communications

P, F & P 3x2

3x2

3x2

Risk controls in place

CRR Ref

Description of Risk Control August 2019

Dec 2019

May 2020

1966

The Trust continues to put in place best practice pathways and models to ensure improved management of non-elective patients. The Trust are working closely with partners to keep developing our approach ensuring it is line with the Trust vision of outstanding and integrated care.

M M

M

2121

The Local Resilience Forum (LRF) stood down Operation Yellowhammer planning and response prior to the 2019 Christmas period. The Trust will continue to adopt a ‘minimal hold position’ as expected nationally and stand down at a local level however work will continue nationally up to 31 December 2020. Further information will be provided in due course regarding the agreements made by the Department of Health and Social Care (DHSC) and central government. The Trust will continue with a Single Point of Contact (SPOC) and email address which will be used for any future questions/queries. Anny work nationally will continue to be aligned to the 7 work streams agreed within the published operational guidance with any individual work stream escalation information circulated via normal channels i.e. Procurement, Human Resources (HR), and Medicine Management etc. Trusts are requested to retain any intelligence and organisational memory from previous arrangements.

M M

M

2375

Executive team updated by Operational lead NHSE/I returns collated as requested Robust on call arrangements in place Weekly update to on call staff to ensure operational teams are aware of the parameters set put by NHSE/I

M M

M

1693

Comprehensive Communications Planner to track and plan for positive and potential adverse publicity. Monthly Communications Planner presented to the Executive Team

H H

H



Source of Assurance

CRR Ref


Negative

Internal or

External

1966 Report to the Executive Team meeting and Trust Board on a monthly basis Dec 2018 Positive Internal

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5

2121

Briefing paper to September 2019 Board. Brexit Contingency Planning arrangements in place and reviewed. Continued Board Updates as contingency planning develops.

May 2019 Positive Internal

2375 Gold/silver governance, monthly updates provided to March committees and Board

March 2020 Positive Internal

1693 Monthly Communications Planner presented to the Executive Team January 2019 Positive Internal


People: will be proud to work for us

Director

Lead Director of Workforce

Board

Committee


CRR Ref

Description of Risk

Director Lead

Alignment to

Committee

Nov 19

Dec 19

May 20

1201

Risk of non-recruitment to vacancies and development of staff in post; Inability to recruit to vacancies within the Trust and non-development of staff may lead to insufficient staffing/skill mix.

Director of Workforce

P, F&P 3x3 3x3

3x3

1199

Risk identified regarding workforce costs; the details and impact are as follows: Controlling staffing costs to meet the 3 year strategy and meet business objectives. These include sickness absence, agency spends and staff pay bill.

Director of Workforce P, F &P 3x2 3x2

3x2


CRR Ref

Description of Risk Control Nov 19

Dec 2019 May 2020

1201

Executive vacancy/agency control panel May 2020 Update: Update to mitigation, explaining mitigation in place and staffin post data to reduce risk score. Implemented new retention initiative 'staydiscussions' introduced in June 19 to improve retention.

M M

M

1199

Executive vacancy/agency control panel Development of Sickness absence reduction plan Reporting of Workforce Dashboard within Performance Framework. Update June 2019: The Trust is part of the South Yorkshire and Bassetlaw collaborative aiming to reduce bank and agency expenditure for Nursing and Medical staff. Significant reductions in expenditure realised. August 2019 Update: The Trust has implemented NHS Professionals. May 2020 update - the Trust continues to utilise the services of NHS Professionals to in order to control and mitigate temporary workforce costs.

M M

M



Source of Assurance

CRR Ref


Negative

Internal or

External

1201 Nurse Staffing Report December 2018 Positive Internal

1199 CBU Insight report May 2018 Positive Internal

1199 Workforce Report December 2018 Positive Internal


People may choose to work at other local provider Organisations.

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6

Strategic Objective 4 i) Operational

Performance: We will achieve our goals sustainably

Director

Lead

Director of Finance & Chief Delivery Officer

Board

Committee


Impact of failing to achieve the strategic objective i) Operational

BHNFT will be unable to deliver all access standards.

CRR Ref

Description of Risk

Director Lead

Alignment to

Committee

Nov 19

Dec 19

May 2020

1025

There is a risk of a sustained failure to deliver on the ED waiting times target or not to achieve the 95% year end position, impacting on quality of service and organisation reputation

Chief Delivery Officer P, F &P 4x3 4x3

5x3

2205

The Breast Imaging Service is at risk due to increased demand from symptomatic and breast screening services. There are 2 key contributing factors: one has been an increase in out of area referrals and the second is national workforce shortages.


4x4

2344

There is a risk that patients have not received follow up treatment and or monitoring which may have resulted in harm and or poor experience. 55,000 patient pathways with open referrals without further activity have been identified as part of the migration to Medway work in the last 2 years.


5x3

1835

Risk identified regarding the on-going Lorenzo performance issues impact on the following: 1. Patient Safety as it takes longer to input data into the systems that are critical for the patient flow through the organisation. 2. Organisational reputation - Increased negative media as appointments are missed. 3. Missed Activity and reduced income - Due to missed appointments and increased DNAs.

Director ICT

P, F & P 3x4 3x4

3x4

1865

Risk identified regarding zero-day (also known as zero-hour or 0-day) vulnerability; this is a disclosed computer-software vulnerability that hackers can exploit to adversely affect computer programs, data, additional computers or a network. It is known as a "zero-day" because once the flaw becomes known, the software's author has zero days in which to plan and advise any mitigation against its exploitation.

Director ICT

P, F & P 3x3 3x3

3x2

2098 Lorenzo replacement Medway causes operational/financial/reputational and clinical safety risks during replacement.

Director ICT

P, F & P 2x5 2x5

2x5

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7

2122 Impact on operational services due to a cyber-security incident due to lack of external support for all computer systems.

Director ICT P, F & P 2x4 2x4

2x4

Risk controls in place Assurance rating CRR Ref

Description of Risk Control Oct 19

Nov 19 May 20

1025

The target was successfully achieved in September and October despite a national deterioration in performance. In November 2019 the target was missed due a significant rise in attendees, early onset of flu and consequent impact on driving activity up. Investment continues in ED staffing, extra beds have been secured as part of escalation and onsite management arrangements have been reinforced. An update presentation was given at December 2019 F&P Committee. The Trust continues to perform in the top quartile of trusts nationally and continues to be monitored in 20/21.

M M M

2205

A number of actions are being taken to address this issue: -Permanent recruitment of a replacement -Recruitment of a locum consultant has been signed off. -Support to a second radiologist returning from mat leave who can cover some of the work. -Recruitment and training of further reporting radiographers. -Weekly review of forward demand and capacity to identify any staffing gaps and alert partners to gain support. -Support for a review of the regional service with the ICS -Consideration of further business cases that increase capacity in the breast service.

M M M

2344

An external review has been commissioned to review the position and an action plan has been developed to address targeted areas of concern. Regular updates have come to ET and an update presented to P, F & P in March 2020. Work being overseen by the Data Quality Group.

M M M

1835

To support all on-going integration projects and this key piece of functionality going forwards an integration expert has been employed. Continuing issues with performance will only be mitigated on full replacement of system, planned for July 2020.

M M M

1865

Ensure subscription to international standard antivirus software. Ensure subscription and follow-up of any CARECERT warnings and notifications. Ensure system patching of any security patches for operating systems. Patching plan in place. 360 Assurance audit to be completed June 2020.

Compliant position for data protection toolkit achieved 31 March 2020 this will be submitted to NHSI/D in September 2020.

M M M

2098

Full governance/project initiation document process with clinical leadership to ensure effective delivery and engagement. May 2020 Update Medway Steering Group re-established and successful Medway training launch. Continuing clinical engagement and communication strategy in place. Microsoft Teams has helped transform the way we communicate whilst people are working away from the hospital site and we’ll be leveraging this to help facilitate our training. The NHS Digital TSSM is still fully engaged at Key Project Gateways to provide full external assurance regarding the position of the project. A fully documented report has been provided with green-amber rating. Highest achievable assurance at this point in the project.

M M M

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8

2122

Currently all clinical and business critical systems have external support. Minor non-critical systems are supported internally. A regular review and assessment is carried out to ensure that business critical computer solutions are supported externally and a risk assessment completed on minor unsupported solutions. May 2020: Full annual cybersecurity assessment by National cybersecurity Centre accredited supplier commissioned for during June 2020. Awaiting the full report to build an appropriate action plan. COVID-19 Risk Assessment completed no further risks identified.

M M M



1025 Insufficient beds and staffing to meet the requirements of peak activity. Issues in social care (staffing) that is leading to a reduced offer of support impacting on the ability to discharge patients efficiently

Performance Review meetings Weekly ED Delivery Board meeting Patient Flow Improvement Plan

Mar 2020

2205 National shortage of Breast Radiologists, pressures on all Breast screening services.

Working with the ICS to develop regional solutions

Mar 2020

2344 Issues relating to Lorenzo and inconsistency in data input. Medway will improve this issue Mar 2020

1835 On-going Lorenzo performance issues. Lorenzo replacement system (Medway) planned for July 2020.

New Medway EPR contract – Go Live Aug 2020

July 2020

1865 Cyber Security Ransomeware Cyber Security Ransomeware plan Jan 2020

Source of Assurance

CRR Ref


Negative

Internal or

External

1025

Performance Review meetings December 2018 Positive Internal

1025 Weekly ED and flow meeting including oversight of the Patient Flow Improvement Plan

January 2019 Positive Internal

2344 Issues relating to Lorenzo and inconsistency in data input update report presented to ET and P, F & P in May 2020, see Chair’s Log ICT Report.


1835 1865 ICT report to People, Finance and Performance Committee May 2020 Positive Internal

1835 Barnsley Hospital Digital Roadmap Board May 2020 Positive External

1865 Assurance Audit completed by Carecert supplier for intrusion detection Sept 2018 Positive External

1865 Cyberscore solution penetration testing with positive results May 2018 Positive Internal

1865 CareCert Cybersecurity Audit. Action Plan from cyber essentials accredited audit of cyber safeguards now in place. Expected to be completed by 31 March 2019.

August 2018 Positive External

2098 Medway - TSSM External Assurance Report March 2020 Positive External

2122 COVID-19 Risk Assessment of all Cybersecurity and IT Risks April 2020 Positive External

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9


ii) Finance

Performance: We will achieve our goals sustainably

Director

Lead

Director of Finance & Chief Delivery Officer

Board

Committee


Impact of failing to achieve the strategic objective ii) Finance

BHNFT will fail to achieve the financial plan which has been set.

CRR Ref

Description of Risk

Director Lead

Alignment to

Committee

Nov 19 Dec 19

May 2020

1943 Failure to develop recurrent CIP schemes impacting on the ability to deliver the overall Trust financial plan.

Director of Finance

P, F & P 3x2 3x2

3x2

1791 Insufficient cash funds to meet the operational requirement of the Trust.

Director of Finance

P, F & P 2x4 2x4

1x4

1713

Failure to deliver the financial plan including CIP programme and clinical activity in accordance with contractual agreements. Failure would adversely impact on the financial stability of the Trust, resulting in the need for further borrowing to support the continuity of services and failure to achieve PSF (cross references to Risks: 1025, 1832, 1849)

Director of Finance P, F & P 4x3 2x4

2x4

2222

Trust currently has approximately £67M of loans from the DHSC, due for repayment within 2020/21. The Trust is unable to meet the repayment.

Director of Finance P, F & P 2x4 2x4

1x4


CRR Ref

Description of Risk Control Nov 19

Dec 2019

May 2020

1943

Cost improvement steering group monitoring the delivery of the plan supported by the Project Management Office. There are a number of schemes identified. On-going review of CBU and Corporate opportunities, including working collaboratively across the system.

M M

M

1791 Micro manage cash flow. Recovery of financial position - delivery of key actions. Work closely with CCG and the Distressed Funding Team at NHS Improvement and Department of Health.

L L

H

1713

A range of control measures in place, including:

• Urgent identification of additional CIP / reduction in expenditure run-rate • Continued work on opportunities arising from coding audits (non-counting and coding) • Successful implementation of NHSP with subsequent agency reduction; especially to be managed during winter with no escalation to high cost agencies. • Continued negotiation with Barnsley CCG.

H H

H

2222

On-going discussion with NHSI and DHSC re deferral of payments to a future date. This is a recognised risk across the system and there are on-going discussions nationally. The loans should be converted to Public Dividend Capital (PDC) in 20/21.

M M

M

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1943 Risk of number of non-recurrent CIP schemes.

Challenge to all Trust Clinical Business Units (CBUs) & departments via the monthly CIP steering group and performance meetings. Continued work on workforce productivity to release recurrent savings. Continued work within the ICS framework to realise long term savings and sustainable models of care for South Yorkshire.

May 20

1713 Lack of Trust control over financial performance of external partners Monthly monitoring May 20

Source of Assurance

CRR Ref


Negative

Internal or

External

1943

Integrated Performance Report /Finance Report May 20 Positive Internal

1943 CIP report May 20 Positive Internal

1713 Monitoring Progress Reports e.g. ICS performance papers at People, Finance and Performance Committee Meetings


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EXECUTIVE SUMMARY

RECOMMENDATIONS

STRATEGIC CONTEXT


REF: BoD: 20/06/04/19

SUBJECT: CHIEF EXECUTIVE’S REPORT

DATE: JUNE 2020

PURPOSE:

Tick as applicable

Tick as applicable

For decision/approval

Assurance

For review Governance For information Strategy

PREPARED BY: Emma Parkes, Director of Marketing & Communications

SPONSORED BY: Dr Richard Jenkins, Chief Executive

PRESENTED BY: Dr Richard Jenkins, Chief Executive

To report particular events, meetings publications and decisions that the Chief Executive would like to bring to the Board’s attention.

This report is intended to give a brief outline of some of the key activities undertaken as Chief Executive since the last meeting and highlight a number of items of interest. The items are not reported in any order of priority.

The Board of Directors is asked to receive and note this report.

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Subject: CHIEF EXECUTIVE’S REPORT Ref: BoD: 20/06/04/19

1. BARNSLEY HOSPITAL 1.1 CORONAVIRUS (COVID-19) UPDATE

Barnsley Hospital continues to work in alignment with national, regional and local preparations to support staff and patients during the Covid-19 global pandemic. A two tier command and communication structure remains in place to manage all activity relation to Covid-19 and the development of comprehensive plans to safely increase activity at Barnsley Hospital. With the transition to Phase 2 of the pandemic, the management approach is slowly transitioning from a daily ‘command and control’ approach to a hybrid approach with the reintroduction of a wider range of management activities.

1.1.1 Covid-19 Stabilisation, the next phase and embedding innovation

The Trust is working towards increasing activity and safe operating in a period of stabilisation during COVID-19. This includes:

Safety and social distance practises in the workplace Social distancing measures for patients and visitors within the hospital site Utilising new technologies for patients and colleagues, according to their needs Safely increasing patient and visitor numbers at an individual service level.

Activity levels from COVID-19 peaked in mid April and have been declining very slowly since however the numbers of cases remains in the high twenties at the time of writing and the hospital pathways separating COVID-19 and non-COVID-19 patients will continue at present. This will be kept under review as we hope to see case numbers fall over coming weeks and months. Non-COVID-19 activity has been much lower than usual with Emergency Department attendances initially falling by 50% but now with a recovery so currently running about 30% lower than expected. Out-patient activity is about half normal with the majority done non-face-to-face using telephone and video alternatives. Urgent and emergency surgery has continued but other surgery has largely ceased due to a national lack of sterile surgical gowns although this is now easing and we hope to make progress on recovery of surgical activity soon. As a result of all these factors, we have seen a reduction in the size of the overall waiting list, due to lower referral numbers, but within this there is an increase in the numbers awaiting surgery which will need to be a priority to recover in the next phase. A range of innovations have been made by staff and the Trust to allow us to adapt to meet the challenge of the pandemic. There are numerous examples from the introduction of video clinics to the use of videoconferencing for meetings to Team Brief using Microsoft Teams. Whilst in the early phase of the pandemic, it was common to talk about the ‘post’ COVID-19 world, we now need to work on the assumption that there will not be a return to how we did things before the pandemic, rather we will have to find ways to deliver our services and support our staff in a world in which COVID-19 is present for a considerable time, or possibly indefinitely. We have undertaken two Executive Team timeout sessions to think through the issues that follow from this perspective and will be taking action to

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capture and embed the successful innovations that we have introduced, whether by frontline staff or as Trust-wide changes. 1.1.2 Recognition of Colleagues

The Trust’s monthly Brilliant Awards process was temporarily suspended in March in line with national social distancing requirements. During this time, messages of gratitude and support to individuals and the hospital overall have been received by members of the public and colleagues and have been shared regularly with staff.

The Trust has reviewed the face-to-face aspect of the Brilliant Awards in order to ensure that we can continue to recognise and thank colleagues going forward. Utilising new technologies available to the NHS, the Brilliant Awards will recommence from 1 June.

1.2 COMMUNICATION AND INFORMATION

1.2.1 Public Information

Public information continues to be published on a regular basis through the Trust’s communication methods and in local and regional media.

1.2.2 Information for Colleagues

Regular briefings covering all aspects of COVID-19 remain in place to inform colleagues of the latest information and requirements. Email updates are sent frequently and Steven Ned, Director of Workforce, meets Staff Side representatives weekly to ensure any issues are quickly captured and addressed. With the recent concerns about the increased risk of COVID-19 in BAME staff, the Trust has written to all staff and to line managers to ensure an updated risk assessment is undertaken for all BAME staff.

1.2.3 Donations and Support

The Trust continues to receive generous donations to support patients and staff. I would once again like to express my gratitude to everyone who has contributed. Significant contributions have been received from the national charity effort and decisions will be taken promptly to ensure staff receive support in the near future.

2. PARTNERSHIP WORKING

The Trust continues to work with partners locally, regionally and at a national level to deliver a co-ordinated and consistent approach to the effective management of COVID-19. Within Barnsley, health and social care organisations are working together to ensure a cohesive approach to the use of face coverings within health and social care settings. This includes mutual aid with PPE when needed and support to care homes from the Infection, Prevention and Control nursing team who have been superb throughout the COVID-19 period.

Dr Richard Jenkins Chief Executive

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1

CHIEF EXECUTIVE REPORT

May 2020

Author(s) Andrew Cash, Chief Executive Officer

Sponsor

Is your report for Approval / Consideration / Noting

For noting and discussion

Links to the STP (please tick)

Reduce

inequalitiesJoin up health

and care

Invest and grow

primary and

community care

Treat the whole

person, mental

and physical

Standardise

acute hospital

care

Simplify urgent

and emergency

care

Develop our

workforce

Use the best

technology

Create financial

sustainability

Work with

patients and the

public to do

Are there any resource implications (including Financial, Staffing etc)?

N/A

Summary of key issues

This monthly paper from the Chief Executive of the South Yorkshire and Bassetlaw Integrated Care System (SYB ICS) provides a summary update on the work of the SYB ICS for the month of April 2020.

Recommendations

The SYB ICS Health Executive Group (HEG) partners are asked to note the update and Chief Executives and Accountable Officers are asked to share the paper with their individual Boards, Governing Bodies and Committees.

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2

South Yorkshire and Bassetlaw Integrated Care System

CHIEF EXECUTIVE REPORT

May 2020 1. Purpose

This paper from the South Yorkshire and Bassetlaw Integrated Care System Chief Executive provides an update on the work of the South Yorkshire and Bassetlaw Integrated Care System for the month of April 2020. 2. Summary update for activity during April 2020 2.1 Coronavirus (Covid-19): The South Yorkshire and Bassetlaw position There is increasing evidence, both nationally and regionally, that the first peak of Covid-19 has now passed. The numbers of patients needing critical care facilities across the hospitals in South Yorkshire and Bassetlaw (SYB) appear to have now plateaued. There is consensus among partners that the immediate Phase One response to Covid-19 is drawing to a close. Attention is now turning to recovery, restoration and resetting health and care services. Simon Stevens and Amanda Pritchard’s letter to the NHS, issued on Wednesday 29th April, helpfully summarised the next steps for Phase Two, setting-out the current position and proposing new ways for the NHS to remodel health and care services in the coming days and weeks. The NHS remains in a Level 4 National Incident with all the altered operating disciplines that requires. There will be a gradual shift away from this in May as the Phase Two stabilisation period begins which will be in place until the end of June. During this stabilisation phase we will consider how best to restart urgent NHS services across SYB taking into account the needs of the population and the clinical priority of patients that need to be treated the soonest. Phase Three will be August to the end of March 2020. During this period we will conduct a comprehensive planning review and focus on building elective services and managing a potential further Covid-19 spike during the winter. Partners are already starting to take stock of the learning from the changes in ways of working since March as well as the experiences from patients, the workforce, SYB partners and the public. These findings will help to develop a framework to shape future working. Phase Four will be from April 2021 and will focus on recovering and developing the NHS towards the ‘new normal’. To support the early thinking on the SYB approach, a strategic workshop with Chief Executives, Accountable Officers, GPs, Primary Care Networks and the NHS England and Improvement Locality Director took place on 29th April. The basis of the discussions was to set out key principles for the reset process whilst working to ensure the prevention of System inequalities in any reconfiguration of services. It was a helpful exercise with insights and informative contributions from across sectors and the feedback is being used to work up the System response. Special thanks to Major Sam McEvoy, the SYB ICS Military Planner who formulated and facilitated the session. 2.2 Phase One reflections

As consideration turns to Phase Two and beyond, it is important to reflect on the enormous strides that have been made during Phase One. These have been in key areas such as workforce, critical care capacity, extensive partnership working and entering new terrain such as working side-by-side with the military. In SYB, a complex cross-regional development of a new Nightingale Hospital in Harrogate was co-

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3

ordinated and the realignment of the FlyDSA Arena Sheffield as a local PPE storage facility was supported. In addition, new mobile testing sites in Barnsley, Sheffield and Doncaster opened, alongside the drive-through coronavirus testing facilities at Doncaster Sheffield Airport (DSA) for South Yorkshire and Bassetlaw key workers in health and care, including those employed in the independent sector, police, fire, local authorities and LRF partner organisations. NHS staff testing expanded with Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust and The Rotherham NHS Foundation Trust joining Sheffield Teaching Hospitals NHS Foundation Trust laboratory capacity to provide up to 2000 tests a day. Together with the key worker facility at DSA and mobile sites, the region is in a good position to maximise testing and allow staff currently unable to return to work because they or a member of their family or household have symptoms of coronavirus to know whether they do have the virus. The SYB System is also in a good position to widen community testing, especially to organisations that are fundamental to the local economy such as universities and colleges. More than 600 final-year nursing and allied health students from Sheffield Hallam University volunteered to join the NHS workforce and support the Covid-19 pandemic. This includes 376 nursing students who are joining NHS colleagues sooner than anticipated as part of the UK’s response to the virus. The healthcare students are in the final six months of their degrees and will be paid volunteers. In addition to work led by NHS England and supported by the ICS Procurement Hub to source PPE, the Mayor of the Sheffield City Region, Dan Jarvis, issued a call to South Yorkshire businesses to join the efforts to help make life-saving medical equipment. This initiative has seen around 50 businesses come forward, many of which are now supporting ongoing requirements for PPE for the region. 2.3 Supporting care homes In Phase Two the NHS will continue to partner with Local Authorities and Local Resilience Forums to provide mutual aid for care homes. In SYB this will build on work that has been taking place since the beginning of the outbreak. While the numbers of cases and deaths in hospitals are showing a downward trend, it is the opposite in care homes. NHS England is working with all regional providers including the North East and Yorkshire and the Humber Region to implement a new Enhanced Universal Support Offer to Care Homes. This is built around four key Principles: Leadership, Prevention, Additional Clinical Support and Workforce. The Enhanced Offer has been developed in conjunction across a number of key stakeholder groups; CCG Directors of Nursing, Directors of Adult Social Services in Local Authorities, Skills for Care, Primary Care, Public Health, Care Home Providers and others across the region. It provides a clear framework for support to care homes which will complement and, where appropriate, strengthen the support currently offered by these organisations. One of the first additional steps being taken, with regional senior nursing support, is for CCGs to quickly identify clinical leads to work alongside each care home. They will explore practical areas where additional support can be offered such as infection control, PPE training, staff not coming in to work if unwell, staff testing and pausing family visiting. 3. Finance update Based on draft year end results the System has exceeded its financial plan for the year. This has brought in £19m of cash support that would not otherwise have been available had the system not been in balance. This is a very creditable performance for the SYB System which has now exceeded its financial plan in each of the last three years.

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4. Next steps An announcement is expected on Sunday 10th May from the Prime Minister on the Covid-19 lockdown exit strategy. We will use this to underpin our approach building on the transformation work seen in the last few months in SYB to reset the NHS over the coming year in four phases which are outlined above. Andrew Cash Chief Executive, South Yorkshire and Bassetlaw Integrated Care System Date 7 May 2020

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new barnsley hospital nhs foundation trust please note:- … · 2020. 6. 3. · dr jenkins provided...

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