board of directors meeting 08.30am 12.20pm, wednesday … 31 05 17 part 1 (e... · presentation...

Board of Directors Meeting

08.30am– 12.20pm, Wednesday 31 May 2017 Seminar Room, Children’s Centre, Dorset County Hospital

AGENDA DEVELOPMENT SESSION

Patient Experience Feedback To discuss

08.30 Sophie Jordan

PART 1 (PUBLIC SESSION)

Page No.

Approx. timings

1 Welcome and Apologies for Absence:

8.50 Chair

2 Declarations of Interest All

3 Chairman’s Remarks

Oral 8.55 Chair

4 Minutes of Board of Directors 29 March

2017 To approve

Enclosure 9.00 Chair

5 Matters Arising from those Minutes and

Actions List To receive


QUALITY AND PERFORMANCE ITEMS

6 Chief Executive’s Report To receive

Oral 9.10 PM

7 Integrated Performance Report: (to

include comments from Committee Chairs)

a. Quality b. Performance c. Finance d. Workforce

To receive and agree any necessary action

Enclosure 9.20 NL JP LW MW

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8 Medical Revalidation Progress Report To receive

To follow 10.20 PL

COFFEE BREAK 10.30

9 Inpatient Survey To receive

Enclosure and Presentation

10.45 NL

STRATEGIC ITEMS

10 Trust Vision – update To approve

Enclosure 11.00 NJ

11 Strategy – Board oversight

To note Enclosure 11.10 NJ

GOVERNANCE ITEMS

12 Corporate Risk Register and Board

Assurance Framework To note

Enclosure 11.20 NL/LW

13 Committee Work Plans

To receive Enclosure 11.35 Committee

Chairs

14 Board Self-Assessment of Effectiveness To review


CONSENT SECTION

The following items are to be taken without discussion unless any Board Member requests prior to the meeting that any be removed from the consent section for further discussion.

11.55

15 Report on Use of the Trust Seal

To receive Enclosure PM

16 Safe Staffing Return (previously reviewed at

Quality Committee) To approve

Enclosure NL

17 Annual Complaints Report (previously

reviewed at Quality Committee To note

Enclosure NL

18 Any Other Business

Chair

Date of Next Meeting (open to the public): Wednesday 26 July 2017, 8.30 a.m., Seminar Room, Children’s Centre, Dorset County Hospital

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Questions from the Council of Governors and Members of the Public – 12.05- 12.20. Fifteen minutes will be allowed for questions, with priority being given to Governor questions submitted in advance of the meeting. Note: The Board will now adopt the resolution that “Governors, members of the public and representatives of the press are excluded from the next part of the meeting because publicity would be prejudicial to the public interest by reason of the confidential nature of the business about to be transacted”.

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BOARD OF DIRECTORS PART 1 (PUBLIC SESSION)

Minutes of the Meeting of 29 March 2017

Seminar Room, Children’s Centre, Dorset County Hospital

Present: Mr Mark Addison (Trust Chair) Mr Peter Greensmith (Vice Chair) Prof Sue Atkinson (Non-Executive Director) from BoD17/022 Mr Graeme Stanley (Non-Executive Director) Mr Matthew Rose (Non-Executive Director) Ms Victoria Hodges (Non-Executive Director) Ms Judy Gillow (Non-Executive Director) Ms Patricia Miller (Chief Executive) Ms Libby Walters (Director of Finance and Resources) Mr Mark Warner (Director of Organisational Development (OD) and Workforce) Ms Julie Pearce (Chief Operating Officer) (COO) Mr Paul Lear (Medical Director) Ms Nicky Lucey (Director of Nursing and Quality) (DoN)

In Attendance: Mr Nick Johnson (Director of Strategy and Business

Development) Dr Richard Jee (Divisional Director Designate) Dr Will McConnell (Divisional Director Designate) Ms Lindsey Perryman (Trust Secretary) Ms Catherine Abery- Williams (Divisional Manager for Family Services) for BoD17/022 Ms Anna Ekerold (Paediatric Matron) for BoD17/022 Ms Sarah Knight (Divisional Manager) for BoD17/030 Ms Sophie Jordan (Divisional Manager) for BoD17/030

Apologies: None Observers: 1 member of the public

BoD17/022 Board Development Session – Patient Experience Feedback

Catherine Abery- Williams, Divisional Manager for Family Services and Anna Ekerold, Paediatric Matron, joined the meeting. Anna advised of a 19 day old baby admitted to Kingfisher Ward in December 2015 with suspected pyloric stenosis. She advised the baby required intravenous fluids which were administered through a peripheral cannula in the foot. The following day, an extravasation injury was confirmed upon the realisation that the baby’s leg was swollen above the knee. The baby was then transferred to Southampton for surgical management of pyloric stenosis. She advised that the root cause analysis had highlighted missed opportunities which may have prevented the extravasation injury become as severe these included;

Staff nurse did not respond to prompts from Health Care Support Worker that

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the patients name band was tight on the ankle 4 hours prior to detection of extravasation.

No Visual Infusion Phlebitis scores were carried out

The baby’s bandage was not removed to visualise the cannula site

The baby’s crying was attributed to hunger rather than pain. Anna advised that the following recommendations from the root cause analysis were implemented:

Risk summary circulated to all Kingfisher staff highlighting the main points of the incident

Extravasation teaching provided to all staff on annual updates

Staff competency developed and implemented for all staff who are signed off to administer fluids or medication via the intravenous route

Yearlong peripheral cannulation audit undertaken, amongst other criteria this also included recorded of VIP scores and documentation.

Anna highlighted that the good news was that there had been no further extravasations since implementation of actions. Patient had follow up daily dressings for 3 weeks post extravasation injury by the CCN team who delivered exceptional care. There was no lasting injury from the extravasation. Anna advised that the baby was readmitted days afterward with bronchiolitis. She highlighted that the parents had expressed some concerns but that staff were able to reassure them and provide safe effective care during this admission. [Sue Atkinson joined the meeting at this point] The Chair questioned how the original incident had been handled. Anna advised that both the consultant and the staff nurse had spoken to the parents and apologised. She advised that she felt the parents were shocked at the time but that their concern surfaced on the second admission. The DoN advised that compliance with cannula checks was now embedded across the organisation. The Chair thanked Anna and Catherine for attending the meeting and for the straightforward and clear explanation of what had gone wrong and how lessons had been learnt.

BoD17/023 Welcome and Apologies for Absence

The Chair welcomed everyone present to the meeting. There were no apologies. The Chair particularly welcomed Will McConnell and Richard Jee who he advised had been invited to attend the Board in advance of their appointment as Divisional Directors from 1 April following which they would be present at Board meetings as non-voting attendees.

BoD17/024 Declarations of Interest

There were no declarations of interest in relation to items on the agenda. The Chair reminded members that declarations of interest could be raised at any time during the meeting should they arise.

BoD17/025 Chairman’s Remarks

The Chair highlighted to the Board that the Trust was now able to report that it would

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be achieving its financial control total for 2016/17. He highlighted the achievement this had been in light of the position the Trust had been in 9 months previously and thanked everybody for their hard work in achieving this. The Chair highlighted the Charity events taking place and in particular the “Walk for Wards”. He advised that he was meeting Canon Eric Woods on 20 March and that he was also hopeful that the Lord Lieutenant would be able to be present at the Trust on 5 April for the photoshoot. The Chair reported that the date for the AGM had been set for the 11 July with a slightly different format. The Trust Secretary advised that the Council of Governors meeting would be held in the afternoon followed by tea and cake prior to the start of the AGM. The Chair advised that he had now met the three new Dorset Chairs and that they would be making arrangements to meet and develop links.

BoD17/026 Minutes of the Previous Meeting held on 25 January 2017

With the correction of a typo, the minutes of the previous meeting held on 25 January 2017 were accepted as a true and accurate record.

BoD17/027 Matters Arising and Actions

BoD17/010 – the Medical Director advised that the Guardian of Safe Working would report to the Quality Committee as well as the Board. The Chair recalled that the Board had agreed that it would receive a written report quarterly with Jonathan Chambers attending on an annual basis to present his report – close. BoD16/109 – Comments from long service awards – the Chief Executive confirmed that these were on display – close. BoD16/109 – Key actions in integrated performance report – the Chair reminded the Board of the need to include the key points from Board committees in the summary of papers. It was noted that there was an issue of timing and that Execs, NEDs and the Trust Secretary would need to work together to ensure these were drawn out, possibly by discussing at the end of the meetings. BoD16/088 – Committee Work programmes – the Chair advised that work on these was almost complete following which they would be presented to the Board. BoD16/092 – STP modelling – the Director of Strategy and Business Development reported that one of the overriding responses to the CSR from all providers was a need for more modelling and that there was a lack of clarity as to what had been modelled. Peter Greensmith advised he had heard that the CCG would be looking at the impact of new homes on GPs which might imply that this was the first time this had been modelled. The Chief Executive highlighted that the CCG had clearly articulated a reduction in acute beds but had not yet responded to the query raised regarding the basis of this. The Chair confirmed that the issue of modelling would be raised when he next met with the CCG.

BoD17/028 Chief Executive’s Report

The Chief Executive presented a previously circulated report providing the Board with information on strategic developments across the NHS and more locally within Dorset. The Chair thanked her for the more personal style of report.

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The Chief Executive highlighted the announcement by NHS England that provider deficits were being covered by the 1% funding that CCGs had been required to retain for supporting system working. She highlighted the NHS cap on new drugs and reported that the statement by Simon Stevens during the last few days about prescription was directly related to supporting the funding of drugs. The Chief Executive highlighted the announcement in the budget of £2.4bn over 3 years but advised that the Local Government Association had indicated that an additional £2B of funding was required in 2017/18 alone to meet current needs She advised that there was no assurance as to where the additional funding would be spent. In respect of the additional £100m of capital funding to support the delivery of the 4 hour standard through closer working with GPs, the COO reported that the Trust had considered how it might bid for capital. The Chief Executive highlighted the report by the CQC which gave a flavour of the findings from their inspections and expressed concern in respect of the number of trusts which were finding themselves rated as inadequate and had not made significant improvements at re-inspection. The Chief Executive drew the Board’s attention to the timetable in respect of the CSR consultation and the expectation of the final decision in September. She advised that the CCG were having two away days in April to consider the responses to the consultation and that the themes would be presented to the Senior Leadership Team. The Chief Executive highlighted the attendance detailed in the report of the divisional management teams at Board and Committees. She advised that that the Divisional Heads of Nursing would also be attending the Quality Committee. The Chief Executive reported that the Trust had had its quarterly meeting with NHS Improvement on 28 March where reasonable confidence had been expressed in the ability of the Trust to deliver but with concern in respect of the short to medium term financial situation and RTT. She confirmed that the Trust had been given approval to delay its external Well-Led review. The Board resolved to note the content of the report.

BoD17/029 Integrated Performance Report

The COO presented a previously circulated report providing an overview of operational performance and highlighting areas of under-performance and risks including the 9 “must dos”. She advised that the new style report was a compilation of input from all of the Executive Team. The COO highlighted the following areas of good performance:

Access standards for ED and 62 day cancer pathway

Access to diagnostic tests – predicted to meet standard for March

Predicted achievement of financial control total The COO highlighted the main performance risks facing the Trust for 2017/18:

Maintaining RTT performance above 90% and demonstrating improvement against an agreed trajectory

Improvement in mortality reporting and coding The COO reported that only the ED 4 hour standard would be linked to STF funding for 2017/18

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. Quality – the DoN highlighted the continued good performance in respect of Infection Prevention and Control. She advised that the Trust continued to underperform against the Dementia standards and that she would be requesting support from the Divisional Directors in embedding this. The DoN reported that work was continuing to try and improve the turnaround time of complaint responses. Sue Atkinson, who had chaired the most recent meeting of the Quality Committee, advised that stroke and dementia standards were both being scrutinised in detail by the Quality Committee. She reported that the last meeting had received a report on mortality and coding but that there was still some reservation that the work in hand would resolve the issues. Judy Gillow asked for an update on the weekend HSMR scores. The Medical Director advised that the understanding was that the level of diagnosis made at the weekend was lower than that during the week. He advised that clinicians had been asked to make a definitive diagnosis. Judy Gillow gave an update on mortality from the National Mortality Review meeting she had attended. She advised that the responsibility of the Board would increase in respect of monitoring a more detailed mortality dashboard, learning and how reviews were undertaken. Judy Gillow confirmed that she was preparing a briefing note for Board members. The Medical Director confirmed to the Board that, although reviews showed a small number of cases where patients could have been managed differently, he was confident there were no issues in regard to the quality of care. Judy Gillow advised that she felt the Trust did not yet have full assurance that there was not an issue. Richard Jee highlighted that, in respect of critical care, assurance could be obtained from the Intensive Care National Audit and Research Centre (ICNARC) data. The Chief Executive confirmed that there were a number of national audits that showed the Trust mortality rates were at or below the expected rates and that there was a need for this information to be pulled together as an assurance piece. Performance – the COO advised that the Trust was considering the feasibility of delivery of the RTT standard by the end of quarter 2. She advised that there were some risks mainly in respect of Ophthalmology and Paediatrics. The COO highlighted that if Ophthalmology was taken out of the equation the Trust achieved the 92% target. Matthew Rose confirmed that RTT was one of the key areas of focus for the Finance and Performance Committee and would continue to be. He advised that the Committee also wanted to enhance the work around activity and the triangulation of contract activity, budget and RTT. The Director of Finance and Resources expressed some concern that the Trust had underperformance against contract, had national funding to support the delivery of RTT but had still not achieved the target. The Chief Executive report that last week it had been announced that STF funding for quarter 4 would be paid purely on the achievement of financial targets. Finance – the Director of Finance and Resources confirmed that the Trust was now forecasting achieving the £1.8m deficit control total due the changes in payment of STF funding for quarter 4 and being able to claim the back payments for the ED 4 hour target. She advised that the overpayment of £750k from the CCG had still to be finalised. The Director of Finance and Resources reported that the cash position was better than planned due to the management of capital payment, delaying payment of creditors and chasing debtors. She advised that the Trust was forecasting requiring

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cash support in July but that it was likely this would be later due to the tendency for slippage in capital expenditure. The Director of Finance and Resources highlighted the need to the Trust to assess whether the activity in the contract and the financial envelope would enable the Trust to achieve the RTT target. She highlighted that there was currently just under £5m of unidentified CIP for 2017/18. Workforce – the Director of Organisational Development and Workforce reported that the Trust had seen a spike in sickness levels for January, however, it was the lowest level of sickness seen in January for four years. He reported that the Trust had seen a reduction in fill rates for agency staff which was reflective of the changes in the market place partially due to the changes in HMRC rules for those engaged on personal services contracts. The Director of Organisational Development and Workforce reported that the level of appraisals had remained constant. He advised that the Trust were now beginning the appraisal cycle with band 7s and above to align with the business planning cycle. The Director of Organisational Development and Workforce reported that a new approach for refresher training for essential skills was being introduced where staff would complete an assessment on line for all refresher modules. He advised that the Trust did not do a cut by staff group but by staffing area. He confirmed that where there was a particularly low compliance in a subject an action plan was put in place. The Director of Organisation Development and Workforce reported that the government had announced this week a 1% pay rise for staff on Agenda for Change payscales and doctors and dentists. The Chair welcomed the excellent new summary dashboard for the Board and requested that any comments were provided to the COO.

Action: ALL The Board resolved to note the issues raised and agree the actions to ensure compliance.

BoD17/030 Trust Performance Management Framework

Sarah Knight and Sophie Jordan attended the meeting for this item. The COO advised that this report had been discussed at Finance and Performance Committee and complemented the Governance Framework to ensure robust processes around all of the Trust’s business. She advised that the Executive Team wanted to work towards earned autonomy for the divisions and that Sophie and Sarah would give a presentation at a high level about work in the divisions and how the framework would help. Sarah and Sophie highlighted the structure of the performance matrix and gave an outline of the structure of the two new divisions each containing 4 care groups. They advised that the divisions would be trying to mirror the processes at a Board level and set the same standards across both divisions. They gave an outline of the priorities for quarter 1:

• Agree metrics and align with performance dashboards • Work with new Transformation Lead to establish levels of intervention and

roles of the team • High Level review of Divisions using established metrics (peer review)

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• Divisions to report at Quarterly Performance Meeting • Agree reporting framework for Care Groups • Implement the Trust Clinical Governance Framework to complement the

performance framework. They advised that during quarter 2 the performance processes would be cascaded to the 8 care groups. The divisional managers confirmed that both divisions had identified HR, finance and information support. In terms of underperformance the divisional managers advised that peer review would be used as an interventional tier. Peter Greensmith highlighted the need for staff at ward level to understand the process and to have given “consent” to follow. The DoN advised that the ward leaders were engaged in the dashboard but that there was a need for the divisional management to coach to embed the change. It was acknowledged that work was required to change the culture. It was agreed that a quality priority should be added to the annual priorities for 2017/18 with the suggestion that this was learning from deaths.

Action: JP

The Director of Strategy and Business Development highlighted the need to look at how performance was aligned to strategic outcomes. The Chief Executive advised that the Executive Team recognised that there was a need to streamline the management processes to support earned autonomy and highlighted the need to ensure that the Head of Transformation was used for transformation and not to tackle poor performance. She reminded the Divisional Managers that it was proposed for the divisions to present to the Board following their quarter 1 self-assessment. In response to a question from the Chair, Richard Jee advised that to some extent the consultant community were not yet engaged but that he was meeting individually with divisional leads. It was agreed that it would be helpful to have a simple assessment tool listing the six or so key things the new model was designed to achieve to enable review in a year. The Board noted the content of the report and agreed to the trial of the first iteration of the framework.

BoD17/031 2016 National Staff Survey Findings

The Chair advised that one of the discussions which had taken place with the Leadership Academy was to have some items presented to the Board where all members were reviewing them at the same time ie they had not been presented to a Board committee or to Executive Directors. This report had accordingly come directly to the Board. The Director of Organisational Development and Workforce reported that the Staff Survey was the most important metric that the Trust had in terms of staff engagement. He advised that it was based on a full paper census which had had a 54% response rate. The Director of Organisational Development and Workforce advised that the Trust was considering the use of a mixture of electronic and paper based survey for the coming year dependent on staff group.

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The Director of Organisational Development and Workforce highlighted the Staff Engagement Index which he advised showed no significant change from last year and was consistent with the national average. He advised that there was no statistically significant change in any of the key findings. The Director of Organisational Development and Workforce advised that it was important to share the outcomes with the divisions and for them to develop their action plans. He highlighted that the People Strategy was focused on staff engagement but that it would be helpful for the Trust to identify 2 or 3 areas to focus on. The Chief Executive advised that she felt there was a need for the Trust to ask staff what would change their level of engagement. The following comments were made in the course of a full discussion:

We should avoid a major new action plan but focus on trying to identify what lies beneath the responses and what local teams could do to address these issues

There was a need to promote front line conversations about what was driving the feedback

Some of the responses and the low level of movement overall from last year seemed at odds with the general feel and culture of the hospital

There was a theme about leadership

We should move towards a “You said, we did” style of feedback and communication

Visibility of middle and senior management appeared to be an issue

The new performance and governance frameworks give the opportunity to link responses to the survey to link to existing initiatives

There need to be a link between the management response and the strategy (to be in the top quartile).

The Board noted the content of the report and the actions in response to the survey set out in the Staff Engagement Action Plan.

BoD17/032 Freedom to Speak Up Guardian

The Director of Organisational Development and Workforce presented a previously circulated report which he advised set out a change to the approach to the requirement to have a Freedom to Speak up Guardian. He advised that Graeme Stanley had been undertaking this role linked to his role as the SID and the Whistleblowing NED but that recent guidance made it clear that this role should not be undertaken by a NED. The Director of Organisational Development and Workforce advised that the proposal was to invite two or three staff to volunteer to take on the role and that it was proposed that these staff would meet with Graeme Stanley, the Chief Executive and himself on a bi-monthly basis. It was agreed that, in terms of the role description, the language should be less formal. The Board approved the proposal for the appointment of Freedom to Speak up Guardians and as for the communication of the new roles to be as straightforward as possible.

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BoD17/033 Easy Guide to Dorset Health The Director of Strategy and Business Development spoke to a single slide which aimed to condense the Dorset landscape onto one page all fitting under the umbrella of the Five Year Forward View. He explained the relationship between the Dorset wide STP with its five work streams, the CSR which he advised was a subset of the STP with the Vanguard delivering some of the CSR. The Director of Strategy and Business Development highlighted the Trust’s five strategic objectives and the corresponding strategic programmes. The Board welcomed the one page explanation.

BoD17/034 Trust response to the Dorset CCG Mental Health Acute Care Pathway

Consultation Questionnaire The Director of Strategy and Business Development presented a previously circulated paper detailing the proposed Trust response based on views from the Senior Management Team and the Emergency Department. The following comments were made:

Concern was expressed regarding the predominance of beds in the East

There should be more data to support the comments in respect of Out of Hours and Crisis

There was a need for better/more data on need

There was no mention of integration

Consideration of changing the response on the degree of support for the proposals from “to some extent” to “not very much”

The Board:

agreed the Mental Health Acute Care Pathway Consultation response subject to amendment to take account of the comments above

delegated authority to the Director of Strategy and Business Development to make any final minor adjustments, in consultation with the Chief Executive, and submit the response on behalf of the Trust by the deadline of 31 March.

BoD17/035 Corporate Risk Register and Board Assurance Framework

The Director of Finance and Resources advised that it was felt it may be useful to bring the Corporate Risk Register and Board Assurance Framework into one document so that operational risks that were becoming so significant they could impact on objectives could be identified. BAF- the Director of Finance and Resources highlighted the two red risks in relation to the ability to deliver transformational change and having sufficient cash. She reported that the Trust had appointed to the Head of Transformation but had failed to recruit a CIP Manager. The Director of Finance and Resources advised that the risk relating to opportunities for services to be tendered not arising had been reduced to green due to looking to the market for business not being key to the Trust at the current point in time. The Director of Finance and Resources highlighted the two risks that had increased from green to amber:

personal records including medical records should be accurate and kept safe and confidential – due to internal audit on the IG Toolkit showing that

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assurance was not as robust as the Trust had thought

trust being open to fraud – due to the need to ensure that cyber security risks had been addressed.

CRR – the DoN reported that the Emergency Department risk had been reduced due to the Trust now meeting the 4 hour standard. She highlighted that there were two new risks:

ENT medical staff – although there had been some mitigation since the report and also return from sick leave

Fire alarm reliability and capability – the DoN advised that this risk had been identified in 2014 but due to plans to resolve being deferred the risk had increased. She advised that the risk was currently being managed with repairs but that these were becoming more frequent.

The DoN advised that in terms of the risk around RTT this was included on the risk register under Ophthalmology. Discussion took place in respect of the current and mitigated risk ratings, particularly in respect of the fire alarm risk. It was agreed that there was a need to consider renaming the current risk rating and to look at clarifying the definitions.

Action: NL

The Director of Finance and Resources confirmed that she had requested a formal update to be presented to the Board on fire safety. It was agreed that the financial sustainability risk should be reviewed considering the cash position and the level of required CIP.

Action: LW The Board noted the Corporate Risk Register and Board Assurance Framework

BoD17/036 Guardian of Safe Working Quarterly Report

The Medical Director presented a previously circulated report outlining the work undertaken to implement the new contact and the potential risks over the next 6 months. It was noted that this report was not in the consent section due to lack of full assurance due to the risk in terms of middle grades particularly in medicine. Will McConnell suggested that the Trust should consider taking an overstaffing risk on the basis that there would always be gaps. He confirmed that the divisions were looking at different staffing models. The Chief Executive advised that the Trust were considering how medical staffing might be reported as there was a need for the Board to be aware of the possible clinical risk and the need for pace in terms of the development of alternative models. The Board noted the content of the report.

BoD17/037 Review of Bi-Monthly Board Meetings

The Chair presented a previously circulated report detailing the output from the survey of Board members regarding the changes to the Board meeting cycle. He advised that there was almost unanimous support of continuing with bi-monthly meetings although there was an understandable concern as to risks of many items

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appearing on the agenda. The Board noted the feedback and agreed to the continuation of holding formal Board meetings on a bi-monthly basis.

BoD17/038 Consent Section

The Chair confirmed that no requests had been received to remove items from the consent section for discussion, and therefore the following were taken as agreed:

Staffer Staffing Return (previously reviewed by the Quality Committee): approved

Vanguard Update: noted

BoD17/039 Any Other Business

Insight Programme – the Chair introduced this initiative which he advised was aimed at developing aspiring but inexperienced potential NEDs. The Board agreed to participate in the programme.

BoD17/040 Date of Next Meeting

The date of the next meeting was scheduled for Wednesday 31 May 2017, Seminar Room, Children’s Centre, Dorset County Hospital, 8.30am.

BoD17/041 Questions from Governors and Members of the Public

The Chair confirmed that no questions had been received in advance of the meeting. The following question/comment was received from Governors/Public present:

The CCG has consistently talked about population projections and having higher than average numbers of elderly people and babies. His own GP surgery had 100 new patients per annum which would result in several thousand new patients across the region. Poundbury has been built fairly recently and the local plan was being reviewed as it was not showing enough land for new housing. Query as to why health did not benefit from section106 payouts as part of the planning permission process.

The Board adopted the resolution that “members of the public, Governors and

representatives of the press are excluded from the next part of the meeting because publicity would be prejudicial to the public interest by reason of the confidential nature of the business about to be transacted”.

…………………………. ……………………. Chair Date

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ACTIONS LIST – BOARD OF DIRECTORS PART 1 31 MAY 2017

Minute Action Owner Timescale Outcome

BoD17/029 Integrated performance report – comments on new dashboard to be provided to COO

All April 2017

BoD17/030 Performance Management Framework - It was agreed that a quality priority should be added to the annual priorities for 2017/18 with the suggestion that this was learning from deaths

JP April 2017 This indicators has been added to the framework and the framework policy and guidelines have been finalised for use by the Divisions & care groups

BoD17/035 Risk Register - Discussion took place in respect of the current and mitigated risk ratings, particularly in respect of the fire alarm risk. It was agreed that there was a need to consider renaming the current risk rating and to look at clarifying the definitions.

NL May 2017 Reviewed with Estates

BoD17/035 Risk Register - It was agreed that the financial sustainability risk should be reviewed considering the cash position and the level of required CIP.

LW May 2017

Actions carried forward from previous meetings

BoD16/088 Committee chairs to review work programmes and bring to board for approval

MA/PM/ committee

Chairs/ lead execs

March 2017

On agenda

BoD16/092 Sustainability and Transformation Plan – details of modelling to be obtained from CCG

NJ Oct 2016 March - issue of modelling to be raised when trust next meets

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Title of Meeting

Board of Directors

Date of Meeting

31 May 2017

Report Title

Performance Report

Author

Executive Team

Responsible Executive

Chief Executive

Purpose of Report (e.g. for decision, information) To inform the board of operational performance for month 1 (April) 2017 and to identify areas of concern and risk

Summary The overall performance demonstrated that improvements in quality and access achieved during Q4 and March 2017 was not sustained during April 2017. This was due to service capacity constraints resulting from key gaps in the medical workforce. In addition, the impact of the transition to the new organisational structure placed extra stress on operational teams. A change in staff and teams taking responsibility for specific services and care groups within the divisions has had an impact on sustaining performance improvement. It is anticipated that this will settle down during May and June. The continued poor and deteriorating performance in ophthalmology means that this service is now subject to internal ‘special measures’ regime as described in the performance management framework, and this means that the service will be subject to close scrutiny by both the divisional and executive team and specific interventions will be required until the service becomes more stable. The improvement regime will be overseen by FPC.

Paper Previously Reviewed By Quality Committee and Finance and Performance Committee on 23rd May 2017 Items for escalation from Quality Committee

Mortality – ongoing focus. It was agreed that a verbal update would be provided in May with a deep dive to include timescales for actions to be presented to the June meeting.

CQC report - assessment of any additional risks since the CQC visit eg current risk regarding middle grade medical staffing

The provision of face to face specialist palliative care service 7 days a week, as identified within the CQC Action plan. An internal pilot provided this service over a 7 day period, and audited the support required by the Trust. This is being discussed with the palliative care team in early June.

Timeliness of complaints. The Trust has not been able to demonstrate the improvements required. A detailed action plan was presented and discussed

There has been a positive improvement in dementia screening, and although the standards are not at the level required, the Committee recognised that significant progress had been made and were presented with the draft Dementia Strategy in support of these improvements.

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Items for escalation from FPC

Overall RTT performance - main area of concern is ophthalmology; further presentation to FPC and Quality Committee in June.

CIP gap

Triangulation of contract/performance from budgeted activity compared with actual delivery – we are behind budget plan and this is a potential contractual risk with CCG

Workforce – survey of nurses, committee asked if this could be cut to show results for those approaching retirement and also detail of comments re lack of support of managers

Strategic Impact The performance of the Trust impacts on two strategic objectives related to sustainability of services and ability to provide good and outstanding care in relation to quality and access.

Risk Evaluation The extreme risk level in ophthalmology and overall poor performance on RTT with a lack of pace to improve the service has placed the service into ‘internal special measures’ as defined in the Trusts performance management framework. The Executive team are working with the division and specialty to over-see the improvement and will be receiving an options paper 1st June

Impact on Care Quality Commission Registration and/or Clinical Quality Performance focuses on all five domains linked to the standards of services underpinning registration and quality of services.

Governance Implications (legal, clinical, equality and diversity or other): Operational performance is governed through the policy and performance management framework and deals with all forms of performance.

Financial Implications Poor performance can result in additional cost associated with a shortfall in capacity in order to improve access for patients. Any patient safety and quality concerns may also carry additional cost

Freedom of Information Implications – can the report be published?

Yes

Recommendations

a) To note the report b) To discuss the issues escalated by quality committee and FPC c) To agree any additional actions

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Balanced-Score Card Performance Report

Report to Board: 31 May 2017

Performance Summary:

The overall performance demonstrated that improvements in quality and access achieved during Q4 and March 2017 was not sustained during April 2017. This was due to service capacity constraints resulting from key gaps in the medical workforce. In addition, the impact of the transition to the new organisational structure placed extra stress on operational teams. A change in staff and teams taking responsibility for specific services and care groups within the divisions has had an impact on sustaining performance improvement. It is anticipated that this will settle down during May and June. The continued poor and deteriorating performance in ophthalmology means that this service is now subject to internal ‘special measures’ regime as described in the performance management framework, and this means that the service will be subject to close scrutiny by both the divisional and executive team and specific interventions will be required until the service becomes more stable. The improvement regime will be overseen by FPC. Main Performance Risks facing the Trust in 2017/18 Quality and Access risks:

- Medical workforce in Medicine, Ophthalmology, Gastroenterology, ENT and Obstetrics/Gynaecology and impact on waiting times for patients; and due to the national supply shortage in medicine and nursing presents a risk in terms of agency usage and cost

- EDS completion partially linked to the IT system configuration between the clinical system and patient administration system - Complaints timeliness - C.difficile annual position due to peak in month - Dementia screening rate – improvement not yet embedded - Access to and waiting times in Ophthalmology – the service is now subject to internal ‘special measures’ - Impact of loss of locum breast radiologist on the fast-track cancer waiting times in the breast service - Data accuracy and quality related to the reporting of mandatory training and appraisal rates

Financial risks

- Gap in cost improvement programme and pace at which the system transformation programme can be prioritised and mobilised to support divisional teams in closing the CIP gap.

- Ability to meet the trust control total and access to sustainability and transformation funding

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Quality and FPC Recommendations Escalation from Quality Committee in April and May:

Mortality – ongoing focus. It was agreed that a verbal update would be provided in May with a deep dive to include timescales for actions to be presented to the June meeting.

CQC report - there was a discussion regarding the risks re middle grade staffing but also acknowledgement of the need to assessment whether any additional risks had arisen since the CQC visit

The provision of face to face specialist palliative care service 7 days a week, as identified within the CQC Action plan. An internal pilot provided this service over a 7 day period, and audited the support required by the Trust. This is being discussed with the palliative care team in early June, and a meeting has been arranged with Weldmar Hospice.

Timeliness of complaints. The Trust has not been able to demonstrate the improvements required. A detailed action plan was presented and discussed with the Quality Committee in May, with divisions confirming that this is now discussed at the divisional Governance meetings. Improvements are expected with the incoming Divisional Heads of Nursing/Quality, supported by the new Quality Managers for each division. The introduction of the Datix system will also allow more transparency.

There has been a positive improvement in dementia screening, and although the standards are not at the level required, the Committee recognised that significant progress had been made and were presented with the draft Dementia Strategy in support of these improvements.

Escalation from FPC in April and May:

Overall RTT performance - main area of concern is ophthalmology; further presentation to FPC and Quality Committee in June.

CIP gap

Triangulation of contract/performance from budgeted activity compared with actual delivery – we are behind budget plan and a potential contractual risk with CCG

Workforce – survey of nurses, committee asked if this could be cut to show results for those approaching retirement and also detail of comments re lack of support of managers

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Are we on track to deliver the 9 Must Dos? Key Performance Metrics Summary

Metric Met? Metric Standard Mar-17 Apr-17 Q1/YTD

MRSA hospital acquired cases (post 48hrs) 0 0 0 0

C-Diff hospital acquired cases (post 72 hours) - Due to lapses in care 14 0 2 2

Never Events 0 0 0 0

Serious Incidents declared on STEIS (under investigation)51

(4 per month)6 2 2

SHMI - Rolling 12 months, 6 months in arrears (Oct-15 to Sep-16) <1.12 N/A N/A 1.15

HSMR - Rolling 12 months, 2 months in arrears (Mar-16 to Feb-17) 100 N/A N/A 99.42

RTT incomplete pathways within 18 weeks (Quarter/Year = Lowest 'in

month' position)92% 89.2% 86.0% 86.0%

All cancers maximum 62 day wait for first treatment from urgent GP

referral85% 89.4% 71.4% 71.4%

Maximum 6 week wait for diagnostic tests 99% 99.4% 95.4% 95.4%

ED maximum waiting time of 4 hours from arrival to admission/transfer/

discharge (Including MIU/UCC activity from November 2016)95% 99.1% 98.7% 98.7%

Elective levels of contracted activity (£)2017/18 = 26,674,034

M1 = 2,222,8362,592,431 2,118,414 2,118,414

Surplus/(deficit) (1,208) 1,138 (497) (497)

CIP - year to date (aggressive cost reduction plans)2017/18 = (8,774)

Q1 = (464)6,794 (154) (154)

Agency spend in month2017/18 = 3,122

Q1 = 1,212216 248 248

Rating Key

Develop and implement an affordable plan to make improvements in

quality. In addition, providers will be required to publish avoidable

mortality rates annually.

Partially

Achieve and maintain the two new mental health waiting time targets.N/A

Improve care for people with learning disabilities including improved

community services and reducing inpatient facilities.Yes

Improve and maintain performance against 18 weeks RTT target. No

Deliver the 62 day cancer waiting time target including two week referral

and 31 day treatment targets and make progress in improving one year

survival rates by increasing the proportion of cancers diagnosed early.

Partially

Qu

ality

Perf

orm

an

ce

Fin

an

ce

Produce a sustainability and transformation plan for the health economy Yes

Return to "aggregate financial balance", deliver savings through the Lord

Carter productivity programme and cap agency spendPartially

Develop and implement a local plan to address the sustainability and

quality of general practice, including workforce and workload issues.N/A

Achieve waiting time targets for A&E patients and ambulance response

times.Yes

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INTEGRATED PERFORMANCE REPORT – Exception Reports by Domain Safe In relation to Infection Prevention and Control, the Trust has not reported any cases of MRSA Bacteraemia, but has seen an increase in cases of C Difficile during this month. Initial analysis of these cases has identified an issue in the prompt isolation of patients experiencing symptoms and this has been cascaded to all staff. The individual cases will be presented to the Infection Prevention and Control Committee once full investigation has been completed. There were 5 patient safety risk events reported resulting in potential severe harm/death during this period; 2 have been reported as Serious Incidents, 3 are to undergo full root cause analysis and presentation to the Learning from Incidents Panel to determine the level of harm caused. These related to 1 failure to escalate a deteriorating patient, 1 Missed follow up appointment, 1 Incorrect suturing post procedure, 1 potential of missed diagnosis of spinal injury on presentation to ED. These are all due to be presented to the Learning from Incidents panel to ascertain if procedures need to be amended and identify where improvements are required. There was also one fall reported during this period which resulted in severe harm. This unfortunate case related to an individual with a prosthetic limb who fell whilst transferring. All correct procedures were followed. Effective The mortality indicators for the Trust remain of concern. There is a detailed action plan to address the areas of improvement and this has been discussed and analysed by the Quality Committee. Although the standards for dementia screening were not achieved during the month, a significant improvement has been identified. This has been discussed through the Dementia Working Group. There remains a risk in fully achieving and sustaining the standards for all elements, which continues to be addressed via the Divisions. Caring Both the response rates and recommendation rates of Inpatient, Emergency Department and Outpatients have been above the agreed standards for this reporting period. Themes of this feedback are discussed at the Patient Experience Group in order to identify any areas of further improvement. The timeliness of complaint responses remains of concern. A full detailed Improvement will be discussed at this month’s Quality Committee for assurance that this standard will meet its improvement trajectory. Well Led The Trust delivered an Income and Expenditure deficit of £497,000 at the end of April which was £711,000 better than planned. This positive variance is due in the main to the majority of the savings plan being expected to be delivered towards the end of the financial year. The Trust has to

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achieve a deficit of no more than £2.9 million in 2017/18 which will require £8.7 million of savings to be delivered. There is currently £4.5 million of savings still to be identified. Temporary staffing spend increased in Month 1 but was below prior year. Sickness absence remained unchanged at 3.35% in March. There was a further decrease in the appraisal rate (-4%) to 74% sitting below the Trust target of 90% and a significant decrease in essential skills compliance (-7%) to 83%. The data quality for both of these metrics is being reviewed: the essential skills data has been subject to updates from the national system which has presented some errors, and the internal process for recording appraisal data is being updated. Significant work has been ongoing to mitigate medical workforce gaps resulting from expected shortfalls in junior doctor placements. Preparation for the Trusts second phase of the Leadership Development programme are well advanced, with the programme for all Band 3-6 team leaders commencing on 21 June.

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Integrated Scorecard 2017/18 - April 2017

MetricThreshold/

StandardType of Standard Mar-17 Apr-17 Q1/YTD

Movement on Previous

period

12 Month

Trend

Safe

Infection Control - Methicillin Resistant Staphylococcus Aureus (MRSA)

bacteraemia hospital acquired post 48hrs0

Contractual (National

Quality Requirement)0 0 0 ↔

Infection Control - C-Diff hospital acquired (post 72 hours) - Due to lapses in

care14


Quality Requirement)0 2 2 ↓

NEW Harm Free Care (Safety Thermometer) 95% Local Plan 98.3% 98.9% 98.9% ↑

Never Events 0Contractual (National

Requirement)0 0 0 ↔

Serious Incidents investigated and confirmed avoidable 0 1 1 ↓

Duty of Candour - Cases completed Contractual (National

Quality Requirement)?0 3 3 ↓

Duty of Candour - Investigations completed with exceptions to meet compliance 0 1 1 ↓

NRLS - Number of patient safety risk events reported resulting in severe harm or

death35 (2 per month)

Local Plan

(2015/16 outturn)1 5 5 ↓

Number of falls resulting in fracture or severe harm 8 for year

Local Plan (10%

reduction on 2015/16

outturn)

1 1 1 ↔

Pressure Ulcers - Hospital acquired (grade 2) confirmed avoidable TBC 0 0 0 ↔

Pressure Ulcers - Hospital acquired (grade 3) confirmed avoidable TBC 0 0 0 ↔

Emergency caesarean section rate 17.6% 17.3% 17.3% ↑

Sepsis Screening - percentage of patients who met the criteria of the local

protocol and were screened for sepsis.90% CQUIN target 66.0% N/A N/A ↑

Effective

Mortality Indicator SHMI (in-hospital and those occurring 30 days post

discharge) - Rolling 12 months [source HSCIC] - 6 months in arrears (Oct-2 or 3

Contractual (Local Quality

Requirement)N/A N/A 1 ↔

Mortality Indicator SHMI (in-hospital and those occurring 30 days post

discharge) - Rolling 12 months [source HSCIC] - 6 months in arrears (Oct-<1.12


Requirement)N/A N/A 1.15 ↔

Mortality Indicator HSMR from CHKS - 2 months in arrears (Mar-16 to Feb-17) 100Contractual (Local Quality

Requirement)100.55 99.42 N/A ↑

Mortality Indicator Weekend Non-Elective HSMR from CHKS - 2 months in

arrears (Mar-16 to Feb-17)100


Requirement)111.60 110.01 N/A ↑

Stroke - Overall SSNAP score C or aboveContractual (Local Quality

Requirement)N/A N/A N/A

Dementia Screening - patients aged 75 and over to whom case finding is applied

within 72 hours following emergency admission 90%


Requirement)70.8% 80.5% 80.5% ↑

Dementia Screening - proportion of those identified as potentially having

dementia or delirium who are appropriately assessed90%


Requirement)100.0% 100.0% 100.0% ↔

Dementia Screening - proportion of those with a diagnostic assessment where

the outcome was positive or inconclusive who are referred on to specialist 90%


Requirement)61.9% 95.7% 95.7% ↑

Caring

Compliance with requirements regarding access to healthcare for people with a

learning disabilityCompliant Compliant Compliant Compliant ↔

Complaints - Number of formal & complex complaints 217 (18 per month)Local Plan

(2015/16 outturn)23 10 10 ↑

Complaints - Percentage response timescale met (1 month in arrears)60% Apr-16

90% Jul-16

Trajectory (monthly

10% increments to 44.0% N/A N/A ↔

Friends and Family - Inpatient - Recommend 95% Mar-16 National Average 99.4% 98.6% 98.6% ↓

Friends and Family - Emergency Department - Recommend 84% Mar-16 National Average 88.8% 88.3% 88.3% ↓

Friends and Family - Outpatients - Recommend 92% Mar-16 National Average 93.7% 92.9% 92.9% ↓

Number of WOW! Award applications received 559 (46 per month)Local Plan

(2015/16 outturn)28 12 12 ↓

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Responsive

Referral To Treatment Waiting Times - % of incomplete pathways within 18

weeks (QTD = Lowest 'in month' position)92%


Operational Standard)89.2% 86.0% 86.0% ↓

Cancer (ALL) - 14 day from urgent gp referral to first seen 93%Contractual (National


Cancer (Breast Symptoms) - 14 day from gp referral to first seen 93%Contractual (National


Cancer (ALL) - 31 day diagnosis to first treatment 96%Contractual (National

Operational Standard)97.1% 97.3% 97.3% ↑

Cancer (ALL) - 31 day DTT for subsequent treatment - Surgery 94%Contractual (National

Operational Standard)77.8% 100.0% 100.0% ↑

Cancer (ALL) - 31 day DTT for subsequent treatment - Anti-cancer drug regimen 98%Contractual (National

Operational Standard)100.0% 100.0% 100.0% ↔

Cancer (ALL) - 31 day DTT for subsequent treatment - Other Palliative 98%Contractual (National


Cancer (ALL) - 62 day referral to treatment following an urgent referral from GP

(post)85%



Cancer (ALL) - 62 day referral to treatment following a referral from screening

service (post)90%



% patients waiting less than 6 weeks for a diagnostic test 99%Contractual (National


ED - Maximum waiting time of 4 hours from arrival to admission/transfer/

discharge 95%



ED - Maximum waiting time of 4 hours from arrival to admission/transfer/

discharge (Including MIU/UCC activity from November 2016)95%



Well Led

Annual leave rate (excluding Ward Manager) % of weeks within threshold 11.5 - 17.5% 50.81% 29.84% 29.84%

Sickness rate (one month in arrears) 3.3%Internal Standard

reported to FPC3.35% N/A N/A ↑

Appraisal rate 90%Internal Standard

reported to FPC78% 74% 76% ↓

Staff Turnover Rate 8 -12%Internal Standard

reported to FPC11.6% 11.3% 11.3% N/A

NHS Staff Survey

CQC Inpatient Survey

GMC Survey

Total Workforce Capacity 2,394Internal Standard

reported to FPC2,245.0 2,248.0 2,248.0 N/A

Vacancy Rate (substantive) <5%Internal Standard

reported to FPC3.4% 6.1% 6.1% ↓

Total Pay Cost 9,634.0Internal Standard

reported to FPC8,965.7 9,065.1 9,065.1 ↓

Number of formal concerns raised under the Whistleblowing Policy in month N/AInternal Standard

reported to FPC0 0 0 N/A

Essential Skill Rate 90%Internal Standard

reported to FPC90% 83% 83% ↓

Elective levels of contracted activity (activity)2017/18 = 26,874

M1 = 2,240 2,468 2,076 2,076 ↓

Elective levels of contracted activity (£)2017/18 = 26,674,034

M1 = 2,222,836 2,592,431 2,118,414 2,118,414 ↓

Surplus/(deficit) (year to date)2017/18 = (2,904)

Q1 = (3,633)Local Plan 1,122 (497) (497) ↑ N/A

Surplus/(deficit) (in month/quarter) (1,208) Local Plan 1,138 (497) (497) ↑

Cash Balance 901 4,427 5,356 5,356 ↑

CIP - year to date (aggressive cost reduction plans)2017/18 = (8,774)

Q1 = (464)Local Plan 6,794 (154) (154) ↑ N/A

Agency spend in month2017/18 = 3,122

Q1 = 1,212216 248 248 ↓

Agency % of pay expenditure2017/18 = 2.9%

Q1 = 4.2%2.4% 2.7% 2.7% ↑

Movement Key

Favourable Movement ↑ Achieving Standard

Adverse Movement ↓ Not Achieving Standard

No Movement ↔

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Title of Meeting

Trust Board

Date of Meeting

May 31st 2017

Report Title

2016 Picker Inpatient Survey Report

Author

Neal Cleaver, Deputy Director of Nursing and Quality


Nicky Lucey, Director of Nursing and Quality

Purpose of Report (e.g. for decision, information) To provide a summary of the Picker Inpatient 2016 survey results. The complete report is attached as an appendix for information.

Summary In comparison to the 2015 Inpatient Survey results , the trust was significantly better on 2 questions and worse on 0 questions:

The Trust has improved significantly on the following questions:

2015 2016

Doctors: did not always have confidence and trust 19 % 14 %

Nurses: talked in front of patients as if they weren't there 20 % 14 %

In comparison to other trusts within the 2016 Inpatient survey, the Trust was significantly better on 19 questions, and worse on 3 questions; therefore the key areas for improvement are:

DCH results were significantly worse than the ‘Picker average’ for the following questions:

Trust Average

Hospital: patients using bath or shower area who shared it with opposite sex 26 % 12 %

Hospital: not always able to take own medication when needed to 40 % 34 %

Surgery: not told how to expect to feel after operation or procedure 46 % 40 %

Paper Previously Reviewed By This paper has been reviewed by the previous Learning From Patients Committee.

Strategic Impact This information will be public and may determine where patients prefer to be treated.

Risk Evaluation 1. Patients care and recovery may be compromised if staff are not communicating what

to expect to them following procedures/operations.

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2. Patients care and recovery may be compromised if they are unable to take their own medication when needed.

Impact on Care Quality Commission Registration and/or Clinical Quality This information will be used by the Care Quality Commission to review the quality of care at the Trust.

Governance Implications (legal, clinical, equality and diversity or other): Inability to achieve progress or sustain set standards could lead to a negative reputational impact and inability to improve patient safety, effectiveness and experience. The report highlights that patients perceive that they share bathroom/shower room accommodation with patients of the opposite sex.

Financial Implications Undetermined, but could incur penalty if unable to achieve agreed standards/targets.


Yes

Recommendations a) To note the report; b) To review the findings

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Title of Meeting

Trust Board

Date of Meeting

31st May 2017

Report Title

Inpatient Survey 2016 Summary Paper (Full Survey as Appendix)

Author

Becky Protopsaltis, Head of Public and Patient Experience Nicola Lucey, Director of Nursing and Quality Neal Cleaver, Deputy Director of Nursing and Quality

INTRODUCTION

1. Introduction:

This document summarises the findings from the Inpatient Survey 2016, carried out by

Picker Institute Europe, on behalf of Dorset County Hospital NHS Foundation Trust.

The Picker Institute was commissioned by 83 trusts to undertake the Inpatient Survey

2016. A total of 1250 patients from our Trust were sent a questionnaire. 1207 patients

were eligible for the survey, of which 622 returned a completed questionnaire, giving a

response rate of 52%.

2. Have we improved our results since the 2015 survey?

A total of 63 questions were used in both the 2015 and 2016

surveys.

Compared to the 2015 survey, DCH is:

Significantly BETTER on 2 questions

Significantly WORSE on 0 questions

The scores show no significant difference on 61 questions

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The Trust has improved significantly on the following questions:

2015 2016



3. How do we compare with other Trusts?

The survey showed that your Trust is:

Significantly BETTER than average on 19 questions

Significantly WORSE than average on 3 questions

The scores were average on 45 questions

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DCH results were significantly better than the ‘Picker average’ for the following questions:

Trust Average

A&E Department: not enough/too much information about condition or treatment 17 % 23 %

A&E Department: not given enough privacy when being examined or treated 12 % 23 %

Planned admission: specialist not given all the necessary information 1 % 2 %

Admission: had to wait long time to get to bed on ward 26 % 36 %

Hospital: room or ward not very or not at all clean 2 % 3 %

Hospital: toilets not very or not at all clean 4 % 5 %

Hospital: food was fair or poor 30 % 39 %

Hospital: not offered a choice of food 12 % 20 %


Nurses: did not always get clear answers to questions 25 % 30 %

Nurses: did not always have confidence and trust 17 % 21 %


Care: did not always have confidence in the decisions made 23 % 27 %

Care: not always enough privacy when being examined or treated 6 % 9 %

Surgery: questions beforehand not fully answered 16 % 21 %

Discharge: was delayed 31 % 41 %

Discharge: staff did not discuss need for additional equipment or home adaptation 10 % 19 %

Overall: did not always feel well looked after by staff 17 % 20 %

Overall: rated experience as less than 7/10 12 % 15 %

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DCH results were significantly worse than the ‘Picker average’ for the following questions:

Trust Average

Hospital: patients using bath or shower area who shared it with opposite sex 26 % 12 %

Hospital: not always able to take own medication when needed to 40 % 34 %

Surgery: not told how to expect to feel after operation or procedure 46 % 40 %

4. Admission to Hospital:

The trust is significantly better than average on 4 questions:

Trust Average

3 A&E Department: not enough/too much information about condition or treatment 17 % 23 %

4 A&E Department: not given enough privacy when being examined or treated 12 % 23 %

5 Planned admission: not offered a choice of hospitals 70 % 69 %

6 Planned admission: should have been admitted sooner 24 % 25 %

7 Planned admission: admission date changed by hospital 19 % 20 %

8 Planned admission: specialist not given all the necessary information 1 % 2 %

9 Admission: had to wait long time to get to bed on ward 26 % 36 %

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There is no significant difference historically:

2011 2012 2013 2014 2015 2016

3 A&E Department: not enough/too much information about

condition or treatment 15 % 21 % 18 % 14 % 19 % 17 %

4 A&E Department: not given enough privacy when being

examined or treated 22 % 19 % 16 % 12 % 14 % 12 %

5 Planned admission: not offered a choice of hospitals 70 % 70 % 72 % 66 % 65 % 70 %

6 Planned admission: should have been admitted sooner 23 % 27 % 19 % 24 % 21 % 24 %

7 Planned admission: admission date changed by hospital 21 % 27 % 26 % 25 % 22 % 19 %

8 Planned admission: specialist not given all the necessary

information - - 2 % 3 % 3 % 1 %

9 Admission: had to wait long time to get to bed on ward 27 % 33 % 34 % 23 % 24 % 26 %

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5. The Hospital and Ward:

The trust is significantly better than average on 4 questions and worse on 2 questions:

Trust Average

11a Hospital: shared sleeping area with opposite sex 7 % 7 %

13a Hospital: patients in more than one ward, sharing sleeping area with opposite sex 4 % 5 %

14+ Hospital: patients using bath or shower area who shared it with opposite sex 26 % 12 %

15 Hospital: bothered by noise at night from other patients 42 % 39 %

16 Hospital: bothered by noise at night from staff 19 % 20 %

17 Hospital: room or ward not very or not at all clean 2 % 3 %

18+ Hospital: toilets not very or not at all clean 4 % 5 %

19 Hospital: felt threatened by other patients or visitors 3 % 3 %

20+ Hospital: did not always get enough help from staff to wash or keep clean 26 % 29 %

21+ Hospital: not always able to take own medication when needed to 40 % 34 %

22+ Hospital: food was fair or poor 30 % 39 %

23 Hospital: not offered a choice of food 12 % 20 %

24+ Hospital: did not always get enough help from staff to eat meals 29 % 36 %

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2011 2012 2013 2014 2015 2016

11a Hospital: shared sleeping area with opposite sex 8 % 5 % 7 % 6 % 10 % 7 %

13a Hospital: patients in more than one ward, sharing sleeping

area with opposite sex 7 % 3 % 3 % 5 % 5 % 4 %

14+ Hospital: patients using bath or shower area who shared it

with opposite sex 30 % 26 % 21 % 20 % 26 % 26 %

15 Hospital: bothered by noise at night from other patients 39 % 45 % 45 % 38 % 44 % 42 %

16 Hospital: bothered by noise at night from staff 19 % 24 % 19 % 19 % 21 % 19 %

17 Hospital: room or ward not very or not at all clean 1 % 2 % 1 % 1 % 1 % 2 %

18+ Hospital: toilets not very or not at all clean 3 % 4 % 3 % 2 % 4 % 4 %

19 Hospital: felt threatened by other patients or visitors 2 % 2 % 2 % 2 % 3 % 3 %

22+ Hospital: food was fair or poor 30 % 30 % 30 % 29 % 28 % 30 %

23 Hospital: not offered a choice of food 10 % 10 % 14 % 17 % 13 % 12 %

24+ Hospital: did not always get enough help from staff to eat

meals 26 % 41 % 40 % 20 % 36 % 29 %

6. Doctors:

The trust is significantly better than average on 1 question and worse on 0 questions:

Trust Average

25+ Doctors: did not always get clear answers to questions 30 % 30 %

26 Doctors: did not always have confidence and trust 14 % 18 %

27 Doctors: talked in front of patients as if they were not there 19 % 22 %

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There is significant improvement historically in 1 question:

2011 2012 2013 2014 2015 2016

25+ Doctors: did not always get clear answers to questions 31 % 31 % 30 % 28 % 30 % 30 %

26 Doctors: did not always have confidence and trust 16 % 21 % 20 % 16 % 19 % 14 %

27 Doctors: talked in front of patients as if they were not

there 23 % 27 % 27 % 22 % 23 % 19 %

7. Nurses:


Trust Average

28+ Nurses: did not always get clear answers to questions 25 % 30 %

29 Nurses: did not always have confidence and trust 17 % 21 %

30 Nurses: talked in front of patients as if they weren't there 14 % 17 %

31 Nurses: sometimes, rarely or never enough on duty 41 % 40 %

32 Nurses: did not always know which nurse was in charge of care 51 % 51 %

There is significant improvement historically in 1 question:

2011 2012 2013 2014 2015 2016

28+ Nurses: did not always get clear answers to questions 26 % 26 % 24 % 22 % 27 % 25 %

29 Nurses: did not always have confidence and trust 24 % 23 % 20 % 17 % 20 % 17 %

30 Nurses: talked in front of patients as if they weren't there 18 % 18 % 15 % 15 % 20 % 14 %

31 Nurses: sometimes, rarely or never enough on duty 36 % 43 % 46 % 34 % 39 % 41 %

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8. Care and Treatment:


Trust Average

33 Care: staff did not always work well together 21 % 22 %

34 Care: staff contradict each other 29 % 31 %

35 Care: wanted to be more involved in decisions 40 % 44 %

36 Care: did not always have confidence in the decisions made 23 % 27 %

37 Care: not enough (or too much) information given on condition or treatment 20 % 19 %

38+ Care: could not always find staff member to discuss concerns with 58 % 62 %

39+ Care: not always enough emotional support from hospital staff 40 % 43 %

40 Care: not always enough privacy when discussing condition or treatment 23 % 24 %

41 Care: not always enough privacy when being examined or treated 6 % 9 %

43 Care: staff did not do everything to help control pain 25 % 29 %

44+ Care: more than 5 minutes to answer call button 16 % 18 %

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2011 2012 2013 2014 2015 2016

33 Care: staff did not always work well together - - - - 22 % 21 %

34 Care: staff contradict each other 31 % 32 % 31 % 26 % 32 % 29 %

35 Care: wanted to be more involved in decisions 42 % 46 % 42 % 41 % 39 % 40 %

36 Care: did not always have confidence in the decisions

made - - - 24 % 26 % 23 %

37 Care: not enough (or too much) information given on


38+ Care: could not always find staff member to discuss

concerns with 55 % 63 % 64 % 59 % 61 % 58 %

39+ Care: not always enough emotional support from hospital

staff 39 % 47 % 40 % 31 % 38 % 40 %

40 Care: not always enough privacy when discussing


41 Care: not always enough privacy when being examined or

treated 8 % 11 % 8 % 6 % 7 % 6 %

43 Care: staff did not do everything to help control pain 29 % 28 % 23 % 19 % 27 % 25 %

44+ Care: more than 5 minutes to answer call button 14 % 21 % 19 % 14 % 17 % 16 %

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9. Operations and Procedures:

The trust is significantly better than average on 1 question and worse on 1 question:

Trust Average

46+ Surgery: risks and benefits not fully explained 15 % 17 %

47+ Surgery: what would be done during operation not fully explained 26 % 23 %

48+ Surgery: questions beforehand not fully answered 16 % 21 %

49 Surgery: not told how to expect to feel after operation or procedure 46 % 40 %

51 Surgery: anaesthetist / other member of staff did not fully explain how would put to

sleep or control pain 13 % 14 %

52 Surgery: results not explained in clear way 31 % 30 %


2011 2012 2013 2014 2015 2016

46+ Surgery: risks and benefits not fully explained 13 % 20 % 13 % 20 % 17 % 15 %

47+ Surgery: what would be done during operation not fully

explained 23 % 28 % 23 % 28 % 27 % 26 %

48+ Surgery: questions beforehand not fully answered 20 % 26 % 20 % 21 % 21 % 16 %

49 Surgery: not told how to expect to feel after operation or

procedure 47 % 46 % 43 % 43 % 44 % 46 %

51 Surgery: anaesthetist / other member of staff did not fully

explain how would put to sleep or control pain 13 % 14 % 12 % 14 % 14 % 13 %

52 Surgery: results not explained in clear way 38 % 35 % 30 % 32 % 35 % 31 %

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10. Leaving Hospital:


Trust Average

53+ Discharge: did not feel involved in decisions about discharge from hospital 45 % 45 %

54 Discharge: not given notice about when discharge would be 44 % 44 %

55 Discharge: was delayed 31 % 41 %

57 Discharge: delayed by 1 hour or more 80 % 85 %

59+ Discharge: did always get enough support from health or social care professionals. 46 % 46 %

60+ Discharge: did not always know what would happen next with care after leaving

hospital 48 % 48 %

61 Discharge: not given any written/printed information about what they should or

should not do after leaving hospital 37 % 36 %

62+ Discharge: not fully told purpose of medications 25 % 25 %

63+ Discharge: not fully told side-effects of medications 64 % 61 %

64+ Discharge: not told how to take medication clearly 23 % 24 %

65+ Discharge: not given completely clear written/printed information about medicines 26 % 28 %

66+ Discharge: not fully told of danger signals to look for 55 % 57 %

67+ Discharge: family or home situation not considered 34 % 37 %

68+ Discharge: family not given enough information to help 49 % 53 %

69 Discharge: not told who to contact if worried 18 % 20 %

70+ Discharge: staff did not discuss need for additional equipment or home adaptation 10 % 19 %

71+ Discharge: staff did not discuss need for further health or social care services 15 % 18 %

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2011 2012 2013 2014 2015 2016

53+ Discharge: did not feel involved in decisions about

discharge from hospital 39 % 49 % 44 % 45 % 43 % 45 %

54 Discharge: not given notice about when discharge would

be - 44 % 42 % 43 % 43 % 44 %

55 Discharge: was delayed 31 % 40 % 35 % 44 % 34 % 31 %

57 Discharge: delayed by 1 hour or more 81 % 84 % 76 % 83 % 79 % 80 %

59+ Discharge: did always get enough support from health or

social care professionals. - - - - 41 % 46 %

61 Discharge: not given any written/printed information about

what they should or should not do after leaving hospital 35 % 35 % 23 % 33 % 36 % 37 %

62+ Discharge: not fully told purpose of medications 25 % 26 % 23 % 23 % 25 % 25 %

63+ Discharge: not fully told side-effects of medications 58 % 64 % 62 % 58 % 62 % 64 %

64+ Discharge: not told how to take medication clearly 24 % 22 % 21 % 24 % 24 % 23 %

65+ Discharge: not given completely clear written/printed

information about medicines 28 % 26 % 20 % 23 % 26 % 26 %

66+ Discharge: not fully told of danger signals to look for 55 % 61 % 52 % 51 % 57 % 55 %

67+ Discharge: family or home situation not considered - 36 % 34 % 28 % 34 % 34 %

68+ Discharge: family not given enough information to help 55 % 57 % 41 % 45 % 54 % 49 %

69 Discharge: not told who to contact if worried 21 % 21 % 14 % 17 % 20 % 18 %

70+ Discharge: staff did not discuss need for additional

equipment or home adaptation - 21 % 9 % 17 % 15 % 10 %

71+ Discharge: staff did not discuss need for further health or

social care services - 17 % 9 % 14 % 18 % 15 %

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11. Overall:


Trust Average

72 Overall: not treated with respect or dignity 14 % 16 %

73 Overall: did not always feel well looked after by staff 17 % 20 %

74+ Overall: rated experience as less than 7/10 12 % 15 %

75 Overall: not asked to give views on quality of care 72 % 70 %

76 Overall: did not receive any information explaining how to complain 60 % 60 %


2011 2012 2013 2014 2015 2016

72 Overall: not treated with respect or dignity 17 % 21 % 17 % 14 % 15 % 14 %

73 Overall: did not always feel well looked after by staff - - - 17 % 18 % 17 %

74+ Overall: rated experience as less than 7/10 - 19 % 15 % 11 % 13 % 12 %

75 Overall: not asked to give views on quality of care 85 % 83 % 73 % 68 % 75 % 72 %

76 Overall: did not receive any information explaining how to

complain - 65 % 59 % 58 % 62 % 60 %

12. Recommendations:

To note the findings of the report

Analysis of patients comments is taking place, and divisional action plans are in

development

To delegate monitoring of the action plan to the newly formed Patient Experience

Group (which will report to the Quality Committee).

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Title of Meeting

Trust Board

Date of Meeting

31 May 2017

Report Title

Mission and Vision Statements Review

Author

Susie Palmer


Nick Johnson

Purpose of Report (e.g. for decision, information) For decision

Summary The Trust Strategy mission and vision statements were reviewed at a Board development session. The output from that session was tested with staff at a focus group and the feedback incorporated into the suggestions outlined here.

Paper Previously Reviewed By N/A

Strategic Impact The mission and vision are an integral part of the strategy

Risk Evaluation Risk to delivery of our strategic aims if we don’t have agreed vision and mission statements to circulate

Impact on Care Quality Commission Registration and/or Clinical Quality The implementation of the strategy is key to delivery of high quality, sustainable care to our patients

Governance Implications (legal, clinical, equality and diversity or other): None

Financial Implications None


Yes

Recommendations

a) The Board agrees the proposed mission and vision statements b) c)

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Trust Strategy Mission and Vision Statements Review

Introduction

The Board reviewed the Trust’s current purpose, vision and mission statements at the April

2017 development session to ensure that they were still relevant and written in a way which

could be communicated simply and effectively to staff at all levels of the organisation and

beyond.

The Board felt that it was time to move on from the current ‘purpose’ of ‘delivering

compassionate, safe and effective healthcare’ and refine the ‘mission and ‘vision’

statements:

Mission: Playing a leading role, in collaboration with our partners, in the development of an

integrated, patient-centred health and care system.

Vision: Providing and enabling outstanding care for our patients and communities in ways

which matter to them.

Board Development Session Outcome

Following group discussions several mission and vision statement options were proposed:

Mission:

Outstanding care for people in ways which matter to them.

The outstanding DGH at the heart of serving the people of central Dorset.

Our outstanding hospital at the heart of the health and care system, improving the

health of people in Dorset.

Vision:

Our hospital, working with our health and social care partners, will be at the heart of

improving the health and wellbeing of our communities.

Dorset County Hospital is now and will be at the heart of a health and care system

providing outstanding care to people in ways which matter to them.

Dorset County Hospital, working with our health and social care partners to improve

the health and wellbeing of our communities.

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These ideas were then refined to present to staff during a focus group to gauge reaction to

specific wording and concepts.

Staff Focus Group Feedback

We ran a focus group of several staff from different areas of the hospital, which included

representatives from clinical and support teams.

Attendees were given some background on the strategy as well as information about what

we mean by a ‘mission’ and ‘vision’ and the key concepts we are trying to get across.

Attendees were also taken through the strategic objectives to check they made sense to

them:

Strategic Objectives

Feedback was positive - the group felt the wording was clear and concise, and the short

explanation under each title was sufficient to explain what each meant.

Mission and Vision

The following options were shared with staff to test how they felt about specific wording:

Mission:

1. Outstanding care for our patients in ways which matter to them

2. Outstanding care for people in ways which matter to them

3. An outstanding district general hospital at the heart of our communities

Vision:

1. Working with our health and social care partners to improve the wellbeing of our

communities – living our values every day.

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2. Our hospital, working with our health and social care partners, will be at the heart of

improving the wellbeing of our communities.

3. Dorset County Hospital will be a key partner in developing a joined-up, patient-

centred health and care system for Dorset.

The group initially favoured Option 1 for the mission statement but after discussion decided

that Option 2 was more appropriate as ‘people’ was a better word as it reflected how we care

for the whole person rather than labelling people as patients. It also reflects that we care for

families and carers as well as the patient themselves.

The group also liked the use of the word ‘outstanding’ as it reflects what we are striving to

achieve.

Some members of the group liked Option 3 but it was felt that not everyone understood what

was meant by a ‘district general hospital’.

There was much discussion around the wording used in the vision options. The group

favoured the use of the words ‘communities’, ‘heart’, ‘partners’ and ‘wellbeing’ as they felt

this reflected our aims. There was also a preference for using the hospital’s name in full.

A line about the Trust values was added to one option to gauge opinion about how we tie in

the values with the strategy. Although the group recognised the values were an integral part

of how the Trust expects staff to behave, they didn’t feel they needed to be specifically

mentioned in the statements. There was positive feedback about how well the values were

being embedded within the organisation, and externally – staff commented that candidates

for vacancies were using them to illustrate why they were suitable for posts.

Recommendation

Based on the feedback received from staff the following options for the mission and vision

statements are proposed for agreement:

Mission: Outstanding care for people in ways which matter to them.

Vision: Dorset County Hospital, working with our health and social care partners, will

be at the heart of improving the wellbeing of our communities.

Next Steps

The Trust Strategy will be launched in the first week of July 2017 with a programme of

activity following to inform staff, governors, members, general public and stakeholders.

Activity will include but is not limited to:

Distribution of supporting materials, including a booklet, leaflet, credit card and poster

Team Brief presentation

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Programme of visits to key departmental staff meetings

Open staff sessions

Restaurant information stand

Dedicated StaffNet page

Screensaver

CEO Brief messages

Social media

Council of Governors meeting presentation

Membership newsletter article

Presentation at AGM/AMM

Dedicated public website page

Annual Review section

Open Day stand/presentation

News release

Message to GPs

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Title of Meeting

Trust Board

Date of Meeting

31 May 2017

Report Title

Strategy Update Report

Author

Nick Johnson


Nick Johnson

Purpose of Report (e.g. for decision, information) For information

Summary This purpose of this report is to provide Board with an update on strategy implementation and activity and enable the Board to monitor progress towards its agreed strategic objectives. It will also ensure Board has regular sight of the core strategy and prompt issues for debate and discussion (either immediately or at a later date). It is intended that the SUR is presented to Board on a quarterly basis. It is expected that the form and content of the SUR will evolve as Board requires.

Paper Previously Reviewed By EMT

Strategic Impact This report will help monitor implementation of the Trust Strategy.

Risk Evaluation Strategic risks will be identified as a result of discussions around this report and will inform BAF updates.

Impact on Care Quality Commission Registration and/or Clinical Quality None arising as a result of this report

Governance Implications (legal, clinical, equality and diversity or other): None arising as a result of this report.

Financial Implications None arising as a result of this report.


Yes.

Recommendations It is recommended that Board:

Note and discuss the Strategy Update Report content and design

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DCH Strategy Update Report

For 31st May 2017 Trust Board

Outstanding Care for people in ways which matter to them

Board Quarterly May17, September 17, January 18, March 18 (part of 18/19 review)

Execs Bi-monthly Focus on corporate priorities progress June, August, October, December, February

SMT Bi-monthly Focus on strategic programmes progress June, August, October, December, February

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6

OutstandingDelivering

outstanding services everyday

IntegratedJoining up our

services

Collaborative Working with our

patients and partners

EnablingEmpowering our

staff

SustainableProductive,

effective and efficient

New care modelsDevelop a sustainable service and financial model for all our services

Strategic Objectives 17/18 Corporate Priorities

System integrationEnsure a clear STP and ACS delivery

plan and drive forward the mid-Dorset hub

VanguardImplement key Vanguard

workstreams – Pathology, Business Support Services , Health Informatics

and Stroke

Commercial developmentDevelop and implement key

commercial ventures – Private Patients, Damers, Pharmacy

Better Information Deliver our Information Strategy

Front-line leadershipDevelop and embed the new Divisional leadership model

- Rated Outstanding- Meeting our

performance targets

- Reduced ED admissions and

hospital bed days per 100,000 population

97+% Friends and Family

Top quartile staff engagement

1% Operating surplus

Strategic Measures

Strategic Service Transformation

Programme

Strategic Programmes

Governance Framework and New Divisional

Structure

Digital Patient Record

Accountable Care System

One Acute Network of services

Acute Care Collaborative Vanguard

Damers Joint Venture

Dorset Care Record

Business Support Services and Health

Informatics

Syste

mO

rganisa

tional

Demand Management

Mid-Dorset Hub

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1. Summary

System working continues at pace. The One Acute Network Programme is being established and DCH must ensure the right engagement

and involvement given the majority of the programme will be focussed on any changes in acute provision in east Dorset as a result of the

CSR.

The Trust continues to make progress in delivering key strategic programmes which contribute towards the achievement of our strategic

objectives.

The key issue for the Trust is the ability to deliver all of the key programmes – system wide and internally – at the pace required in order to

impact demand, financial and workforce pressures in the timeframes required.

National

The result of the general election is awaited which may bring a new Health Secretary. The timing of the general election has upset

assumptions that there may have been some extra funding for the NHS in 2018 to mark the NHS’ 70th Birthday.

The purdah period arising due to the general election has limited recent national activity, however, the recent release of the Five Year

Forward View Next Steps document on 31st March which was designed to set clear priorities around urgent and emergency care, primary

care, mental health, and efficiency (briefing at appendix 1).

The Naylor Review of NHS Property and Estates was published on 31st March setting our recommendations for better management of

property and estates. The Trust is reviewing the document to ensure its plans – in particular around Damers site – align to the Naylor

review recommendations where applicable (e.g. a drive to use land for key worker housing). (briefing at appendix 2)

System-wide & Sustainability and Transformation Partnership

An expression of interest was submitted to NHS England by the Dorset SLT to be considered a wave one STP/Accountable Care System.

A Programme Director has been appointed by Poole Hospital and RBCH for the One Acute Network Programme. Discussions are taking

place between DCH, Poole and RBCH over the Terms of Reference for the One Acute Network Programme Board.

A high-level Business Case was submitted to NHSE/I for capital funding for acute reconfiguration in the east.

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DCH staff have been working closely with system partners on developing an Accountable Care System programme and delivering key

ACC Vanguard workstreams on pathology, stroke, Health informatics and business support services.

DCH

The new divisional structure, performance framework and governance structure have been implemented and are now being embedded.

The development of an internal Transformation Programme following the Strategic Service Review has not yet been finalised as a result of

competing system wide-priorities.

The procurement for the Strategic Estates Partner for the Damers site development and wider site master planning is currently on

programme and due to be completed in June.

Key commercial strategy milestones/achievements with signing of Costa lease, agreement with NHS England to set up the Pharmacy

Sub-Co and DCH Pharmacy being awarded the Dorset Healthcare Pharmacy contract.

A Staff Focus Group was held in May to test the Mission and Vision (separate report forthcoming).

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2. Strategic Objectives

Strategic Priorities Update

Outstanding - Delivering outstanding services everyday

Key enabling areas/areas of focus

to place the patient at the centre of all we do ensuring safe, effective and caring services

to develop a culture of continuous improvement, supporting clinical teams to improve their quality, safety and efficiency

to look within our organisation and ensure services are joined-up and integrated across specialities to the benefit of the patient

to implement a comprehensive and robust governance approach across the organisation

Performance Management Framework has been a launched.

Monthly meetings between Division and Executive will review the immediate past and future and review corrective actions

Quarterly Performance Management Meetings involving Division and Executives will focus on the forward view across all aspects of performance, quality, service improvement, finance and workforce development

Divisions will work towards full autonomy through the provision of robust assurance and delivery against required standards across the performance and quality agenda

Transformation Office is supporting the delivery of a Continuous Quality Improvement culture within the Trust, including encouraging and supporting service to actively engage in co-design with patients and carers as part of service improvement strategies

Integrated – Joining up our services


to work with our partners to establish an Accountable Care Partnership to develop shared care pathways and a holistic care approach for our patients and deliver care closer to home

to develop a healthcare hub on the DCH site working with our partners in community and primary care and in particular with our Mid-Dorset GP colleagues

to strengthen relationships with primary care, supporting the sustainability and education of the sector

ACS in section 3 below

GP/Primary care The Deputy Medical Director will commence in post in October to take forward this agenda

Other key service developments Collaborative key service developments already in early development stages include working with Dorset HealthCare Foundation Trust on Sexual Health Services, Pulmonary Rehabilitation provision and Diabetes care closer to home. Models include consultants assisting Primary and Community health colleagues in the management of patients with long term conditions through a multidisciplinary approach that aims to prevent escalation of symptoms and the need for hospital referral or admission.

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Collaborative – Working with our patients and partners


to work with our Acute Care Collaborative Vanguard partners to deliver outstanding services which reflect the needs of our local populations

to strengthen links between health and social care and mental health providers to provide joined-up services

to establish a comprehensive transformation programme for our services focussed on co-design and outcomes

One Acute Network & Vanguard progress – see section 3 below

Transformation Programme – see section 3 below

Enabling – Empowering our staff


to implement our ‘People Strategy 2015’ to develop the our ability to deliver safe, effective and compassionate care

to review our enabling and support services to ensure they support the delivery of our aims and objectives and meet the needs of our patients and staff

to ensure relevant data is easily accessible, in multiple locations using technology, and enabling a culture of evidence based decision making

to speed up the adoption of relevant research and innovation and define our role within science, education and training, and research and development, working with the AHSN.

to appreciate and further develop our social responsibility in the community

People Strategy update – implementation of 3 year plan continues on track. Values developed and re-launched, appraisal paperwork relaunched to include assessment against behaviours, induction re-viewed, phase one of Leadership Development Programme delivered, and second phase commencing June2017, Workforce planning governance reviewed and in place. Support Services

DCH is engaged in the system wide work exploring the potential to join-up support services across Dorset where appropriate. This covers, estates, procurement, finance, HR and Health Informatics (ICT).

DPR/DCR The Digital Patient Record is due to go live in June and will be rolled out to all staff by the end of June. Clinical and support staff have been involved in the design of the solution to ensure it enables staff in delivery of our aims and objectives including support for integrated care across care settings. As an ongoing development the solution will be responsive in enabling continuous improvement.

The Dorset Care Record Programme has selected a supplier. The programme is currently over budget. R&D and/or Innovation updates – none to report

Social/community engagement activity – none to report

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Sustainable – Productive, effective and efficient


to embed a culture of value management and deliver efficiency projects across the organisation, using the Carter principles as a foundation

to develop our commercial capacity and capability building commercial partnerships to help achieve this

to drive value from our assets, in particular our estates and property, and enhance the patient experience

A Finance Improvement Team is in place and working with the divisions to support them in delivering CIPs and developing a culture of value management. The Better Value Better Care Group is reviewing the Carter metrics to ensure efficiencies are maximised.

The commercial strategy is being implemented with a year one review due to take place shortly. The Costa commercial concession is due to open on 26th June. The Pharmacy Subsidiary Company will be established shortly and the Pharmacy Team recently won the DHC Pharmacy contract. Other commercial initiatives are in early planning phases.

We are currently undergoing a procurement dialogue process to identify a Strategic Estates Partner to take forward the development of the estate.

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3. Strategic programmes

Strategic Programme Update and progress since last report Key issues affecting delivery and resolution approach

Accountable Care System

Dorset was named as one of the 9 potential STPs which could apply to be a wave 1 ACS/ACO. A short Expression of Interest has been submitted to NHSE/I. Dorset County Hospital is working with partners in Primary, Community, Social and Urgent Care sectors to agree key steps towards creation of an Accountable Care System for West Dorset. Numerous programmes across the providers to integrate and simplify pathways will be launched in the first Quarter of 2017/18.

-An agreed definition/blueprint for a Dorset ACS has not yet been developed and delivery plan is not yet in place. -Consideration needs to be given to how the west/east split for any ACS is dealt with

One Acute Network of Services

Discussions with Poole and RBH regarding the Programme approach for delivery of the One Acute Network workstream are ongoing.

The major programme in the workstream will be re-configuration in the east. There is a risk that all the focus is on this reconfiguration rather than the wider goal of sustainable networks across Dorset.

Acute Care Collaborative Vanguard (a sub-programme of One Acute Network)

Agreement on the direction of travel for Business Support Services and Health Informatics is agreed. Pathology and Stroke workstreams are progressing

The evolution and sustainability of Vanguard after funding expires in 17/18? How the Vanguard programme will merge into One Acute Network Programme?

Demand Management – Right Referral, Right Care

9 specialties across 4 providers are involved in an iterative change program. The first Learning Week, testing assumptions or new pathways will be held in mid-May and this will inform the next iteration of the work-program. There are Learning Weeks planned for each Quarter in 2017/18.

Clinical capacity to engage with change program involving cross-county collaboration Understanding the current provision and pathways in place across multiple partners Weekly management and service improvement teleconferences in place to mitigate project slippage.

Mid-Dorset Hub

Dorset County Hospital is working with partners in Primary, Community,

and Social Care. 4 key workstreams have been identified to progress the

initial integrated working. There is senior clinician input from secondary

and primary care to each group and a dashboard will be developed to

monitor outcomes.

Identification of resource savings across the health

economy linked to the hub development proves a

challenge. The workstreams are anticipated to reduce

activity across the system but are not isolated from other

initiatives complicating the ability to measure impact.

Expanding the hub and establishing a permanent base

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within DCH and as close to ED as possible.

Service Transformation Programme

Transformation office is now fully staffed. Two members have been released to take part in the training program for Quality Service Improvement and Redesign run by NHS Improvements. Once qualified in September and as associate members of the QSIR College they will be able to deliver the program locally and grow quality service improvement knowledge and engagement within the Trust. Colleagues at the CCG and Dorset HealthCare Trusts have expressed an interest in taking part in this program alongside DCH personnel.

A methodology for accessing Transformation Office support at the appropriate level to be signed off in Quarter 1 Program content for 2017/18 Patient Flow Transformation to be agreed, this program needs to compliment the external agenda supporting the development of the Integrated Primary and Community Care Services and Accountable Care System programs with the STP partners.

Damers Joint Venture

The Damers Joint Venture procurement is progressing well and on schedule. Subject to approvals a JV partner is due to be selected in June and a site masterplan will be finalised in the autumn.

Procurement challenge risk is thought to be low but always possible. Wider system interest may have an impact but is being managed.

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4. Strategic measures

Strategic measure Narrative Update Baseline (April 2017) Current

2020/21 Target

Exec Lead Source

Rated outstanding by the Care Quality Commission

CQC action plan to address gaps in assurance progressing well with significant assurance from Internal auditors on action plan Quality Committee priorities in work plan drafted for board approval, includes: - Mortality surveillance - Sepsis and the deteriorating patient - Board triangulation of quality assurance - Quality assessment of STP and new models - Governance embedding of new framework and ward to board exemplar for well-led.- Quality account/report priorities agreed with partners and all have plans in progress: - SAFE: Avoidable falls reduction/ mortality surveillance and reducing variation (Including End of Life care)/ Sepsis - CLINICAL EFFECTIVENSS: Electronic discharge/ promote health and wellbeing staff and patients/ Volunteers and social isolation improved support to improve outcomes - PATIENT EXPERIENCE: Dementia/ Timely and compassionate response to complaints/ Information for patients

Requires Improvement

Requires Improvement

Outstanding NL CQC report Quality Report

Meeting our key performance targets

ED Achieving Achieving

Achieving 4/4

JP IPR/BI team

RTT – improvement plans to be presented at Finance Performance Committee in June 2017.

Requires improvement


Cancer, referral levels in March and April outstripped available capacity in addition to unplanned absences in key areas.

Achieving Requires improvement

Diagnostics – two areas only experiencing capacity constraints



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Reduced ED admissions per 100,000 population

Patient Flow Program (internal) and Better Care Program (external) initiatives in development to further improve non-elective flow through the system

ED Attendances 3,753 TBD TBD JP IPR/BI team Admissions via ED 1,240

Reduced number of hospital bed days per 1000,000

population

Patient Flow Program (internal) and Better Care Program (external) initiatives in development to further improve non-elective flow through the system

Bed Days (total excluding Regular Day Admissions) 12,297

TBD TBD JP BI Team

Bed Days (Non-elective Only) 9,190

Achieving a top quartile%* our friends and family test

*National benchmark

publication 1st June 2017

Inpatients: FFT well-embedded. Paediatrics trailing new

ways to engage children and young people in FFT

returns

CQUIN 95% 96%*

85%*

96%*

92%*

96% NL BI Team

Emergency department: Well-embedded and

performing well against set CQUIN based on national

benchmark

CQUIN 84%

Maternity: Not achieving and to be refreshed on the

engagement to complete returns

CQUIN 96%

Outpatient: Embedded and achieving CQUIN 92%

Top quartile for staff engagement

The People Strategy is the strategic programme to raise

levels of staff engagement. The delivery of the people

Strategy is on track, as described above, however the

overall staff engagement metric currently remains a the

national average for Acute Trusts. Annual action are

developed and managed centrally and within divisions.

3.80 3.80, compared

to national

average for

Acute Trusts of

3.81

Top quartile MW Workforce

report/HR

team

Financially sustainable; self-sufficient in cash terms with an operating surplus of 1%

The control total for 17/18 of a £2.9 million deficit will

not enable us to achieve this in the current financial

Forecast for

17/18 £2.9

£7.4 million

deficit 1% surplus LW Finance report/finance team

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without funding support year. A cash loan will be required this financial year. million deficit

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Appendix 1 – Dorset System and DCH Strategy programmes

Prevention at Scale

One Acute Network

Integrated Community

Services

Leading and Working

Differently

Digitally Enabled Dorset

toprovide

services to meet the

needs of local people and

deliver better outcomes

Accountable Care

Acute Hospital Re-

Configuration

Maternity and

Paediatrics with Yeovil

Community Hubs

Mid-Dorset Community

Hub

Clinical Services Review

Vanguard

STP Workstreams

Sustainability and Transformation Plan

System Implementation Programmes

Dorset Care Record

Mental HealthStrategy

Primary Care Strategy

Outstanding Care for our patients in ways which matter to

them

Outstanding

Collaborative

Integrated

Sustainable

Enabling

CIP

Digital Patient Record

Damers Road JV

Div Structure

Service T’mation

Governance

GP E’ment

People Strategy

Business Support Services

Right Care

Continuous Quality Improvement

DCH Strategy

Service T’mation

Service T’mation

STP VisionDCH

Strategic objectives

DCH Vision

Five Year Forward View

DCH Strategic Programmes

Right Care and Demand

Management

Str

ateg

y -

Boa

rd o

vers

ight

of 132

Title of Meeting

Board of Directors

Date of Meeting

31 May 2017

Report Title

Corporate Risk Register and Board Assurance Framework

Author

Mandy Ford, Head of Risk Management and Quality Assurance Lindsey Perryman, Trust Secretary


Nicky Lucey, Director of Nursing and Quality Libby Walters, Director of Finance and Resources

Purpose of Report (e.g. for decision, information) For information.

Summary

Corporate Risk Register The Risk Items on the Corporate Risk Register have been reviewed by the appropriate risk leads and the Executive Team.

The Trust Risk Register outlines the current position regarding all of the active Risk Items which have been identified by the Trust. There are currently 15 Risk Items on the Corporate Risk Register. Summarised below are key changes;

Increased Risks Impact

1009 Added 01/12/2016 No compliant mental health interview room, no footprint available.

Increased 14.4 HIGH RISK Ongoing

1045 Added 01/12/2016 Opthalmology Service Capacity

Increased 20.0 EXTREME RISK Ongoing

1009 Added 01/12/2016 Financial Sustainablity

Increased 13.6 HIGH RISK Ongoing

NEW

1059 Added 11.05.17

Recruitment and retention of staff across specialities

NEW Risk Rating 16 EXTREME RISK Outstanding

1060 Added 05/05/2017

Temporary Medical Workforce planning and capacity

NEW Risk Rating 12 HIGH RISK Outstanding

Cor

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te R

isk

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iste

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Board Assurance Framework Following the development of the Trust’s Strategy, the Board Assurance Framework has been reworked and mapped against the Trust’s Strategic Objectives and the priorities for achievement of the objective. The following risks are rated as RED:

Not being able to deliver transformational savings at a fast enough pace

Insufficient cash to ensure the continuity of services

An unsustainable financial position could result in a reduced quality of both clinical and support services and reduce the autonomy the Trust has in providing high quality services to its population.

Opthalmology: An unsustainable financial position could result in a reduced quality of both clinical and support services and reduce the autonomy the Trust has in providing high quality services to its population.

There have been changes to risk ratings of the BAF since the last review by Audit Committee.

Risks or emerging risks that are or could impact on the strategic priorities The following risks have been identified above as having the potential to impact on “outstanding”:

Emergency Department Target, Delays to Care & Patient Flow

ENT Medical Staffing

Waiting lists and staffing for Gastroenterology

Staffing within ED

Ability to meet targets because of staffing issues

Previously Reviewed by Corporate Risk Register - appropriate risk leads and the Executive Team.

Board Assurance Framework - Audit Committee, March 2017 - no changes to the BAF were requested at this meeting

Strategic Impact The Corporate Risk Register outlines the identified risks to the achievement of quality and performance standards. Failure to identity and control risks could lead to the Trust failing to meet its strategic objectives.

Risk Evaluation Each risk item is individually evaluated using the current Trust Risk Matrix.

Impact on Care Quality Commission Registration and/or Clinical Quality

Cor

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It is a requirement to regularly identify, capture and monitor risks to the achievement of quality and performance standards. The Trust Risk Register provides the Board with an opportunity to gain oversight of the identified risks and work streams being carried out to address them, and provide assurance to the Trust Board on these issues.

Governance Implications (legal, clinical, equality and diversity or other): The Trust Risk Register highlights that risks have been identified and capture. The Document provides an outline of the work being undertaken to manage and mitigate each risk and gives an opportunity for the Board to consider the effectiveness of the activities being undertaken. Where there are governance implications to risks on the Board Assurance Framework these will be considered as part of the mitigating actions.

Financial Implications The Trust Risk Register includes risks items relating to financial performance and the financial impact of individual quality and performance issues. The Board Assurance Framework includes risks to long term financial stability and the controls and mitigations the Trust has in place.


Yes

Recommendations

The Board are asked to:

note the Corporate Risk Register

note the Board Assurance Framework

consider additional emerging risks that need to be captured and monitored within the Trust Risk Register

consider whether those risk which are consider to have/potentially have an impact on the Trust’s strategic objectives should be included in the next iteration of the Board Assurance Framework

C

orpo

rate

Ris

k R

egis

ter

of 132

1045 V3 01/12/2016 Risk Rating

20.0 EXTREME RISK POST MITIGATION

12.0 HIGH RISK

1055 V1 06/03/2017 Risk Rating


11.2 HIGH RISK

1059 V1 11/05/2017 Risk Rating


1056 V1 08/03/2017 Risk Rating


3.6 LOW RISK

1009 V3 01/12/2016 Risk Rating

14.4 HIGH RISK 9.0 HIGH RISK

1017 V3 01/12/2016 Risk Rating

14.0 HIGH RISK POST MITIGATION

4.8 MODERATE RISK

1015 V3 01/12/2016 Risk Rating


7.8 HIGH RISK

1049 V3 01/12/2016 Risk Rating


6.6 MODERATE RISK

1011 V3 01/12/2016 Risk Rating


12.0 HIGH RISK

1051 V3 01/12/2016 Risk Rating


4.8 MODERATE RISK

1052 V3 08/03/2017 Risk Rating


5.4 MODERATE RISK

1060 V1 05/05/2017 Risk Rating


6.0 MODERATE RISK

1041 V3 01/12/2016 Risk Rating


4.8 MODERATE RISK

1047 V4 22/02/2017 Risk Rating


6.0 MODERATE RISK

1050 V3 01/12/2016 Risk Rating


4.4 MODERATE RISK

Workforce Planning & Capacity for Nursing/Midwifery Staff

Mortality Indicator

Temporary Medical Workforce Planning & Capacity

Medical Device Management - Training

Fire Alarm Reliability and Capacity

Financial Sustainability

Access to Care in the Community

Therapy Capacity

Sepsis: recognition, diagnosis and early management

Failure to manage the deteriorating patient effectively

This report provides a summary of the risks currently identified within the Department, Service or Function

SUMMARY

TRUST CORPORATE RISK REGISTER May 2017

Quality of Electronic Discharge Summaries

Recruitment and retention of staff across specialities

ENT Medical Staffing

Ophthalmology Service Capacity

Emergency Department Target, Delays to Care & Patient Flow

Cor

pora

te R

isk

Reg

iste

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Ref

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une

2017

) • T

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omet

rists

to s

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rt in

clin

ics

with

a v

iew

to w

orki

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uton

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sly

in th

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mm

unity

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r 201

6)• S

topp

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rout

ine

post

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e ca

tara

ct fo

llow

ups

to b

e pi

lote

d ad

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mew

ork

used

at R

oyal

Dev

on &

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ter h

ospi

tal s

ince

200

9 (J

une

2017

)• S

top

rout

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g fo

r cat

arac

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ond

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and

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ter g

uide

lines

to b

e in

trodu

ced

for f

irst e

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g (M

arch

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7)• R

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w lo

ng te

rm te

nder

opt

ions

to s

uppo

rt sp

ecifi

c pa

thw

ays

or e

ntire

ser

vice

. (J

un 1

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apac

ity P

lan

• R

evie

w c

apac

ity &

dem

and

mod

ellin

g w

ith n

ew p

osts

onl

ine.

(May

17)

• Und

erta

ke e

xten

sive

in d

epth

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idat

ion

– in

itial

val

idat

ion

sugg

ests

sev

eral

pa

thw

ays

coul

d be

clo

sed.

(May

17)

• SIT

to re

view

out

patie

nt a

nd th

eatre

sta

ndar

ds a

nd e

ffien

cies

and

cre

ate

rapi

d im

prov

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t pla

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rocu

rem

ent r

isk

asse

ssed

inso

urci

ng/o

utso

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ng w

ithou

t ten

derin

g. M

edin

et

and

YDH

eng

aged

to p

rovi

de q

uote

s/av

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capa

city

. (M

ay 1

7)• E

xten

d cu

rren

t Loc

um u

ntil

Sep

tem

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7. (M

ay 1

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evie

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ay 1

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atar

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y Ja

nuar

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17• A

dditi

onal

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trodu

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ting

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e.g.

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lopl

astic

s (O

ngoi

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ition

al o

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tient

clin

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to b

e in

trodu

ced

by fl

exin

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rren

t con

sulta

nt jo

b pl

ans

(Ong

oing

)• A

ttem

pt to

recr

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o co

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vac

ancy

(Mar

ch 2

017)

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lore

Joi

nt c

onsu

ltant

app

oint

men

t with

RB

H (M

arch

201

7)• R

evie

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kill

mix

afte

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igna

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of A

ssoc

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Spe

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ist t

o re

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ecem

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grad

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und

erta

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res

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ill to

be

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new

Ban

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nurs

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ug 2

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top

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lase

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ay 2

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ition

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linic

cap

acity

pla

nned

thro

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ut M

ay 1

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80

Out

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TRU

ST C

OR

POR

ATE

RIS

K R

EGIS

TER

May

201

7

This

repo

rt pr

ovid

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sum

mar

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the

risks

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rent

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entif

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with

in th

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ervi

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r Fun

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n

Ver

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Ris

k S

tate

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t

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Man

ager

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xtre

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Ther

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and

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acity

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uffic

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sta

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ls,

and

chal

leng

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f prio

ritis

atio

n of

new

and

chr

onic

pat

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s us

ing

a pa

rtial

boo

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ser

vice

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patie

nt w

aitin

g tim

es to

firs

t ap

poin

tmen

t now

una

ccep

tabl

y lo

ng a

nd p

ose

a po

tent

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atie

nt s

afet

y ris

k.

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with

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urse

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rthop

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pos

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adv

ert i

n M

arch

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.R

ecru

itmen

t –

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d 5

& 6

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optis

ts in

terv

iew

ed a

nd a

ppoi

nted

. Sta

rt da

tes

conf

irmed

for A

ug 1

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arly

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ellin

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gges

ts th

e fo

llow

ing

incr

ease

in y

early

out

patie

nt c

apac

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post

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line,

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spec

ialis

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se a

dver

t has

bee

n un

succ

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ul a

fter 3

roun

ds o

f adv

erts

. Rol

e re

view

ed a

nd to

be

rew

ritte

n as

1 W

TE

Clin

ical

Opt

omet

rist w

ith a

pla

n to

adv

ertis

e M

ay 1

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onsu

ltant

pos

ts n

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ith H

unte

rs H

ealth

care

to s

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tabl

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ndid

ates

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igh

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clin

ics

– hi

gh fl

ow g

lauc

oma

and

AM

D c

linic

s to

be

trial

led

to in

crea

se c

apac

ity w

ithou

t ext

ra m

edic

al s

taff.

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t clin

ic

plan

ned

for (

AM

D) 0

9/05

/17

with

18

patie

nts

book

ed a

s op

pose

d to

usu

al 1

2. G

lauc

oma

trial

stil

l to

be p

lann

ed.

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ucom

a R

efer

ral r

efin

emen

t – C

ontra

ct d

rafte

d by

pro

cure

men

t and

sen

t ove

r to

prov

ider

(Dor

set L

OC

) to

sign

. Pla

n to

co

mm

ence

ser

vice

Jun

e 17

.B

and

6 N

ursi

ng c

ompe

tenc

ies

– C

ompe

tenc

ies

draf

ted

and

agre

ed fo

r 2x

B6

Juni

or s

iste

rs in

the

RE

I to

unde

rtake

clin

ical

wor

k.

Trai

ning

pro

gram

me

agre

ed. P

lan

for s

uper

vise

d cl

inic

s to

com

men

ce e

nd o

f Jul

y/be

ginn

ing

Aug

17

once

initi

al tr

aini

ng

com

plet

e.In

ject

ion

capa

city

– L

ead

Orth

optis

t sta

rted

unde

rtaki

ng in

ject

ion

lists

Mar

17.

Thi

s ha

s re

plac

ed th

e lo

st c

apac

ity fr

om th

e pr

evio

us a

ssoc

iate

spe

cial

ist p

ositi

on.

22/0

3/20

16

Soph

ie J

orda

n, D

ivis

iona

l Man

ager

(Div

isio

n B

)B

en L

eigh

, Dire

ctor

ate

Man

ager

(Car

e G

roup

2)

Cor

pora

te R

isk

Reg

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of 132

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acan

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to b

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llow

pos

ts to

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ng R

oyal

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lege

to g

et p

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fo

rmal

ly re

cogn

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Dea

dlin

e fo

r adv

erts

- 31

/03/

17• D

iscu

ssio

ns w

ith It

alia

n un

iver

sity

to s

ecur

e re

gula

r SP

R tr

aine

es. P

lan

to h

ave

2 S

PR

's a

t a ti

me

unde

rtaki

ng m

inim

al s

ervi

ce a

nd e

mer

genc

y w

ork

in-b

etw

een

train

ing

wee

ks. F

irst S

PR

sec

ured

and

join

ing

the

depa

rtmen

t for

12

mon

ths

star

ting

28/0

2/17

• Loc

um a

ppro

ved

and

secu

red

to c

over

gap

- D

elay

ed, 2

2 cl

inic

s lo

st d

ue to

no

Locu

m th

roug

hout

Dec

, onl

y se

cure

d fro

m 1

6/01

/201

7 –

31/0

3/17

.C

onsu

ltant

long

term

Sic

knes

s• L

ocum

mid

dle

grad

e co

verin

g ge

nera

l clin

ics.

Red

uced

Impa

ct, N

o Lo

cum

th

roug

hout

Dec

embe

r res

ultin

g in

loss

of 6

clin

ics

as o

ther

cov

ered

by

cons

ulta

nt

colle

ague

s.• C

onsu

ltant

retu

rned

on

phas

ed b

asis

w/c

13/

02/1

7. W

ill u

nder

take

2 s

essi

ons

1st w

eek,

3 s

essi

ons

2nd

and

will

then

revi

ew w

ith O

H. C

onsu

lt ha

s ex

pres

sed

wis

h to

retu

rn to

5 d

ay w

orki

ng u

nder

taki

ng 5

clin

ical

ses

sion

s pe

r wee

k.

Aw

aitin

g ou

tcom

e of

Occ

upat

iona

l Hea

lth v

isit

28/0

2/17

.A

dmitt

ed b

ackl

og• R

TT m

onie

s se

cure

d fro

m N

HS

Eng

land

. Pla

n to

und

erta

ke a

t lea

st 5

0 ad

ditio

nal c

ases

bef

ore

end

of th

e fin

anci

al y

ear.

Wor

k to

be

unde

rtake

n by

DC

H

cons

ulta

nts

with

ME

DIN

ET

supp

lyin

g th

eatre

sta

ff at

wee

kend

s. D

eadl

ine

for

wor

k to

be

com

plet

ed -

31/0

3/17

• Wai

ting

list r

evie

wed

regu

larly

and

pat

ient

s tre

at in

turn

of c

linic

al p

riorit

y.

Adm

itted

per

form

ance

has

see

n a

stea

dy in

crea

se o

ver p

ast 4

mon

ths.

Non

-Adm

itted

Bac

klog

• Circ

a 60

pat

ient

s aw

aitin

g 1s

t OP

A o

ver 1

8w d

ue to

nee

ding

Aud

iogr

am p

rior t

o 1s

t OP

A. A

udio

logy

& E

NT

runn

ing

addi

tiona

l cap

acity

to s

ee p

atie

nts

in

Febr

uary

17.

Thi

s w

ill e

limin

ate

this

bac

klog

and

a n

ew jo

int p

roce

ss is

in p

lace

w

ith A

udio

logy

to e

nsur

e th

is d

oes

not h

appe

n ag

ain.

• 10

extra

clin

ics

plan

ned

thro

ugho

ut M

arch

17.

Thi

s gi

ves

capa

city

for a

n ad

ditio

nal 1

20 p

atie

nts

to b

e se

en.

Em

erge

ncy

cove

r• C

onsu

ltant

s ro

ta’s

/job

plan

s re

-writ

ten

to e

nsur

e th

ere

is a

con

sulta

nt o

n si

te

ever

y da

y to

cov

er m

iddl

e gr

ades

& S

HO

’s.

Pro

gres

s R

epor

tR

isk

Man

agem

ent

Pla

n &

Tim

esca

le

06/0

3/20

17

Cor

pora

te R

isk

Reg

iste

r

of 132

Ref

CU

RR

EN

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ISK

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ATI

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ST

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TIN

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Add

ed to

Ris

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egis

ter

Div

isio

nal L

eads

Ris

k M

anag

emen

t P

lan

& T

imes

cale

Man

y di

ffere

nt a

ppro

ache

s ar

e be

ing

adop

ted

to m

eet t

hese

risk

s, a

nd th

e so

lutio

n w

ill va

ry d

epen

ding

on

the

spec

ialty

and

par

ticul

ar is

sues

.

We

have

est

ablis

hed

a R

esou

rcin

g S

trate

gy B

oard

to c

onsi

der o

ur s

trate

gic

appr

oach

to

long

term

med

ical

gap

s, a

nd E

xecu

tives

mee

t on

a w

eekl

y ba

sis

to re

view

all

med

ical

ga

ps a

nd p

rogr

ess

agai

nst s

peci

fic re

crui

tmen

t pla

ns.

In a

reas

whe

re w

e ha

ve k

now

n sk

ill sh

orta

ges

and

hard

to fi

ll ro

les,

alte

rnat

ive

wor

kfor

ce

mod

els

are

bein

g co

nsid

ered

and

impl

emen

ted.

For

exa

mpl

e, tr

aini

ng O

ptom

etris

ts to

su

ppor

t in

clin

ics

with

a v

iew

to w

orki

ng in

depe

nden

tly in

the

com

mun

ity.

We

are

wor

king

with

our

Van

guar

d pa

rtner

s to

mak

e jo

int a

ppoi

ntm

ents

, with

a v

iew

to

mak

ing

role

s m

ore

attra

ctiv

e to

can

dida

tes

and

deliv

erin

g be

nefit

to b

oth

orga

nisa

tions

(for

ex

ampl

e w

ithin

Oph

thal

mol

ogy.

)

Alte

rnat

ive

job

plan

s al

so b

eing

dev

elop

ed to

app

eal t

o a

wid

er a

pplic

ant p

ool.

An

exam

ple

bein

g w

ithin

EN

T w

here

2 fe

llow

pos

ts h

ave

been

dev

elop

ed in

con

junc

tion

with

th

e R

oyal

Col

lege

.

We

are

also

act

ivel

y re

crui

ting

Phy

sici

an A

ssis

tant

s to

redu

ce th

e de

man

d on

med

ical

do

ctor

s in

trai

ning

. Thi

s ha

s be

en a

suc

cess

ful a

ppro

ach

in a

naes

thet

ics,

and

we

are

wor

king

with

HE

E to

dev

elop

a tr

aini

ng p

rogr

amm

e fo

r PA

s w

ithin

Dor

set.

This

is a

long

er

term

app

roac

h, b

ut w

ill in

crea

se o

ur a

bilit

y to

recr

uit a

nd re

tain

PA

s in

the

futu

re, a

nd

bene

fit fr

om th

eir t

rain

ing

plac

emen

ts.

Car

e pa

thw

ays

are

also

bei

ng re

view

ed to

redu

ce d

eman

d w

ithin

spe

cific

spe

cial

ties,

for

exam

ple,

the

use

of O

ptom

etris

ts to

refin

e th

e re

ferra

l pro

cess

– p

artic

ular

ly in

the

case

of

Gla

ucom

a.

We

are

parti

cipa

ting

in a

sch

eme

led

by th

e C

CG

to o

ffer p

lace

men

ts to

pos

t gra

duat

e G

P

train

ees,

whi

ch p

rovi

des

a sm

all n

umbe

r of s

essi

ons

for t

hese

doc

tors

for a

12

mon

th

perio

d (C

aree

r Fle

x).

We

are

recr

uitin

g ov

erse

as m

edic

al tr

aine

es th

roug

h th

e M

edic

al T

rain

ee In

itiat

ive

(MTI

) sc

hem

e.

NE

W

Ver

sion

Ris

k S

tate

men

t

Rec

ruitm

ent a

nd re

tent

ion

of s

taff

acro

ss s

peci

aliti

esLe

ad M

anag

erTh

is ri

sk a

mal

gam

ates

risk

s id

entif

ied

prev

ious

ly re

fere

nces

: 105

5 (E

NT

Med

ical

Sta

ffing

), 10

45(O

phth

alm

olog

y C

apac

ity L

evel

s du

e to

Sta

ffing

) an

d ne

w s

taffi

ng ri

sks

bein

g id

entif

ied

in o

ther

spe

cial

ties.

11/0

5/20

17

Pro

gres

s R

epor

t

Ris

k S

tate

men

t

Pro

gres

s ag

ains

t eac

h of

thes

e ris

k m

anag

emen

t pla

ns is

at d

iffer

ent s

tage

s de

pend

ing

on th

e sp

ecia

lty.

In te

rms

of th

e ge

neric

act

ions

:G

over

nanc

e an

d tra

ckin

g no

w in

pla

ce.

Phy

sici

an A

ssoc

iate

s be

ing

activ

ely

recr

uite

d at

job

fair

on 1

5th

May

. Fur

ther

mee

ting

with

HE

E a

nd

educ

atio

n pr

ovid

ers

bein

g ar

rang

ed b

y H

EE

.. C

once

rns

with

pac

e of

pro

gres

s ra

ised

at D

orse

t Wor

kfor

ce

Act

ion

Boa

rd a

t May

mee

ting.

Re-

desi

gn o

f car

e pa

thw

ay’s

is o

ngoi

ng.

Pla

cem

ents

for C

CG

Car

e Fl

ex s

chem

e be

ing

iden

tifie

d.

MTI

recr

uitm

ent c

omm

ence

d an

d on

goin

g.

Cor

pora

te R

isk

Reg

iste

r

of 132

Ref

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RR

EN

T R

ISK

R

ATI

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15EX

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ISK

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RIS

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Ala

rm R

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bilit

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d C

apac

ity15

.0 E

xtre

me

Ris

k

08/0

3/20

17

Ver

sion

Ris

k S

tate

men

t

Ther

e is

a la

ck o

f cap

acity

for e

xpan

ding

the

num

ber o

f pro

tect

ion

devi

ces,

repa

irs a

re b

ecom

ing

mor

e fre

quen

t as

the

syst

em a

ges

and

the

clos

ed p

roto

col n

atur

e of

the

syst

em m

akes

us

relia

nt o

n th

e m

anuf

actu

rer f

or m

aint

enan

ce a

nd re

pairs

. In

add

ition

, all

of E

ast W

ing

and

Leve

ls 0

, 1 a

nd 2

Sou

th

Win

g, n

eed

to b

e un

grad

ed to

L1

stan

dard

to m

eet B

S58

39 a

nd th

e R

egul

ator

y R

efor

m (F

ire S

afet

y)

Ord

er 2

005

Andy

Mor

ris

Full

revi

ew o

f req

uire

men

ts to

repl

ace

the

exis

ting

syst

em, i

nclu

ding

ope

n pr

otoc

ol.

Firs

t pha

se to

in

clud

e th

e re

plac

emen

t of t

he m

ain

fire

alar

m c

ontro

l pan

el a

nd a

ssoc

iate

d w

orks

in th

e N

orth

Win

g,

subs

eque

nt w

orks

to u

pgra

de th

e E

ast a

nd S

outh

Win

gs.

S

ub p

anel

faul

t has

bee

n re

ctifi

ed w

ith in

stal

latio

n of

a n

ew p

anel

and

has

resu

lted

in fe

wer

faul

ts.

The

E

stat

es O

ffice

r Ele

ctric

al h

as c

omm

ence

d th

e pr

oces

s of

iden

tifyi

ng a

con

sulta

nt to

ass

ist w

ith th

e re

view

pr

oces

s.

Pro

gres

s R

epor

t

Ris

k S

tate

men

tLe

ad M

anag

er

Ris

k M

anag

emen

t P

lan

& T

imes

cale

This

risk

was

firs

t ide

ntifi

ed in

ear

ly 2

014.

At t

he ti

me

we

gave

an

unde

rtaki

ng to

the

Fire

Ser

vice

that

a s

yste

mat

ic a

ppro

ach

wou

ld b

e ta

ken

to re

plac

e th

e fir

e al

arm

sys

tem

ove

r a n

umbe

r of y

ears

. Sin

ce th

en

the

fire

alar

m u

pgra

de h

as b

een

push

ed b

ack

as p

art o

f cap

ital b

udge

t al

tera

tions

. Bas

ed o

n cu

rrent

bud

gets

we

will

be

doin

g th

e fo

llow

ing:

2016

/17

- ful

l sys

tem

revi

ew to

iden

tify

wor

k ne

eded

(£10

0,00

0). B

egin

te

nder

for o

pen

prot

ocol

sys

tem

.20

17/1

8 - £

400,

000

for E

ast w

ing

upgr

ade

2018

/19

- £35

0,00

0 fo

r Sou

th w

ing

upgr

ade

Cor

pora

te R

isk

Reg

iste

r

of 132

Ref

CU

RR

EN

T R

ISK

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ATI

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14H

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HIG

H R

ISK

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ed to

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k R

egis

ter

Pro

gres

s R

epor

tR

isk

Man

agem

ent

Pla

n &

Tim

esca

leTo

exp

lore

all

optio

ns re

gard

ing

bette

r util

isat

ion

of c

urre

nt s

pace

and

pl

ans

to e

xpan

d ar

ea.

Fina

l wor

ks p

lan

agre

ed.

To g

o ou

t to

tend

er.

Wor

ks p

lan

to b

e ris

k as

sess

ed to

dev

elop

a b

usin

ess

cont

inui

ty p

lan

whi

le 5

maj

ors

spac

es c

lose

d fo

r con

stru

ctio

n, c

onsi

derin

g pa

tient

saf

ety

and

impa

ct o

n pe

rform

ance

. Sta

rt da

te fo

r wor

ks to

be

conf

irmed

; sta

rt da

te w

ill im

pact

on

BC

P d

ue to

cha

nges

in c

ase

mix

and

pos

sibl

e sp

ace

crea

ted

as p

art o

f the

bed

reco

nfig

urat

ion

plan

. Nur

sing

- N

ursi

ng

lead

ersh

ip s

truct

ure

revi

ewed

, with

adj

ustm

ents

to b

and

6 an

d 7

ratio

, with

a

view

to im

prov

ing

gove

rnan

ce (D

ec 2

016)

. C

reat

ion

of 2

x A

NP

role

s,

both

hav

e be

en re

crui

ted

to w

ith s

tart

date

s in

Mar

ch a

nd M

ay 2

017)

. B

and

4 nu

rsin

g ro

les

in d

evel

opm

ent t

o su

ppor

t exi

stin

g st

aff m

odel

. O

ngoi

ng re

crui

tmen

t to

vaca

ncie

s in

ban

d 5

esta

blis

hmen

t. M

edic

al

Sta

ffing

- Id

entif

icat

ion

of u

pcom

ing

gaps

in G

PTV

s ro

ta a

nd ju

nior

doc

tor

rota

, with

new

recr

uits

app

oint

ed w

ith s

tart

date

s in

Mar

ch 2

017.

E

xplo

ring

use

of p

hysi

cian

's a

ssoc

iate

s an

d m

ajor

s ad

vanc

ed

prac

titio

ners

to b

road

en w

orkf

orce

. Upc

omin

g M

G v

acan

cy o

ut to

adv

ert

sinc

e no

tice

rece

ived

; so

far u

nsuc

cess

ful.

App

oint

ed c

onsu

ltant

to

upco

min

g va

canc

y, s

tarte

d 24

Apr

il 20

17.

Wor

king

with

all

spec

ialti

es to

id

entif

y an

d de

velo

p st

ream

ing

path

way

s fo

r spe

cific

pre

sent

ing

cond

ition

s. D

evel

opm

ent o

f int

erna

l pro

fess

iona

l sta

ndar

ds to

form

alis

e an

d co

dify

the

man

agem

ent o

f spe

cial

ty p

atie

nts

in E

D. M

eetin

gs w

ith

spec

ialti

es to

dis

cuss

cha

lleng

es a

nd th

e de

velo

pmen

t of m

utua

lly

agre

eabl

e so

lutio

ns.

Red

esig

n of

mon

thly

bre

ach

repo

rt to

incr

ease

aw

are

of th

e im

pact

of e

ach

divi

sion

on

ED

per

form

ance

. O

ngoi

ng c

lose

w

orki

ng w

ith W

eym

outh

Urg

ent C

are

Cen

tre, r

otat

ing

cons

ulta

nt a

nd

mid

dle

grad

e co

ver t

o th

e U

CC

and

the

shar

ing

of le

arni

ng a

nd b

est

prac

tice.

Stre

ngth

enin

g of

rela

tions

hips

with

loca

l MIU

s.

Ris

k S

tate

men

tLe

ad M

anag

er

Ver

sion

Ris

k S

tate

men

t

Emer

genc

y D

epar

tmen

t Tar

get,

Del

ays

to C

are

& P

atie

nt F

low

10.6

Inco

nsis

tent

ach

ieve

men

t of t

he 4

-hou

r sta

ndar

d, c

ause

d by

cro

wdi

ng, h

igh

atte

ndan

ce n

umbe

rs,

insu

ffici

ent b

ed/a

sses

smen

t uni

t cap

acity

, and

sta

ffing

cha

lleng

es, l

eadi

ng to

ext

erna

l reg

ulat

or s

crut

iny,

im

pact

on

over

all p

erfo

rman

ce (l

inke

d to

STF

pac

kage

), am

bula

nce

hand

over

del

ays,

and

pat

ient

saf

ety

risks

.

Fund

ing

agre

ed to

com

plet

e a

porti

on o

f req

uest

ed e

stat

es w

ork.

Wor

k w

ill b

e pr

iorit

ised

, with

the

min

or o

ps ro

om

and

the

old

eye

room

to b

e co

mpl

eted

as

a m

atte

r of u

rgen

cy.

This

will

ens

ure

that

dep

artm

ent c

ompl

ies

with

CQ

C

requ

irem

ents

, res

olve

s th

e is

sue

with

trol

ley

acce

ssib

ility

in th

e ey

e ro

om, a

nd c

reat

es o

ne a

dditi

onal

maj

ors

spac

e.

Wor

ks o

ut to

tend

er, w

ith a

ctiv

ity p

lann

ed to

occ

ur in

Jun

-Aug

201

7. B

uild

ing

wor

ks w

ill c

ompr

omis

e m

ajor

s ca

paci

ty s

igni

fican

tly.

Pla

ns to

miti

gate

the

impa

ct o

f thi

s ar

e be

ing

expl

ored

incl

udin

g m

ovin

g E

DA

U to

a w

ard

envi

ronm

ent,

usin

g th

e E

DA

U s

pace

to re

acco

mm

odat

e th

e m

ajor

s pa

tient

s, a

nd p

ossi

bly

repu

rpos

e an

offi

ce in

to

an a

dditi

onal

trea

tmen

t spa

ce te

mpo

raril

y. A

dvan

ced

Nur

se P

ract

ition

er ro

le a

gree

d an

d su

cces

sful

ly re

crui

ted

into

, st

art d

ates

in M

arch

and

May

201

7. T

his

role

will

incr

ease

cov

er 7

day

s pe

r wee

k, in

clud

ing

until

mid

nigh

t on

Fri-

Sat

, to

cove

r pea

k ac

tivity

tim

es.

Iden

tifie

d ga

ps d

ue to

non

-allo

catio

n of

GP

VTS

hav

e be

en re

crui

ted

into

, sta

rt da

tes

in M

arch

201

7. A

ltern

ativ

e st

affin

g m

odel

s be

ing

cons

ider

ed.

Sho

rtage

of j

unio

r doc

tors

from

Aug

ust 2

017

note

d in

bus

ines

s ca

se, f

undi

ng a

ppro

ved,

and

role

s ou

t to

adve

rt w

ith o

ne a

ppoi

nted

to.

New

con

sulta

nt s

tarte

d in

po

st in

Apr

il to

sup

port

depa

rtmen

t dur

ing

perio

d of

MG

vac

ancy

and

to s

uppo

rt de

partm

enta

l per

form

ance

.

01/1

2/20

15

Sara

h K

nigh

t, D

ivis

iona

l Man

ager

(Med

icin

e)Je

ni F

ram

pton

, Ste

ph T

hom

as

Cor

pora

te R

isk

Reg

iste

r

of 132

Ref

CU

RR

EN

T R

ISK

R

ATI

NG

14H

IGH

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ager

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DER

ATE

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Add

ed to

Ris

k R

egis

ter

Ris

k S

tate

men

t

14 30/0

8/20

13

Ver

sion

Qua

lity

of E

lect

roni

c D

isch

arge

Sum

mar

ies

Ris

k S

tate

men

tC

athe

rine

Aber

y-W

illia

ms,

Ser

vice

Impr

ovem

ent P

rogr

amm

e M

anag

erTh

e Tr

ust p

erio

dica

lly re

ceiv

es re

ports

from

par

tner

age

ncie

s w

hich

hig

hlig

ht th

at p

robl

ems,

del

ays,

inac

cura

cy o

f det

ails

in E

DS

do

cum

ents

occ

urs

or m

ultip

le E

Ds

are

sent

. Thi

s ca

n ca

use

dela

ys in

trea

tmen

t or f

ollo

w-u

p. A

pla

n to

regu

larly

edu

cate

clin

ical

st

aff i

s in

pla

ce. T

he d

evel

opm

ent o

f a p

olic

y do

cum

ent i

s be

ing

unde

rtake

n un

der t

he g

uida

nce

of th

e M

edic

al D

irect

or.

Con

side

ratio

n of

furth

er a

reas

pur

suin

g nu

rse-

led

disc

harg

es is

und

er re

view

. A lo

ng te

rm p

lan

is in

pla

ce to

link

Ele

ctro

nic

Dis

char

ge S

umm

ary

(ED

S) t

o th

e pl

anne

d el

ectro

nic

pres

crib

ing

softw

are.

The

Tru

st c

ontin

ues

to re

ceiv

e ris

k ev

ents

from

GP

pr

actic

es in

rela

tion

to d

elay

ed o

r ina

ccur

ate

ED

S d

ocum

ents

and

mul

tiple

ED

Ss

sent

.

To p

riorit

ise

this

issu

e, w

hich

des

pite

the

cons

ider

able

wor

k st

ream

s du

ring

rece

nt y

ears

con

tinue

s to

repr

esen

t a ri

sk o

f pat

ient

ha

rm, a

task

& fi

nish

gro

up is

bei

ng le

d by

the

Med

ical

Dire

ctor

, Chi

ef O

pera

ting

Offi

cer a

nd S

ervi

ce Im

prov

emen

t Pro

gram

me

Man

ager

, Cat

herin

e A

bery

-Willi

ams.

The

grou

p ha

ve id

entif

ied

an is

sue

with

the

syst

em p

roce

ss a

nd a

re c

urre

ntly

in d

iscu

ssio

ns w

ith S

unqu

est f

or a

n up

date

to

impr

ove

the

syst

em to

rect

ify d

uplic

ate

ED

Ss

bein

g se

nt.

Ris

k M

anag

emen

t P

lan

& T

imes

cale

The

aim

is to

ach

ieve

a h

igh

stan

dard

of t

imel

y an

d ac

cura

te d

ischa

rge

sum

mar

ies.

The

re is

an

Impr

ovem

ent P

lan

whi

ch is

revi

ewed

mon

thly

in o

rder

to

mon

itor s

et m

ilest

ones

and

inte

rven

tion

requ

ired

to a

ddre

ss id

entif

ied

IT is

sues

th

at a

re c

reat

ing

issue

s or d

uplic

ates

/ del

ays.

Cor

pora

te R

isk

Reg

iste

r

of 132

Ref

CU

RR

EN

T R

ISK

14

HIG

H R

ISK

1015

V3

01/1

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16P

revi

ous

Rat

ing

PO

ST

MIT

IGA

TIO

N

RA

TIN

G8

HIG

H R

ISK

Add

ed to

Ris

k R

egis

ter

Pro

gres

s R

epor

t

Lead

Man

ager

Shar

on M

oone

y, N

urse

Con

sulta

nt

Failu

re to

man

age

the

dete

riora

ting

patie

nt e

ffect

ivel

y

Ris

k M

anag

emen

t P

lan

& T

imes

cale

It is

pla

nned

that

the

curre

nt o

utre

ach

serv

ice

will

exp

and

to b

e av

aila

ble

24hr

s/da

y fro

m A

ugus

t 201

7.

Sta

ff ar

e cu

rrent

ly b

eing

trai

ned

up to

und

erta

ke th

is ro

le.

Sep

sis

com

mitt

ee e

stab

lishe

d w

ith m

ulti-

prof

essi

onal

atte

ndan

ce a

nd is

exp

andi

ng to

cov

er a

cute

kid

ney

inju

ry.

This

has

ena

bled

coo

rdin

atio

n of

ac

tion

to m

itiga

te th

e ris

k. T

his

has

incl

uded

dev

elop

men

t of a

scr

eeni

ng to

ol, b

ased

on

Nat

iona

l gu

idan

ce, p

rodu

ctio

n of

a g

uide

line

for t

he m

anag

emen

t of t

his

grou

p of

pat

ient

s an

d pr

oduc

tion

of a

n ed

ucat

ion

mat

rix to

mon

itor a

ttend

ance

at t

rain

ing.

The

Vita

lPA

C a

lgor

ithm

will

cont

ain

guid

ance

on

whe

n to

sep

sis

scre

en p

atie

nts,

ach

ievi

ng a

cer

tain

sco

re, i

n th

e ne

xt u

pgra

de.

The

seps

is s

cree

ning

tool

is

now

an

inte

gral

par

t of t

he m

edic

al a

dmis

sion

s pr

o-fo

rma

and

the

nurs

ing

AIR

S d

ocum

ent.

As

part

of th

e W

AH

SN

pro

gram

me

a pr

ojec

t to

impr

ove

the

accu

racy

of f

luid

bal

ance

man

agem

ent,

ofte

n re

quire

d by

th

e de

terio

ratin

g pa

tient

s is

to b

e un

derta

ken.

A d

eter

iora

ting

patie

nts

grou

p is

to b

e es

tabl

ishe

d, s

peci

fical

ly to

look

at t

he ti

min

g, a

ccur

acy

and

esca

latio

n of

obs

erva

tions

. Th

e se

psis

act

ion

plan

con

tinue

s to

be

impl

emen

ted.

Scr

eeni

ng h

as a

lread

y im

prov

ed in

ED

and

use

of t

he s

cree

ning

tool

is in

crea

sing

. Fu

rther

aud

it is

pla

nned

to e

nsur

e th

at th

is

succ

ess

is ro

lling

out,

initi

ally

to o

ther

adm

issi

on a

reas

. Th

e ba

se li

ne a

sses

smen

t for

AK

I has

bee

n co

mpl

eted

and

act

ions

are

und

erw

ay to

impr

ove

the

man

agem

ent o

f thi

s gr

oup

of p

atie

nts.

The

crit

ical

ca

re o

utre

ach

serv

ice

will

be

cove

ring

twilig

ht s

hifts

from

the

mid

dle

of M

arch

with

the

plan

stil

l to

go 2

4/7

in A

ugus

t 201

7 w

hen

the

train

ees

will

have

com

plet

ed th

eir t

rain

ing.

The

WA

HS

N p

roje

ct to

impr

ove

fluid

ba

lanc

e m

onito

ring

mod

ule

of th

e V

italP

AC

sys

tem

has

bee

n re

view

ed b

y th

e gr

oup

and

this

will

be

goin

g in

to te

st s

hortl

y.19

/10/

2015

Ris

k S

tate

men

t13

.6V

ersi

on

A c

ritic

al c

are

outre

ach

serv

ice

has

been

est

ablis

hed

whi

ch c

urre

ntly

co

vers

08.

00 to

20.

00 a

cros

s th

e Tr

ust.

In a

dditi

on, t

he T

rust

is

deve

lopi

ng a

Hos

pita

l at N

ight

ser

vice

for c

over

out

side

of t

hese

hou

rs.

Crit

ical

Car

e O

utre

ach

assi

sts

war

d st

aff t

o id

entif

y an

d m

anag

e ac

utel

y de

terio

ratin

g pa

tient

s an

d su

ppor

ts th

eir e

duca

tion

in th

is.

A m

ulti-

prof

essi

onal

sep

sis

com

mitt

ee h

as b

een

form

ed, w

ith a

n E

xecu

tive

lead

, w

hich

has

ove

rsee

n th

e de

velo

pmen

t and

intro

duct

ion

of a

sep

sis

scre

enin

g to

ol to

aid

in th

e id

entif

icat

ion

and

man

agem

ent o

f thi

s gr

oup

of

patie

nts.

The

scr

eeni

ng to

ol a

lso

dire

cts

staf

f to

the

Sep

sis

6 ca

re b

undl

e to

exp

edite

app

ropr

iate

man

agem

ent.

The

Tru

st h

as s

igne

d up

to th

e W

esse

x A

cade

mic

Hea

lth S

cien

ce N

etw

ork

safe

ty p

rogr

amm

e w

hich

, thi

s ye

ar, i

s fo

cusi

ng o

n th

e de

terio

ratin

g pa

tient

.

It is

kno

wn

that

, at t

imes

, qua

lity

of w

ard

care

with

rega

rd to

the

iden

tific

atio

n an

d m

anag

emen

t of t

he

dete

riora

ting

patie

nt m

ay b

e va

riabl

e an

d st

udie

s ha

ve s

how

n th

at th

is h

as a

n ef

fect

on

patie

nt m

orta

lity

and

mor

bidi

ty.

At p

rese

nt th

ere

is a

'tra

ck a

nd tr

igge

r' (V

iEW

S) s

yste

m w

ithin

the

Trus

t to

iden

tify

patie

nts

at ri

sk o

f det

erio

ratio

n. T

his

syst

em d

oes

not o

verri

de c

linic

al ju

dgem

ent a

nd re

cogn

ition

of t

his

dete

riora

tion

and

appr

opria

te e

scal

atio

n st

ill ne

eds

to h

appe

n. T

his

is n

ot a

lway

s th

e ca

se, l

eadi

ng to

a

num

ber o

f ser

ious

eve

nts

whe

re p

atie

nts

have

det

erio

rate

d du

e to

del

ayed

reco

gniti

on a

nd in

appr

opria

te

or in

adeq

uate

trea

tmen

t. T

his

is n

ot o

nly

a cl

inic

al ri

sk fo

r the

pat

ient

s bu

t als

o ha

s im

plic

atio

ns fo

r the

pr

ofes

sion

al a

ccou

ntab

ility

of th

e st

aff c

arin

g fo

r the

m.

Ris

k S

tate

men

t

Cor

pora

te R

isk

Reg

iste

r

of 132

Ref

CU

RR

EN

T R

ISK

R

ATI

NG

14H

IGH

RIS

K

1049

V3

01/1

2/20

16P

revi

ous

Rat

ing

PO

ST

MIT

IGA

TIO

N

RA

TIN

G7

MO

DER

ATE

RIS

K

Add

ed to

Ris

k R

egis

ter

Of t

he £

4.2

milli

on o

f CIP

sch

emes

iden

tifie

d to

dat

e th

e B

VB

C g

roup

hav

e id

entif

ied

that

£1

milli

on a

re

high

risk

and

wor

k is

und

erw

ay to

ens

ure

they

are

all

robu

st p

lans

. D

orse

t wid

e C

IP p

lans

are

bei

ng

deve

lope

d bu

t the

re a

re n

o de

taile

d pl

ans

in p

lace

as

yet.

Ris

k M

anag

emen

t P

lan

& T

imes

cale

Mar

ch 1

7 –

June

17:

A D

orse

t wid

e fin

anci

al c

ontro

l tot

al is

in p

lace

and

w

ork

is h

appe

ning

acr

oss

the

syst

em to

ens

ure

Dor

set a

s w

hole

ach

ieve

s its

fina

ncia

l con

trol t

otal

. T

he fi

nanc

ial g

ap c

an b

e re

duce

d th

roug

h th

e pr

iorit

isat

ion

of th

e st

rate

gic

serv

ices

revi

ew, m

aint

aini

ng fi

nanc

ial r

un

rate

s at

the

sam

e le

vel a

s in

201

6/17

and

clo

ser w

orki

ng w

ith o

ther

pr

ovid

ers

acro

ss D

orse

t. E

ach

divi

sion

has

a s

avin

gs ta

rget

to d

eliv

er

and

the

Fina

nce

Impr

ovem

ent T

eam

is s

uppo

rting

ser

vice

s to

iden

tify

and

deliv

er fu

rther

fina

ncia

l sav

ings

. Th

e B

ette

r Val

ue B

ette

r Car

e G

roup

co

ntin

ue to

ove

rsee

the

CIP

del

iver

y.C

ash

borro

win

g fa

cilit

ies

are

in p

lace

for w

hen

requ

ired.

Thi

s is

not

an

ticip

ated

to b

e un

til th

e se

cond

hal

f of t

he fi

nanc

ial y

ear.

28/0

1/20

16

Ris

k S

tate

men

tLe

ad M

anag

er

Pro

gres

s R

epor

t

Reb

ecca

Kin

g, D

eput

y D

irect

or o

f Fin

ance

Ver

sion

Fina

ncia

l Sus

tain

abili

ty

An

unsu

stai

nabl

e fin

anci

al p

ositi

on c

ould

resu

lt in

a re

duce

d qu

ality

of b

oth

clin

ical

and

sup

port

serv

ices

an

d re

duce

the

auto

nom

y th

e Tr

ust h

as in

pro

vidi

ng h

igh

qual

ity s

ervi

ces

to it

s po

pula

tion.

Ris

k S

tate

men

t

12.8

Cor

pora

te R

isk

Reg

iste

r

of 132

Ref

CU

RR

EN

T R

ISK

R

ATI

NG

13H

IGH

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K

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ISK

Add

ed to

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k R

egis

ter

Pro

gres

s R

epor

tR

isk

Man

agem

ent

Pla

n &

Tim

esca

le

Acce

ss to

Car

e in

the

Com

mun

ity

Ris

k S

tate

men

t

30/0

1/20

14

Ver

sion

Jenn

ifer F

ram

pton

, Ser

vice

Man

ager

13 The

aim

is to

ach

ieve

d a

sust

aine

d re

duct

ion

in d

elay

ed tr

ansf

ers

of c

are

and

to s

usta

ined

le

vel l

ower

than

15

patie

nts

by th

e en

d of

Q3

16/1

7

The

wor

k w

ith p

artn

er o

rgan

isat

ions

has

pro

gres

sed

sign

ifica

ntly

, but

is y

et to

real

ise

a no

tabl

e re

duct

ion

in d

elay

s.A

pilo

t at Q

ueen

Cha

rlotte

Nur

sing

Hom

e co

mm

ence

d on

1st

Feb

ruar

y 20

17 fo

r ste

p-do

wn

asse

ssm

ent f

or lo

ng te

rm c

are.

Thi

s is

bei

ng d

eliv

ered

in p

artn

ersh

ip w

ith D

CC

, Wey

mou

th G

Ps

and

Kin

gsle

y H

ealth

care

. The

pro

ject

has

alre

ady

seen

a re

duct

ion

in th

e de

laye

d di

scha

rge

list (

for n

ursi

ng c

are)

, whi

ch is

the

high

est c

ateg

ory

of d

elay

at D

CH

. The

pilo

t will

be e

valu

ated

mid

-end

M

ay 2

017.

Ane

cdot

al e

vide

nce

from

the

proj

ect h

as in

dica

ted

that

pat

ient

car

e ne

eds

are

ofte

n re

duce

d fo

llow

ing

trans

fer t

o Q

ueen

Cha

rlotte

, with

ver

y po

sitiv

e pa

tient

exp

erie

nces

repo

rted.

A m

eetin

g to

det

erm

ine

a pi

lot f

or d

isch

arge

to a

sses

s (h

ome)

at s

cale

has

take

n pl

ace,

bet

wee

n D

CH

, DC

C, D

HU

FT a

nd

Tric

uro.

Res

ourc

e m

appi

ng to

be

done

follo

wed

by

a pr

oces

s m

appi

ng e

xerc

ise.

Initi

ally

, the

pilo

t has

bee

n ag

reed

to ta

ke p

lace

in

Wey

mou

th/P

ortla

nd. P

lan

to b

e pr

oduc

ed, d

ates

for p

ilot t

o be

agr

eed.

Pap

er to

be

prod

uced

to o

utlin

e In

tegr

ated

Dis

char

ge te

am, i

nvol

ving

DC

C, D

HU

FT, V

olun

tary

sec

tor.

Key

obj

ectiv

es a

re

stre

amlin

ing

proc

esse

s fo

r com

plex

dis

char

ge (p

atie

nts

who

nee

d su

ppor

t to

retu

rn h

ome)

, 7 d

ay s

uppo

rt fo

r dis

char

ge, c

o-or

dina

ting

com

plex

dis

char

ges

in h

ospi

tal a

nd in

con

junc

tion

with

com

mun

ity s

ervi

ces.

Trus

ted

prac

titio

ner t

rain

ing

has

been

del

ayed

, but

Tie

r 1 is

bei

ng re

sche

dule

d de

pend

ent u

pon

DC

C a

vaila

bilit

y.. T

rain

ing

will

be

1.5

hour

s fo

r all

inpa

tient

sta

ff. T

ier 1

trai

ning

will

prov

ide

a fo

cus

on in

form

atio

n an

d ad

vice

. Dis

cuss

ions

hav

e co

mm

ence

d on

ho

w th

is m

ay b

e lin

ked

into

Dis

char

ge tr

aini

ng c

urre

ntly

bei

ng p

rovi

ded.

Impl

emen

tatio

n of

Sup

port

at H

ome

serv

ice

in p

artn

ersh

ip w

ith th

e R

ed C

ross

is n

ow in

pla

ce, f

or a

per

iod

of 1

8 m

onth

s. A

si

mila

r sch

eme

but t

hrou

gh D

orse

t Fire

and

Res

cue

serv

ice,

usi

ng th

eir v

olun

teer

s is

due

to c

omm

ence

in J

anua

ry 2

017

as a

pi

lot o

n D

ay-L

ewis

, Pur

beck

and

Rid

gew

ay w

ards

. Th

is w

ill in

clud

e tra

nspo

rt an

d lo

w le

vel i

nter

vent

ions

suc

h as

app

lyin

g Te

d st

ocki

ngs.

DC

H w

ill be

pro

vidi

ng th

e tra

inin

g. F

urth

er m

eetin

gs a

re in

pla

ce to

dis

cuss

impr

oved

use

of v

olun

tary

sec

tor a

nd

supp

ort f

or p

atie

nts

to re

turn

hom

e. A

Dis

char

ge p

roje

ct p

lan

is in

pla

ce, w

hich

incl

udes

trai

ning

for a

ll w

ards

. Th

e co

nten

t of t

his

train

ing

incl

udes

trai

ning

del

iver

ed b

y th

e C

hapl

ain

in d

eliv

erin

g di

fficu

lt m

essa

ges

as w

ell a

s up

date

s on

CH

C, M

CA

and

ther

apy

unit.

CH

S (s

elf-f

unde

rs) –

is n

ow li

ve, t

his

is a

pilo

t sch

eme

for e

nhan

ced

supp

ort f

or s

elf-f

unde

rs is

due

to b

e in

pla

ce fr

om 3

0th

Janu

ary

2017

unt

il 30

th J

une

2017

. Th

is is

ant

icip

ated

to re

duce

sel

f-fun

ding

del

ays

by 5

0% (c

urre

nt D

CH

bas

elin

e is

10

days

, C

HS

targ

et is

5 d

ays)

. Int

erim

revi

ew o

f pilo

t has

bee

n la

rgel

y po

sitiv

e, w

ith d

elay

s re

duce

d by

app

roxi

mat

ely

50%

(dep

ende

nt

upon

met

hodo

logy

use

d).

Indi

cativ

e sa

ving

s as

com

pare

d to

ben

chm

arke

d p

erio

ds h

ave

been

sig

nific

ant a

s w

ell.

Pat

hway

s - F

railt

y pa

thw

ay h

as b

een

draf

ted

at a

hig

h le

vel,

anot

her m

eetin

g ha

s be

en c

ompl

eted

with

acu

te p

hysi

cian

s, s

ocia

l se

rvic

es a

nd o

ther

par

tner

s. D

iscu

ssio

n w

ith p

rimar

y ca

re/c

omm

unity

ser

vice

s is

pla

nned

for t

he th

ird w

orks

hop

(tbc)

. EoL

di

scha

rge

path

way

has

bee

n co

mpl

eted

in d

raft.

Com

plex

dis

char

ge p

athw

ays

will

com

men

ce in

Feb

ruar

y 20

17.

A C

are

Hom

e Fo

rum

has

bee

n ar

rang

ed fo

r 5th

Apr

il in

volv

ing

resi

dent

ial,

nurs

ing

and

dom

icilia

ry c

are

prov

ider

s fo

llow

ing

an

initi

al m

eetin

g in

Nov

embe

r. P

rovi

ders

will

be in

vite

d in

to m

eet W

ard

Sis

ters

and

bui

ld re

latio

nshi

ps to

sup

port

proa

ctiv

e di

scha

rge

path

way

s fo

r pat

ient

s. T

his

mee

ting

was

ver

y su

cces

sful

, with

sev

eral

car

e ho

mes

and

pro

vide

rs re

pres

ente

d. T

his

prov

ided

a fo

rum

for o

pen

and

frank

dis

cuss

ion

and

shar

ing

lear

ning

whi

ch is

bei

ng s

hare

d vi

a S

iste

rs’ m

eetin

gs.

Incr

ease

d de

man

ds o

n D

CH

ser

vice

s an

d po

or p

atie

nt e

xper

ienc

e ar

isin

g fro

m in

effe

ctiv

e lin

ks b

etw

een

com

mun

ity a

nd a

cute

ser

vice

pro

visi

on -

resu

lting

in in

crea

sed

acce

ss to

acu

te s

ervi

ces

and

dela

yed

disc

harg

ed to

alte

rnat

ive

care

Ris

k S

tate

men

tLe

ad M

anag

er

Cor

pora

te R

isk

Reg

iste

r

of 132

Ref

CU

RR

EN

T R

ISK

R

ATI

NG

12H

IGH

RIS

K

1051

V3

01/1

2/20

16P

revi

ous

Rat

ing

Ris

k M

anag

emen

t P

lan

& T

imes

cale

PO

ST

MIT

IGA

TIO

N

RA

TIN

G5

MO

DER

ATE

RIS

K

Add

ed to

Ris

k R

egis

ter

Pro

gres

s R

epor

t

Lead

Man

ager

The

Trus

t has

a S

EP

SIS

gro

up w

hich

coo

rdin

ates

wor

k ac

ross

the

orga

nisa

tion

on th

is to

pic.

The

NIC

E

guid

elin

es p

ublis

hed

July

201

6 ar

e be

ing

revi

ewed

to in

form

loca

l pol

icy

and

it is

the

inte

ntio

n of

they

gr

oup

to la

unch

a n

ew T

rust

gui

delin

e to

refle

ct N

ICE

gui

danc

e w

ith s

cree

ning

tool

in S

epte

mbe

r 201

6.

The

curre

nt e

duca

tion

prog

ram

me

is b

eing

revi

ewed

to id

entif

y a

gap

anal

ysis

, with

the

inte

ntio

n of

de

velo

ping

a tr

aini

ng p

lan.

The

grou

p w

ill c

oord

inat

e an

aud

it of

com

plia

nce

with

the

scre

enin

g to

ol fo

r Em

erge

ncy

Adm

issi

ons

and

this

we

be re

peat

ed o

n a

mon

thly

bas

is fr

om O

ctob

er o

nwar

ds 2

016.

To e

nhan

ce th

e m

anag

emen

t and

scr

eeni

ng o

f det

erio

ratin

g pa

tient

s fo

llow

ing

adm

issi

on, w

here

sep

sis

may

be

the

mai

n or

con

tribu

ting

fact

or, M

atro

ns a

re to

revi

ew th

e sa

fety

han

dove

r pro

cess

, to

incl

ude

a sy

stem

atic

app

roac

h to

iden

tifyi

ng p

oten

tially

sep

tic p

atie

nts

(e.g

. Vita

lPA

C o

verv

iew

scr

een)

.

To e

nsur

e ac

cura

cy o

f the

dat

a us

ed to

mea

sure

per

form

ance

the

grou

p w

ill o

vers

ee a

revi

ew o

f the

cl

inic

al c

odin

g fo

r acc

urac

y an

d de

velo

p pr

opos

al w

ith c

linic

ians

.

Dr R

uth

Thom

as,

Anne

Sm

ith, S

haro

n M

oone

y

01/0

8/20

16

Ris

k S

tate

men

t

12 The

Trus

t is

mai

ntai

ning

the

Sep

sis

grou

p, w

hich

ove

rsee

s w

ork

on th

is

topi

c ac

ross

the

Trus

t.

New

nat

iona

l gui

danc

e ha

s be

en p

ublis

hed

and

this

is b

eing

revi

ewed

to

ensu

re th

at T

rust

gui

delin

es re

flect

the

mos

t up

to d

ate

posi

tion

and

the

scre

enin

g to

ol u

sed

for s

epsi

s is

em

bedd

ed in

to p

ract

ice.

The

edu

catio

n pr

ogra

mm

e is

bei

ng re

view

ed to

ens

ure

that

enh

ance

men

ts c

an b

e m

ade

and

impr

ove

awar

enes

s.

Ris

k S

tate

men

tR

isk

of a

void

able

dea

th o

r sev

ere

/ pro

long

ed il

l hea

lth to

pat

ient

s du

e to

del

ays

in re

cogn

ition

&

diag

nosi

s of

sep

sis

and

failu

re to

com

men

ce a

ppro

pria

te e

arly

trea

tmen

t pat

hway

s, a

risin

g fro

m li

mite

d aw

aren

ess

and

effe

ctiv

e to

ols

to a

ssis

t clin

icia

ns in

this

dia

gnos

is

Ver

sion

Seps

is: r

ecog

nitio

n, d

iagn

osis

and

ear

ly m

anag

emen

t

Cor

pora

te R

isk

Reg

iste

r

of 132

Ref

CU

RR

EN

T R

ISK

R

ATI

NG

12H

IGH

RIS

K

1052

V3

08/0

3/20

17P

revi

ous

Rat

ing

PO

ST

MIT

IGA

TIO

N

RA

TIN

G5

MO

DER

ATE

RIS

K

Add

ed to

Ris

k R

egis

ter

Ris

k S

tate

men

tLe

ad M

anag

er

Ther

apy

Cap

acity

12

Ris

k S

tate

men

tV

ersi

on

Ther

e ha

s be

en a

sig

nific

ant r

ecru

itmen

t and

rete

ntio

n is

sue

in T

hera

py S

taff

(OT

in p

artic

ular

) rel

atin

g to

va

canc

ies

and

turn

over

. E

stab

lishm

ent o

f The

rapy

Sta

ff ha

s be

en re

view

ed a

nd b

ench

mar

king

pro

vide

d. P

riorit

ies

for t

he T

rust

ar

e to

ach

ieve

the

mai

n ob

ject

ives

to a

) avo

id a

dmis

sion

to h

ospi

tal b

) effe

ctiv

ely

and

timel

y di

scha

rge

from

hos

pita

l.

Pre

cept

orsh

ips:

2 W

TE O

T pr

ecep

tors

recr

uite

d, n

ow s

lotti

ng in

to fu

nded

est

ablis

hmen

t. P

hysi

othe

rapy

pr

ecep

tor r

emai

ns u

nfille

d. H

owev

er, r

ecru

itmen

t offi

ce h

as s

uppo

rted

iden

tific

atio

n of

pot

entia

l ca

ndid

ates

thro

ugh

a re

crui

tmen

t fai

r in

Dub

lin.

• Acc

eler

ator

Pro

gram

me:

in p

lace

and

all

acce

lera

tor p

osts

fille

d.

• Pat

ient

Pat

hway

: mee

tings

cur

rent

ly in

pro

gres

s w

ith D

UH

FT.

Join

t rec

ruitm

ent o

ppor

tuni

ties

disc

usse

d an

d be

ing

deve

lope

d, a

long

side

pot

entia

l for

rota

tion

post

s to

attr

act t

hera

py s

taff

to w

ork

for b

oth

orga

nisa

tions

. D

iscu

ssio

ns w

ith S

ocia

l Ser

vice

s ar

e pl

anne

d, a

lthou

gh th

e po

tent

ial t

o sh

are

rota

ting

post

s is

less

er d

ue to

spe

cial

ism

s in

the

field

.

• Ben

chm

arki

ng: u

nder

take

n w

ith P

GH

and

RB

H. F

urth

er c

ompa

rison

s w

ill b

e m

ade

to D

CH

figu

res

and

furth

er a

naly

sis

of th

e M

odel

Hos

pita

l will

be

unde

rtake

n w

ith s

uppo

rt fro

m th

e fin

ance

team

.

• Cur

rent

ly th

ere

are

no o

utst

andi

ng v

acan

cies

with

in th

e th

erap

y se

rvic

es.

How

ever

, due

to a

vaila

bilit

y of

se

nior

sta

ff, th

e sk

ill m

ix w

ithin

the

serv

ice

has

need

ed to

alte

r to

mee

t dem

ands

in a

diff

eren

t way

.

• Fur

ther

pro

activ

e re

crui

tmen

t pla

nnin

g an

d so

me

agre

emen

t to

risk

over

-est

ablis

hmen

t is

bein

g pl

anne

d in

ord

er to

miti

gate

the

high

turn

over

rate

. F

urth

er w

ork

is b

eing

und

erta

ken

to d

eter

min

e th

e na

tura

l ra

nge

of tu

rnov

er e

xpec

ted

and

any

proa

ctiv

e w

ork

poss

ible

to m

anag

e re

duct

ions

in tu

rnov

er.

• The

out

stan

ding

risk

rem

ains

whe

ther

the

serv

ice

is e

stab

lishe

d to

the

exte

nt re

quire

d to

pro

vide

full

inpa

tient

ser

vice

s. N

o ad

ditio

nal f

undi

ng o

r bus

ines

s ca

se h

as b

een

agre

ed fo

r 201

7/18

to th

is e

nd.

The

OT

benc

hmar

king

has

bee

n co

mpl

eted

, Phy

sio

is b

eing

revi

ewed

. Th

e m

odel

of s

ervi

ce p

rovi

sion

is n

ow

unde

r rev

iew

to d

eter

min

e w

heth

er th

e se

rvic

e ca

n be

pro

vide

d in

an

alte

rnat

ive

way

with

ble

nded

role

s an

d pa

rtner

ship

wor

k w

ith D

orse

t Hea

lth C

are.

Som

e pr

ovis

ion

for f

undi

ng is

pos

sibl

e vi

a th

e be

d m

odel

ling

busi

ness

cas

e, if

app

rove

d.

31/0

8/20

16

Chr

istin

a C

ollin

s-G

ilchr

ist

Kar

yn S

tew

art D

odd

Pro

gres

s R

epor

tR

isk

Man

agem

ent

Pla

n &

Tim

esca

le1.

Incr

easi

ng C

apac

ity

a) R

ecru

it O

ver E

stab

lishm

ent:

Pla

ns a

re in

pla

ce to

incr

ease

cap

acity

by

over

re

crui

ting

on c

urre

nt e

stab

lishm

ent l

evel

s by

mea

ns o

f a P

rece

ptor

ship

P

rogr

amm

e. T

o da

te 2

WTE

OTs

wer

e ap

poin

ted

(pla

nned

3.0

0wte

OT

and

1.00

wte

PT)

. Fin

al y

ear s

tude

nts

are

empl

oyed

as

Ban

d 3’

s an

d th

en u

pgra

ded

to

Ban

d 5’

s on

ce th

ey h

ave

been

regi

ster

ed.

This

act

ion

now

com

plet

ed.

2. S

taff

Ret

entio

n M

easu

res

a) A

ccel

erat

or P

rogr

amm

e: B

and

5’s

(OT/

PT)

are

bei

ng re

crui

ted

and

then

pr

omot

ed to

Ban

d 6

role

s af

ter 1

2 –

18 m

onth

s on

ce th

eir c

ompe

tenc

ies

have

be

en a

chie

ved.

Thi

s in

crea

ses

the

leve

l of s

kill

mix

and

resi

lienc

e. C

urre

ntly

in

plac

e.

b) R

otat

ions

with

Com

mun

ity S

ervi

ces:

OTs

/PTs

rota

te in

to th

e co

mm

unity

to

incr

ease

ski

ll le

vels

and

to b

uild

rela

tions

hips

to im

prov

e co

mm

unic

atio

n an

d fa

cilit

ate

patie

nt fl

ow. T

rain

ing

and

Sup

ervi

sion

Pro

gram

mes

are

in p

lace

to

max

imis

e st

aff c

apac

ity fo

r ser

vice

del

iver

y

3. P

atie

nt P

athw

ay

a) P

athw

ay P

lann

ing

with

Com

mun

ity a

nd S

ocia

l Car

e is

bei

ng d

evel

oped

to

desi

gn p

atie

nt p

athw

ays

to p

rom

ote

info

rmat

ion

shar

ing

to a

void

adm

issi

ons,

re

duce

LoS

and

saf

e di

scha

rge.

Joi

nt p

osts

are

bei

ng e

xplo

red

e.g.

CO

PD

, S

troke

, Hea

rt Fa

ilure

and

Tra

uma

as th

ese

are

area

s th

at h

ave

high

er th

an

expe

cted

LO

S a

nd re

adm

issi

on ra

tes.

Par

tially

impl

emen

ted

with

ant

icip

atio

n of

S

ocia

l Ser

vice

s in

volv

emen

t. b)

Ser

vice

Inte

grat

ion:

OT

and

PT

team

s w

ill b

e fu

lly in

tegr

atin

g to

incr

ease

pr

oduc

tivity

and

con

tinui

ty o

f ser

vice

del

iver

y.

4. B

ench

mar

king

a) T

o ill

ustra

te a

nd e

vide

nce

benc

hmar

king

of T

hera

py S

taff

in li

ne w

ith

obje

ctiv

es a

) adm

issi

on a

void

ance

b) e

ffect

ive

and

timel

y di

scha

rge

from

hos

pita

l us

ing

othe

r loc

al h

ospi

tals

and

Mod

el H

ospi

tal e

vide

nce

to p

rovi

de c

ompa

rabl

e.

This

will

be

achi

eved

with

in th

e ne

xt 6

mon

ths.

Cor

pora

te R

isk

Reg

iste

r

of 132

Ref

CU

RR

EN

T R

ISK

R

ATI

NG

12H

IGH

RIS

K

1060

V1

05/0

5/20

17P

revi

ous

Rat

ing

PO

ST

MIT

IGA

TIO

N

RA

TIN

G6

MO

DER

ATE

RIS

K

Add

ed to

Ris

k R

egis

ter

NE

WTe

mpo

rary

Med

ical

Wor

kfor

ce P

lann

ing

& C

apac

ity

The

Trus

t rec

ently

mad

e tw

o si

gnifi

cant

inve

stm

ents

to im

prov

e bo

th

recr

uitm

ent a

nd te

mpo

rary

sta

ffing

:• T

he a

ppoi

ntm

ent o

f a B

and

5 Te

am M

anag

er fo

r Med

ical

Rec

ruitm

ent

adds

sig

nific

ant c

apac

ity fo

r cam

paig

n de

sign

and

del

iver

y, v

acan

cy

mon

itorin

g an

d th

e de

velo

pmen

t of n

ew re

crui

tmen

t med

ia (e

.g. C

aree

rs

Tran

sitio

n P

artn

ersh

ip, B

MJ

Jobs

, Gua

rdia

n N

etw

ork,

Lin

kedI

N e

tc.).

The

di

visi

ons

are

now

act

ing

proa

ctiv

ely

to a

ddre

ss k

now

n ga

ps in

CM

Ts

thro

ugh

the

recr

uitm

ent o

f LA

S a

nd M

TI c

over

. Thi

s ac

tivity

will

be

supp

orte

d w

ith c

opy-

writ

ten

adve

rtisi

ng a

nd re

crui

tmen

t vid

eos.

• T

he T

rust

will

laun

ch th

e Te

mpR

E a

genc

y bo

okin

g sy

stem

on

24 A

pril,

w

orki

ng w

ith L

iais

on a

nd th

e H

TE. F

ram

ewor

k to

acc

ess

a la

rger

sup

plie

r ba

se in

a ti

mel

y an

d ef

ficie

nt m

anne

r. Th

e ne

w H

ead

of W

orkf

orce

Res

ourc

ing,

join

ing

in M

ay 2

017,

has

ex

tens

ive

Med

ical

HR

and

Rec

ruitm

ent e

xper

ienc

e w

ithin

the

Lond

on

mar

ket.

It is

ant

icip

ated

that

this

will

sig

nific

antly

stre

ngth

en th

e M

edic

al

recr

uitm

ent p

lans

for 2

017-

18

Ris

k S

tate

men

tV

ersi

on

Ris

k S

tate

men

tLe

ad M

anag

erTB

D

1. J

ane

Whi

te –

Med

ical

Rec

ruitm

ent T

eam

Man

ager

, in

post

from

1 A

pril

2017

2. M

edic

al V

acan

cy L

ist w

ith c

omm

enta

ry p

ublis

hed

wee

kly

from

1 A

pril

2017

3. H

TE. F

ram

ewor

k liv

e in

Mar

ch 2

017

4. T

empR

E li

ve fr

om 2

4 A

pril

2017

5. M

edic

al fo

cuse

d H

ead

of W

ork

Res

ourc

ing

in p

ost f

rom

8 M

ay 2

017

05/0

5/20

17

Inab

ility

to s

ourc

e ap

prop

riate

ly s

kille

d an

d co

mpe

tent

sta

ff to

mee

t sho

rt te

rm re

quire

men

ts fo

r te

mpo

rary

sta

ffing

Pro

gres

s R

epor

tR

isk

Man

agem

ent

Pla

n &

Tim

esca

le

Cor

pora

te R

isk

Reg

iste

r

of 132

Ref

CU

RR

EN

T R

ISK

11

HIG

H R

ISK

1041

V3

01/1

2/20

16P

revi

ous

Rat

ing

PO

ST

MIT

IGA

TIO

N

RA

TIN

G5

MO

DER

ATE

RIS

K

Add

ed to

Ris

k R

egis

ter

27/1

0/20

15

Ris

k M

anag

emen

t P

lan

& T

imes

cale

A w

orki

ng g

roup

was

com

men

ced

in 2

014

to o

vers

ee w

ork

stre

ams

that

ar

e in

tend

ed to

ens

ure

that

sta

ff w

ho h

ave

iden

tifie

d a

train

ing

requ

irem

ent i

n re

latio

n to

the

use

of m

edic

al d

evic

es re

ceiv

e th

e ne

cess

ary

train

ing

and

that

the

prop

ortio

n of

sta

ff re

quiri

ng tr

aini

ng is

m

aint

aine

d in

a s

imila

r way

to o

ther

man

dato

ry tr

aini

ng p

rogr

amm

esLi

mite

d tra

inin

g ha

s be

en d

eliv

ered

to e

xist

ing

staf

f dur

ing

2015

/16

and

a re

view

of t

he p

ositi

on u

nder

take

n to

out

line

next

ste

ps. M

anda

tory

trai

ning

m

onito

red

at D

ivis

iona

l Per

form

ance

revi

ews.

Ris

k S

tate

men

tLe

ad M

anag

erAn

dy M

orris

, Hea

d of

Est

ates

& F

acili

ties

Fran

k W

illia

ms,

Hea

d of

Med

ical

Eng

inee

ring

Ris

k S

tate

men

t11

.2V

ersi

onM

edic

al D

evic

e M

anag

emen

t - T

rain

ing

Pot

entia

l leg

isla

tive

impa

ct a

nd s

afet

y co

ncer

ns a

risin

g fro

m s

taff

not b

een

appr

opria

tely

trai

ned

in th

e us

e of

Med

ical

Dev

ices

. Pot

entia

l dis

rupt

ion

to s

ervi

ces

if st

aff u

nabl

e to

use

med

ical

dev

ices

unt

il th

ey

are

adeq

uate

ly tr

aine

d.

Pro

gres

s R

epor

t

An

urge

nt w

orki

ng g

roup

was

com

men

ced

to fo

cus

wor

k on

ens

urin

g th

at a

ssur

ance

can

be

gain

ed

rega

rdin

g tra

inin

g in

med

ical

dev

ices

acr

oss

the

orga

nisa

tion.

A s

uite

of t

rain

ing

prog

ram

mes

has

bee

n la

unch

ed fo

r all

devi

ce u

sers

. All

new

sta

rters

will

atte

nd th

is tr

aini

ng a

s pa

rt of

thei

r ind

uctio

n. A

se

cond

men

t pos

t fo

r a M

edic

al D

evic

e Tr

aini

ng C

oord

inat

or w

ill co

mm

ence

in D

ecem

ber 2

016.

The

y w

ill be

trai

ned

on th

e ne

w a

sset

man

agem

ent s

yste

m F

2 an

OLM

(ES

R).

The

ir pr

imar

y ta

sks

will

be

to

com

pile

a s

tand

ardi

sed

train

ing

repo

rt te

mpl

ate

and

popu

late

OLM

with

the

up to

dat

e m

edic

al d

evic

es

train

ing.

The

sta

ndar

dise

d tra

inin

g re

port

tem

plat

e w

ill be

sub

mitt

ed to

the

Med

ical

Dev

ices

Com

mitt

ee

for a

ppro

val.

Onc

e th

e te

mpl

ate

is a

ppro

ved,

repo

rts fo

r all

the

othe

r war

ds w

ill b

e pr

oduc

ed.

With

the

war

d re

ports

, tra

inin

g of

con

cern

can

be

tack

led

with

spe

cific

cou

rses

, as

requ

ired.

The

cur

rent

mon

thly

tra

inin

g co

urse

is e

xpec

ted

to c

ontin

ue th

roug

h 20

17.

A

Med

ical

Dev

ices

Tra

inin

g C

oord

inat

or s

econ

dmen

t will

be

in p

ost a

s of

12t

h D

ecem

ber 2

016.

The

y w

ill

be tr

aine

d on

the

new

ass

et m

anag

emen

t sys

tem

F2

and

OLM

(ES

R).

Thei

r prim

ary

task

s w

ill b

e to

co

mpi

le a

sta

ndar

dise

d tra

inin

g re

port

tem

plat

e, a

nd p

opul

ate

OLM

with

the

up to

dat

e m

edic

al d

evic

e tra

inin

g re

cord

s. T

he s

tand

ardi

sed

train

ing

repo

rt te

mpl

ate

will

be s

ubm

itted

to th

e M

edic

al D

evic

es

Com

mitt

ee fo

r app

rova

l. O

nce

the

tem

plat

e is

app

rove

d, re

ports

for a

ll th

e ot

her w

ards

will

be

prod

uced

. W

ith th

e w

ard

repo

rts, t

rain

ing

of c

once

rn c

an b

e ta

ckle

d w

ith s

peci

fic c

ours

es, a

s re

quire

d. T

he c

urre

nt

mon

thly

trai

ning

cou

rse

is e

xpec

ted

to c

ontin

ue th

roug

h 20

17. W

e ha

ve s

tarte

d th

e im

plem

enta

tion

actio

n pl

an to

pro

duct

the

new

risk

/ass

uran

ce b

ased

med

ical

dev

ices

trai

ning

dat

abas

e, th

e cu

rrent

Saf

e us

e of

M

edic

al d

evic

es p

olic

y is

und

er re

view

to in

corp

orat

e th

e ch

ange

s ne

cess

ary.

The

new

med

ical

dev

ices

tra

inin

g co

-ord

inat

or is

in p

ost a

nd is

bei

ng tr

aine

d to

ope

rate

ES

R/O

LM a

long

side

the

new

ass

et

man

agem

ent s

yste

m F

2. T

he n

ew c

ombi

ned

syst

em w

ill be

test

ed o

n Fo

rtune

swel

l war

d an

d th

e re

ports

ge

nera

ted

repo

rted

up to

the

Med

ical

dev

ices

com

mitt

ee in

Mar

ch 2

017

for a

ppro

val b

efor

e ro

lling

out t

he

new

sys

tem

Tru

st w

ide.

We

have

test

ed s

ever

al o

f the

key

com

pone

nts

of th

e in

tegr

ated

trai

ning

pa

ckag

e de

velo

ped

by m

edic

al e

ngin

eerin

g th

e M

edic

al d

evic

e tra

inin

g co

-ord

inat

or h

as p

rove

d se

vera

l of

the

links

to E

SR

/OLM

that

com

bine

with

the

med

ical

dev

ices

inve

ntor

y. T

he a

ctio

n pl

an h

as b

een

upda

te.

The

final

pro

cess

is th

e st

art o

f F2

the

new

ass

et m

anag

emen

t sys

tem

whi

ch is

pla

nned

for t

he 2

nd w

eek

in M

arch

this

will

giv

e us

the

repo

rting

func

tions

. The

roll

out w

ill th

en ti

e- in

with

the

new

hyb

rid m

attre

ss

syst

em a

cros

s th

e su

rgic

al d

ivis

ion

durin

g A

pril

may

Jun

e A

ctio

n pl

an a

ttach

ed.

Cor

pora

te R

isk

Reg

iste

r

of 132

Ref

CU

RR

EN

T R

ISK

R

ATI

NG

10H

IGH

RIS

K

1047

V4

22/0

2/20

17P

revi

ous

Rat

ing

Lead

Man

ager

Ris

k M

anag

emen

t P

lan

& T

imes

cale

PO

ST

MIT

IGA

TIO

N

6M

OD

ERAT

E R

ISK

Add

ed to

Ris

k R

egis

ter

Ris

k S

tate

men

t

10.4

Ver

sion

1) R

ecru

itmen

t eve

nts

are

plan

ned

thro

ugho

ut th

e co

urse

of t

he fo

llow

ing

year

and

hav

e pr

ovid

ed li

mite

d su

cces

s.

Atte

ndan

ce a

t Uni

vers

ity o

pen

days

has

yie

lded

a g

ood

resp

onse

with

man

y ne

wly

qua

lifie

d st

aff c

urre

ntly

offe

red

posi

tions

with

in th

e Tr

ust.

2)

Exp

lora

tion

of th

e ba

nd 4

'Ass

ocia

te N

urse

' pos

t is

prog

ress

ing

and

a re

view

of t

he

Job

desc

riptio

ns fo

r ban

d 2

and

band

3 H

ealth

Car

e A

ssis

tant

s be

ing

unde

rtake

n to

ens

ure

effe

ctiv

e us

e of

re

sour

ces.

3) A

ltern

ativ

e sk

ill m

ixes

and

mod

els

of w

orki

ng a

re b

eing

pro

gres

sed

to e

nsur

e th

at th

e Tr

ust i

s ab

le to

su

stai

n an

d pr

ovid

e se

rvic

es in

the

long

er te

rm.

Iden

tific

atio

n of

sta

ff gr

oup

who

hav

e cu

rrent

regi

stra

tion

outs

ide

of th

e U

K.

4) Id

entif

icat

ion

of w

hat s

uppo

rt th

e Tr

ust c

ould

offe

r in

orde

r for

them

to g

ain

NM

C re

gist

ratio

n.

The

Trus

t has

est

ablis

hed

robu

st p

roce

sses

to re

view

recr

uitm

ent

(the

Res

ourc

ing

Stra

tegy

Boa

rd) a

nd te

mpo

rary

sta

ffing

(the

R

esou

rcin

g O

pera

tions

Gro

up) T

he T

rust

’s o

bjec

tive

is to

min

imis

e ag

ency

cos

ts th

roug

h in

crea

sed

subs

tant

ive

recr

uitm

ent,

whe

re

nece

ssar

y su

ppor

ted

by a

genc

y/se

arch

pro

vide

rs.

Initi

ativ

es h

ave

been

und

erta

ken

to e

ncou

rage

app

licat

ions

to s

ubst

antiv

e po

sitio

ns

such

as

relo

catio

n co

sts

incl

uded

, pro

visi

on o

f rot

atio

nal p

osts

for

care

er d

evel

opm

ent,

Nat

iona

l rec

ruitm

ent e

vent

s an

d th

e de

velo

pmen

t of a

robu

st P

rece

ptor

ship

pro

gram

me

for n

ewly

qu

alifi

ed s

taff.

08/1

0/20

15

Wor

kfor

ce P

lann

ing

& C

apac

ity fo

r Nur

sing

/Mid

wife

ry S

taff

Andr

ew B

lake

sley

, Nea

l Cle

aver

Inab

ility

to s

ourc

e ap

prop

riate

ly s

kille

d an

d co

mpe

tent

sta

ff to

mee

t req

uire

men

ts fo

r Nur

sing

/ Mid

wife

ry s

taffi

ng

Cor

pora

te R

isk

Reg

iste

r

of 132

Ref

CU

RR

EN

T R

ISK

R

ATI

NG

10H

IGH

RIS

K

1050

V3

01/1

2/20

16P

revi

ous

Rat

ing

Lead

Man

ager

Ris

k M

anag

emen

t P

lan

& T

imes

cale

PO

ST

MIT

IGA

TIO

N

4M

OD

ERAT

E R

ISK

Add

ed to

Ris

k R

egis

ter

Ver

sion

Mor

talit

y In

dica

tor

Ris

k S

tate

men

t

9.6 Div

isio

nal D

irect

ors

Pot

entia

l for

incr

ease

d m

orta

lity

in p

atie

nts

acce

ssin

g se

rvic

es a

t DC

H d

ue to

out

lyin

g st

atus

of S

HM

I and

HS

MR

m

easu

res

NH

S E

ngla

nd u

tilis

es th

e S

umm

ary

Hos

pita

l-lev

el M

orta

lity

Indi

cato

r (S

HM

I) an

d th

e H

ospi

tal S

tand

ardi

sed

Mor

talit

y R

atio

(HS

MR

). Th

ese

are

colle

cted

from

dat

a pu

blis

hed

by a

ll Tr

usts

in re

latio

n to

pat

ient

s tre

ated

. The

dat

a in

dica

tes

that

DC

H is

an

outli

er in

term

s of

the

num

ber o

f pat

ient

s w

ho d

ie d

urin

g, o

r in

the

perio

d fo

llow

ing,

car

e at

th

e ho

spita

l, w

hen

com

pare

d to

sim

ilar o

rgan

isat

ions

.

An

inde

pend

ent r

evie

w o

f the

dat

a su

bmitt

ed to

the

natio

nal d

atas

et h

as b

een

unde

rtake

n an

d an

act

ion

plan

has

be

en d

evel

oped

to a

ddre

ss th

e is

sues

hig

hlig

hted

. The

re a

re c

once

rns

abou

t the

acc

urac

y of

the

codi

ng a

pplie

d to

th

e pa

tient

dat

a su

bmitt

ed b

y th

e Tr

ust,

whi

ch c

ould

be

impa

ctin

g on

the

data

.

In a

dditi

on to

con

cern

s ab

out d

ata

accu

racy

, the

pub

lishe

d da

ta a

ppea

rs to

sug

gest

that

pat

ient

s ad

mitt

ed to

DC

H

at w

eeke

nds

have

a g

reat

er ri

sk o

f mor

talit

y w

hen

com

pare

d to

thos

e ad

mitt

ed d

urin

g a

wee

kday

.Th

e Tr

ust h

as in

trodu

ced

a M

orta

lity

Sur

veill

ance

Gro

up, l

ed b

y th

e M

edic

al D

irect

or -

whi

ch w

ill re

view

the

care

of

patie

nts

who

die

in h

ospi

tal,

or w

ho d

ie w

ithin

a d

efin

ed p

erio

d of

dis

char

ge. T

his

will

pro

vide

ass

uran

ce re

gard

ing

the

natio

nal m

orta

lity

data

and

will

pro

vide

a m

ore

resp

onsi

ve e

scal

atio

n of

any

con

cern

s re

latin

g to

car

e.

An

exte

rnal

revi

ew o

f mor

talit

y da

ta, i

nclu

ding

the

codi

ng

info

rmat

ion

used

for s

ubm

issi

on to

the

natio

nal d

atas

et h

as b

een

com

plet

ed a

nd a

n ac

tion

plan

has

bee

n de

velo

ped

to a

ddre

ss th

e is

sues

rais

ed. I

ssue

s re

gard

ing

the

accu

racy

of c

odin

g in

form

atio

n ha

ve b

een

high

light

ed a

nd a

revi

ew o

f pro

cess

is b

eing

und

erta

ken

by th

e C

hief

Info

rmat

ion

Offi

cer -

this

exp

ecte

d to

hav

e re

porte

d an

d ch

ange

s im

plem

ente

d du

ring

Q1

16/1

7.Th

e M

edic

al D

irect

or

cont

inue

s to

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Reg

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r

of 132

Board Assurance Framework (BAF) 2015/16

Strategic Objective Priorities Principal Risk Risk Owner Key Controls Sources of assuranceGaps in

control/assuranceActions for addressing gaps

RAG

Rating

Failure to engage staff in an

integrated care model

J Pearce/

M Warner

Engagement programme planned

with staff. Strategic direction for the

organisation embedded within the

Leadership development

programme.

Staff Survey

Survey Monkey

Approach to staff engagement

based on delivery of the People

Strategy, recognising that staff

engagement is a long term

endeavour.

Amber

Pace of change of the Dorset

wide review too slow.

P Miller

Executive membership on Dorset

wide review group.

Dorset STP being identified as an

early implementer

NHSE - external

assurance

Exec meetings

SMT

Trust Board

Public consultation

now delayed until

November 2016

Acute providers are now a

ACC vanguard site in order to

move the acute care

reconfiguration forward at

pace. STP operational delivery

plan in development. Further

work required on the

sequencing of key

workstreams to ensure

financial sustainability of the

provider landscape

Amber

CSR deters open

engagement with other

Trusts.

J Pearce

Dorset Cluster meetings to continue

throughout the CSR. Accountable

Care partnership meetings

established to enable and

encourage whole system

approaches to implementing the

Integrated Community Services

component of the CSR.

Exec meetings

SMT

Trust Board

CSR work-stream on

developing integrated

community services

has now started and

will form an important

part of the STP for the

county. High level

modelling only and

assurance around

predicted activity and

cost shifts not detailed

enough to provide the

assurance.

Initial meeting held to scope

Accountable Care Partnership

for West Dorset. Initial meeting

of the Accountable Care

partnership has happened and

a programme of work is being

developed to focus initially on

admission avoidance and

reducing delayed transfers of

care. It will also begin to

explore implementation of the

CSR-ICS; ICS major

component of the public

consultation to commence in

Autumn 2016. CCG due

diligence has been undertaken

and agreed with NHS-E

Green

(3) To strengthen relationships

with primary care, supporting

the sustainability and

education of the sector

Gaining access to GPs who

don't readily engage with the

Trust.

P Lear

Stakeholder engagement plan to be

developed.

Exec meetings

SMT

Trust Board

The Chair of the Medical

Staffing Committee has

established a GP and

consultant network forum

which will hold its first meeting

in March and meet bimonthly

thereafter

Develop a GP Engagement

Programme with a named

programme manager

Mid-Dorset hub project building

relationships with all mid-

Dorset GPs.

Amber

Board Assurance Framework - as at end March 2017

INTEGRATEDJoining up our services

We will drive forward more

joined up patient pathways,

particularly working more

closely with and supporting

GPs

(1) To work with our partners

to establish an Accountable

Care Partnership to develop

shared care pathways and a

holistic care approach for our

patients and deliver care

closer to home

1

BAF

of 132


Board Assurance Framework - as at end March 2017(4) To work with our acute

Care Collaborative vanguard

partners to deliver outstanding

services which reflect the

needs of our local populations

Failure to deliver the objective

of the Acute Care vanguard

Programme

P Miller

Vanguard Governance Structure in

place.

- Vanguard Executive

Management Steering

Group

- Chairs and Chief

Executives Group

- External assurance via

NHS England

- Integration and

Collaboration Board

- No dedicated DCH

Programme

Manager/Lead

- Vanguard PMO now in place

led by a Programme Director.

Reasonable progress being

made against core work

streams. SOC agreed for

Pathology and SOC for stroke

services expected in Oct/Nov.

SOC for Health Informatics

approved Jan 17

Amber

(5) To strengthen links

between health and social

care and mental health

providers to provide joined-up

services

Failure to engage social care

and Mental health providers in

service design and

development

J Pearce

- Standardised service

development methodology

- Engagement through Accountable

Care Partnership programme

- Newly formed

Integration and

Transformation Group

- No

project/programme

structure in place.

Dorset-wide System

leadership team to

agree the toR for the

ACO/ACP and the

scope of involvement

in the implementation

of the ICS component

of the CSR. Integrated

community and primary

care services steering

group set up by CCG

ToR for ACP to be re-reviewed

to ensure clarity of purpose

and the development of an

overall project plan. System

awaiting clarification from SLT

on the approach to ACO/ACS

and the alignment to local

authority boundaries

Amber

(6) To establish a

comprehensive transformation

programme for our services

focussed on co-design and

outcomes

Not being able to deliver

transformational savings at a

fast enough pace to

safeguard quality and secure

efficiency and productivity

gains.

L Walters/

J Pearce/ N Lucey

Integration & Collaboration

Transformation Board in place

Service Transformation Group in

place.

Quality impact assessments to be

developed.

Better Value, Better Care Board in

place. Executive team providing

extra support and challenge to key

areas of CIP programme

Reports through to FPC Project management to

be strengthened.

Quality assurance to

be embedded.

Insufficient capability

and capacity to take

the savings out at the

scale and pace

required.

Quality impact assessment to be

embedded. Better Value, Better

Care Board in place. Quality impact

to be embedded into the CIP

reporting - completed. Review of

capacity and capability requirements

to be undertaken. Structure and

resources required to deliver the

Improvements and savings being re-

reviewed, capability & capacity

challenges needs to be addressed.

CIP Programme manager post

vacant and an alternative solution

being identified. Head of

Transformation appointed.

Red

COLLABORATIVEWorking with our

patients and partners

We will work with all of our

partners across Dorset to co-

design and deliver efficient

and sustainable patient-

centred, outcome focussed

services

2

BAF

of 132


Board Assurance Framework - as at end March 2017Not having safe staffing levels

through national skill

shortages, inadequate

workforce planning and local

recruitment challenges.

Additional pressures on

medical staffing as a result of

new junior doctor contract.

P Lear/

J Pearce

M Warner

HR co-ordinate the production of

two and five-year workforce plans

which are updated on annual basis.

Divisions report on workforce

planning and recruitment issues at

monthly performance meetings.

Periodic review of worksorce issues

at FPC.

Established a Resourcing

Strategy group to look at

longer term resourcing

plans.

Twice yearly dependency

audit for nursing.

Systematic dependency

review carried out in the

latter part of 2015/16 and

recommendations for

investment presented to

SMT,FPC and Trust

Board.

Junior doctor exception

reporting and GOSW

Board report.

Nursing & Midwifery

establishment review

identified some areas

of mis-match between

the ward establishment

and the acuity (level of

care) and dependency

(nursing workload) in

some key areas of the

Trust including ED,

Medical and Surgical

Assessment Units,

Maternity Unit and

Children's ward.

Medical gaps through

low resiliance in

medical establishment,

or know areas of hard

to fill medical roles.

E-rostering to be used to

produce accurate information

for robust workforce planning

to be undertaken. Develop new

models of care with different

skills mix, to address hard to fill

medical middle grade posts.

Divisons highlighting plans for

skill mix changes and

development as part of annual

business planning cycle.

Development of longer term

workforce plans for medical

gaps, and to increase

resiliance.

Six monthly acuity and

dependency review has

highlighted areas for

investment. The case for

change to be presented to

Amber

Availability to fund backfill

training relating to new

models of care.

M Warner

Trust working with HEE Wessex to

ensure availability appropriate

SMT approving new positions.

Annaul budget setting process.

Divisional Governance

Meetings

Locum usage review.

Feedback from GMC

survey.

New junior doctor rotas

have identified a

pressure of medical

rotaos in some

specialties.

Long term medical

vacancies in hard to fill

specialities suggests a

need to invest in new

models of care.

Build into divisional workforce

plans through business

planning process. Seek

support from HEW.

Develop Trust wide approach

to investment in physician

Assistants and ANPs.

Amber

Workforce plans

unaffordable.

M Warner/

L Walters

Workforce plans built into budget

setting

FPC review of workforce plans and

agency usage

Divisional Governance

Meetings

Monthly review of medical

vacancies at SMT and

GOSW reports.

Potential risk in terms

of reduced medical

training posts provided.

Ensure DCH requirements are

fed into HEW commissioning

timetable

Review long terms resourcing

models at Resourcing Strategy

Group

Amber

(8) To review our enabling and

support service to ensure they

support the delivery of our

aims and objectives and meet

the needs of our patients and

staff

Inadequate business support

services to support clinical

services due to significant

savings required as identified

through Carter.

N Johnson

Business support services being

reviewed through the Vanguard

project.

Vanguard workstream

and Executive Steering

Group

Business support services

programme developing with

focus on quality, resilience and

efficiency. Design principles

include focus on service quality

Amber

(7) To implement our "People

Strategy 2015" to develop the

organisation and deliver safe,

effective and compassionate

care

ENABLINGEmpowering our staff

We will engage with our staff

to ensure our workforce is

empowered and fit for the

future

3

BAF

of 132


Board Assurance Framework - as at end March 2017Poor data quality impacting

on decision making.

L Walters

Information Assurance Group in

place but further work planned to

develop its role. Information

strategy aprpoved by FPC Nov 16.

Overseen by Health Information

Programme Board.

Independent PbR Audit

raised a number of

concerns on the quality of

costing raised and these

have been addressed.

External review has

identified areas for

improving mortality data

and action plan is being

implemented.

IAG to be embedded. Coding group set up to review

quality of coding. Info strategy

approved by Board and

Information Strategy Project

Team commenced its

implementation. Mortality

coding action plan being

implemented. Mortality coding

dashboard developed to

enable impact on actions to be

seen quickly.

Amber

Personal records, including

medical records should be

accurate and kept safe and

confidential.

L Walters

Corporate Records Management

and Information Lifecycle Policy;

Data Protection and Confidentiality

Policy; Health Records Standards

including Retention Schedules

Policy; Information Governance

Strategy and Policy; Information

Risk policy; Information Security

Policy; Safe Haven Policy.

Caldicott Guardian in place. SIRO

identified. Staff training for IGC as

mandatory training.

CQC inspection identified

weaknesses ensuring all

medical records secure in

public areas. Action

taken to address this.

Internal audit on the IG

Toolkit planned 2016/17.

Standardised locked medical

records trollies have been

purchased.

Amber

(10) Implementing a Digital

Care Records for all patients

to ensure safe and efficient

care is provided

Ensuring we can continue to

deliver safe care whilst

implementing Digital Care

RecordsM Sinclair

Programme Project Board and

Team structure in place to oversee

which reports to Health Informatics

Board.

HIPB

Internal audit -

assessment of Significant

Assurance with Minor

Improvement

Opportunities

Governance process to be

embedded.

Amber

(11) To speed up the adoption

of relevant research and

innovation and define our role

within science, education and

training, and research and

development, working with the

AHSN

Loss of opportunities to

improve care and/or reduce

costs through slow adoption

of new technology and

innovative methods

P Lear

Wessex CRN annual overview and

quarterly returns. Funding

determined by recruitment numbers

into non-commercial studies.

Increased activity and

engagement by new

consultants in

Commercial trials

Potential sources of

research income

(diabetes in particular)

show little engagement

The R & D manager is retiring

in March and we have taken

the opportunity to recruit a new

manager from Bournemouth

University which will enhance

DCH working with outside

partners. We have promoted

an internal candidate to take

charge of the day to day

management within the

department.

Amber





future

(9) To ensure relevant data is

easily accessible, in multiple

locations using technology,

and enabling a culture of

evidence based decision

making

4

BAF

of 132


Board Assurance Framework - as at end March 2017

(12) To appreciate and further

develop our social

responsibility in the community

Community does not support

the Trust, affecting choice

and contributions

N Johnson

Policies and procedures Exec meetings

SMT

Trust Board

no monitoring of

activity, no guidance

for staff

Current significant support for

DCH from the local and

surrounding communities.

Possible increasing risk

depending upon Maternity and

Peadiatric developments with

Yeovil

Corporate Social Responsibility

Framework still to be

developed.

Amber

(13) Ensuring a safe and

efficient estate is provided to

enable safe service to be

delivered

Harm to patients or staff

A Morris

Policies and procedures

Maintenance programmes and

inspections

Capital Planning Group Development of estates

strategy

Development of estates

masterplan

Development of the Damers

site

Amber





future

5

BAF

of 132


Board Assurance Framework - as at end March 2017(14) To embed a culture of

value management and deliver

efficiency projects across the

organisation, using the Carter

principles as a foundation

Savings not optimised or

delivered safely

L Walters

Better Value Better Care Board

overviews this work.

CIP Internal Audit 15/16 Capacity and capability

to deliver at scale.

Service transformation function to be

developed. Finance Improvement

Team in place for 2017/18.

Amber

Loss of core business through

CCG tender exercise

N Johnson

Development of commercial

strategy focussed on increasing non

NHS income

Commercial Board

FPC

Resource to monitor

opportunities

Opportunity Pipeline has been

developed to identify potential

business and possible risks.

Strategy and Business

Development Manager

appointed to monitor pipeline

and provide facilitation for any

bids as they arise.

Currently no anticipated tender

exercises which would affect

core business of the Trust.

Some tenders which Trust

should consider pursuing for

startegic purposes

Green

Investments not resulting in

value for money. L Walters

Business cases approved at SMT

and Board of Directors as outlined

in SFI's.

FPC and Board of

Directors

Post project evaluation not undertaken.Post project evaluation to be

implemented. Amber

Opportunities for services to

be tendered not arising

N Johnson

Executive membership on Dorset

wide review group.

Strong relationships being built with

Commissioners to influence

change.

Commercial Board

FPC

Resource to take

advantage of

opportunities arising

CCG shift away from

competitive tendering.

Collaborative working with

partners is encouraged

Executives to continue to work

with and influence

Commissioners.

Development of opportunity

pipeline to identify future tender

opportunities. Beginning to

see a number of tenders

coming out or due. Do not have

the capacity to bid everything

so will have to be selective

Green

SUSTAINABLEProductive, effective and

efficient

We will ensure we are

productive and efficient in all

that we do to achieve long-

term financial sustainability

(15) To be bold in our

investment strategy to deliver

long-term financial benefit and

sustainability

6

BAF

of 132


Board Assurance Framework - as at end March 2017Insufficient cash to ensure the

continuity of services.

L Walters

Liquidity strategy in place and

reviewed by FPC.

Daily, weekly, monthly cash flows

taken. Loan facility in place with

NHS England.

Internal audit January

2017 highlighted no cash

management concerns

(rated - significant

assurance with minor

improvement

opportunities).

Formally notified NHS

Improvement of

distressed status. Monitor

undertook a site visit in

March 16 and advised we

apply for central cash

support.

Loan facility in place to use as

required.

Red

(16) To develop our

commercial capacity and

capability, building

partnerships to help achieve

this

Insufficient resources to take

advantage of opportunities to

develop commercial income

streams

N Johnson

Commercial Strategy developed

and resources identified for initial

income target. Stretch targets may

require additional resource

Commercial Board

FPC

Resource in place for PP development as

largest non-NHS income stream

Strategy and BD Manager recruited.

Resources still limited and therefore

capacity to pursue and realise commercial

income streams is limited. Capacity has to

be focussed on key areas. These are:

Private Patient Manager

- Private patients

- overseas patients

Strategy and BD Manager

- Damers development Programme

Management

- Coffee Concession

- Tender pipeline

- Active tenders and imminent- currently

Pharmacy SomPar and DHC, dermatology,

extra care, prisons, Integrated Urgent Care

Advice and Access Service

- Contract management process

Development of Commercial Estates Joint

Venture for Damers development

Amber

Not ensuring the safety,

availability and suitability of

equipment.

L Walters

Medical devised policy in place.

Regular reporting of compliance

with maintenance and training

reviewed at Medical Devices

Committee

Internal audit undertaken

2014/15. Limited

assurance given.

A lack of resilience in

the provision of

equipment training.

New system being

implemented Q3 2016/17.

Medical device training post

recruited to. Training audit to

be undertaken Q4 2016/17 and

full training programme and

recording to be in place Q1

2017/18. A review of all

departments responsible for

medical devices has taken

place and an action plan is

being developed to address a

number of gaps.

Amber


efficient





(17) To drive value from our

assets, in particular our

estates and property, and

enhance the patient

experience

(15) To be bold in our

investment strategy to deliver

long-term financial benefit and

sustainability

7

BAF

of 132


Board Assurance Framework - as at end March 2017Trust being open to fraud.

L Walters

Counter Fraud contract in place

with external provider.; Annual fraud

plan in place based on risk

assessment;

Regular reports to the Audit

Committee; Local Counter Fraud

and Corruption Policy: Regular

report to Audit Committee.

Internal audit 2014/15

gave adequate assurance

on the main accounting

system.

Work still to be

undertaken in respect

of cyber security

Amber


efficient





(17) To drive value from our

assets, in particular our

estates and property, and

enhance the patient

experience

8

BAF

of 132


Board Assurance Framework - as at end March 2017Not achieving required

standard of cleanliness and

robust infection control

practice, to ensure people are

cared for in a clean and safe

environment, therefore

reducing the risk of hospital

acquired infections.

N Lucey

Infection Prevention and Control

Committee reports to the Clinical

Governance Committee.

Monthly cleaning audits. Weekly

managerial audits. Monthly Patient

Safety and Quality Scorecard for

Trust Board. Annual IPC work plan.

CQC inspection raised no

concerns on infection

control.

No evidence of cross

contamination through

ribotyping.

Annual PLACE inspection

excellent.

Reduction in standards

may not be evident to

staff who are familiar

with the environment.

Weekly managerial audits,

GAT reviews and Matrons walk

about provide intelligence into

standard of cleanliness

Green

Not safeguarding people who

use services from abuse and

respecting their human rights.

N Lucey

Safeguarding Adults Committee;

Safeguarding Children's Committee;

Lead Doctors and Named Nurse in

place; safeguarding children's

policy; 3 levels of Child Protection

Training provided.

Safeguarding Adults Policy. Training

matrix in place for ADULT

safeguarding, MCA and DoLS.

Annual reports from safeguarding

adult and children to Quality

Committee.

Clinical audit highlighted a

number of actions to be

completed. Results of

clinical audit discussed at

safeguarding committees

demonstrate improvement

on the previous

recommendations. Audits

will be repeated six-

monthly

Section 11 completed for

children safeguarding.

DSCB review to take place.

Focus on training has led to

improved compliance with

training needs. CCG

inspections to support

knowledge in practice.

Compliance with

mandatory/essential training

remains an issue across the

Trust with Divisional teams

addressing.

Green

Failure of staff to engage in

Patient Charter.

N Lucey

People strategy to reflect the values

and behaviours that form the basis

for the Patients Charter.

Implementation of the

Charter and related

outcomes to be monitored

at Learning from Patient

Experience Committee,

the Quality Committee

and the Trust Board.

The ability to share

with hard to reach

groups

Patient Charter developed and

launched in line with the 175th

Anniversary of the trust.

Agreement to hold the roll out

until the people strategy values

and behaviours were finalised.

Board to agreed final version

September 2016. Launch in

progress. Patients charter has

been approved by the Trust

Board. Light launch

undertaken at Team brief with

full implementation plans being

developed. Launched and now

monitor through Patient

Experience committee

Green

(18) To place the patient at the

centre of all we do ensuring

safe, effective and caring

services

OUTSTANDINGDelivering outstanding

services everyday

We will be one of the very best

performing Trusts in the

country delivering outstanding

services for our patients

9

BAF

of 132


Board Assurance Framework - as at end March 2017Patient Charter may not meet

patient expectations.

N Lucey

Charter based on feedback from

patients at internal and public

events.

Implementation of the

Charter and related

outcomes to be monitored

at Learning from Patient

Experience Committee,

the Quality Committee

and the Trust Board.

Patients charter to be

developed using EBD

principles and building on the

work of the Trust Values.

Patient charter in draft and

currently being tested with

patients and public through the

CoG and membership. Final

version to be agreed by Board

in September. Patients charter

has been approved by the

Trust Board. Light launch

undertaken at Team brief with

full implementation plans being

developed

Green

Consent to care and

treatment not in place prior to

any treatment being provided.

P Lear

Consent policy in place.

All new trainee doctors have

consent training.

National consent forms are used.

Consent forms under the mental

capacity act and deprivation of

liberty safeguards.

CQC inspection identified

inadequate

documentation regarding

patients capacity to

consent.

Clinical audit on consent

to treatment in 2012

highlighted no concerns.

Clinical audit on

documentation and

consent in 2012 raised no

concerns.

CQC action plan identified

awareness increase required

and further training

Documentation and consent

audit currently being

undertaken Amber

Not meeting the nutritional

needs for each of our

patients.

N Lucey

The Nutritional Steering Group

reviews the clinical standards

aligned to good nutritional status.

Quarterly MUST assessment audits

are undertaken and reported to the

Trust Board on the quality

scorecard.

Protected mealtimes are in place in

all wards and are reviewed by the

Matrons. Trained volunteers act as

dining companions assist patients

who need support with nutritional

needs. Introduction of care rounds

ensures that the most vulnerable

patients are offered and given fluids

every two hours as a minimum.

Volunteer meal time support system

in place.

CQC inspection raised no

concerns.

PLACE inspection raised

no concerns.

Governor assurance visits

raised not concerns.

Dysphagia audit

highlighted concerns

regarding food texture.

Diet requirements from

SALT to catering to be

improved. Failure to

consistently achieve

MUST assessments

performance

Action plans in place Repeat

audit planned and results

shared with sisters. Nutrition

champions for each ward

identified and bespoke training

programme currently being

rolled out by SALT and

dietetics team. Nutritional

nurse specialist taking forward

'snack attacks' to ensure

patients have access to snacks

in-between meals. Plan to re-

audit in Q1. Nutritional policy

and protocol for stroke patients

presented to CGC for

ratification in May 2016.

Performance objectives and

management via Matrons.

Amber




services


services everyday





10

BAF

of 132


Board Assurance Framework - as at end March 2017Not respecting and involving

patients in discussions about

their care and treatment.

N Lucey

Learning from Patients Committee,

quarterly report to Trust Board.

Patient Story at every Trust Board

meeting.

Cancer patients receive care plan at

appointment.

Friends and family test

feedback highlights no

significant concerns. FFT

feedback for ED is slightly

below the national

average. National patients

survey performance good

with some areas for

improvement identified.

National cancer patient

survey.

Mapping of patient

forums and

involvement groups

currently under-way to

identify where there

may be any specific

gaps

Action plan developed with a

multi professional group to

improve services aligned to

areas identified through patient

survey. Patient survey for 2015

(published March 2016) has

highlighted areas that have

improved from the previous

year and also where further

improvements can be made.

The draft improvement plan

was presented to the Quality

Committee in March.

Green

Poor management of patients'

experience leads to a

negative reputation.

N Lucey

PALs; Complaints Policy, trend

analysis of complaints, patient

stories, privacy and dignity audit; the

results of which are displayed on

individual wards.

Internal audit on learning

from issues undertaken

2014/15. High assurance

given.

Current performance

on complaints

response times is

being addressed and

an improvement

trajectory is to be

agreed with each

division. Pace of

improvement slow, a

review of the resources

supporting the

complaints handling

process underway.

Using EBD and NICE criteria

will ensure the organisation

learns from the key messages

from patient's and provide a

framework for improvement.

50% reduction in formal

complaints noted in 18 months.

Repeat complaints reducing.

Annual complaints report

prepared and will be presented

to Quality Committee in June

2016. New Datix module will

allow better analysis and

monitoring of performance.

Anticipated delivery expected

to align with new Governance

structure April 2017.

Complaints timeliness to

respond remains and issue

with an action plan being

reviewed through Quality

Committee.

Amber




services


services everyday





11

BAF

of 132


Board Assurance Framework - as at end March 2017Not ensuring the care and

welfare of people who use our

services to ensure we meet

their needs and support their

rights.

N Lucey

All patients to have a plan of care

agreed on admission. Policy's on

safeguarding adults and children,

Deprivation of liberty and caring for

individuals with a learning disability

in place and enacted.

Nursing care indicators test out and

display the results at ward level.

CQC safeguarding

inspection (November

2015) highlighted a

potential risk of harm and

inadequate

documentation in some

areas of practice. Adult

safeguarding lead will be

leaving the Trust in

August.

No verbal feedback

from the full CQC

Inspection 2016

highlighted any

concerns. Awaiting the

full report to identify

any further areas that

require addressing.

CQC safeguarding action plan

to be delivered. Actions being

monitored by the CCG and

good progress noted. CCG

have signed off that all actions

associated with the action plan

for DCH have now been

completed. Successful

recruitment of adult

safeguarding lead to start in

August; specialist nurse for

Learning Disabilities post

established and has been

successfully recruited to start in

July 2016

Green

Service risks develop due to

budget holders not taking

responsibility for financial

performance.L Walters

Financial planning framework in

place;

Budgets signed off annually by

budget holders; monthly reporting of

budgetary performance as part of

integrated performance meetings.

Internal audit January

2014 highlighted no

significant concerns.

Internal audit 2014/15 on

Financial Reporting gave

adequate assurance.

Gaps remain in the

identification of CIP

scheme.

The Better Value, Better Care

Board are focusing on closing

the gap. CIP Programme

Manager recruited to January

17. Finance Improvement

Team in place for 2017/18.

Amber

Not having processes and

systems in place to ensure we

learn from complaints and

reduced quality performance.

N Lucey

Learning from Patients Committee,

quarterly report to Trust Board.

Patient Story at every Trust Board

meeting.

Nurse sensitive indicators as part of

performance management and

Divisional performance reviews,

with exception reporting to Quality

committee areas of support

required.

PALs: Complaints Policy, trend

analysis of complaints, patient

stories, privacy and dignity audit as

part of nursing care indicators, the

results of which are displayed on

individual wards EBD and NICE

indicators.

Trends in patient

feedback. Annual

programme of patient

surveys.

Internal audit.

No robust evidence

that learning from

complaints is

embedded in service

delivery. Variability in

divisional performance

management of key

improvement targets

and exception

reporting.

Internal audit planned for 2014/15

will provide independent assurance.

Revision of divisional exception

reporting and development of nurse

sensitive dashboards and

department/ward boards to drive a

culture of striving for excellence.

Divisions now required to provide

this evidence. Template to be

developed to theme issues and

produced a focused action plan.

Some signs of better engagement

within divisions and embedded

learning will be a feature of the

implementation of the improved

governance arrangements within

divisions. Complaints module on

Datix transition to enable further

learning from complaints and embed

in divisional quality management.

Amber

(19) To develop a culture of

continuous improvement,

supporting clinical teams to

improve their quality, safety

and efficiency




services


services everyday





12

BAF

of 132


Board Assurance Framework - as at end March 2017Significant changes required

to implement seven day

service delivery.

J Pearce

Project board established which will

report into SMT.

Trust working with DH

Lead to complete a gap

analysis against the ten

national clinical standards.

Implementation of

nationally negotiated

changes to the consultant

contract.

Audit of 14 hour

consultant review across

7 days.

Internal audit on job

planning planned 2016/17

No assurance that the

national negotiations

will deliver changes to

the consultant contract.

Project Board in place to

implement.

Service transformation team

undertaken a gap analysis to

understand where 7 days

services delivery is required.

Action plan to be agreed to

complete the first 5 standards

across the Trust by March

2016. Some progress has

been made but the pace of

change is slow. Progress on

delivering the standards

unlikely to be achieved until the

job-plans have been reviewed.

Amber

CQUIN schemes not being

delivered

N Lucey

Each CQUIN scheme has a

responsible manager and lead

Executive Director identified.

Monthly reporting to SMT and Board

on performance.

Commissioner contract

meetings not raising any

concerns Quarterly

meetings with CCG and

providers review progress

and revise targets to

demonstrate realistic

improvements. End of

year position on CQUINs

included in Quality

Account. New set of

CQUINs agreed with

commissioners for

2016/17 contract which

are currently being

worked up for

implementation. 2017/18

has new nationally

mandated CQUIN

scheme for 2 year period

Engagement and

progress variability with

assigned leads. New

leads for the 2016/17

CQUIN programme to

be agreed. Completed

Monthly updates on action

plans to ensure progress is

being achieved. Quarterly

reports to SMT. Two areas of

CQUIN currently under-

performing against an agreed

trajectory and recovery plans

have been agreed. Final report

on CQUINs for 2015/16

included in quality account

Green

Failure to manage medicines

to ensure patients get

medicines when they need

them and in a safe way.

A Prowse

Divisional Pharmacists in place plus

ward based pharmacists to support

prescribing and dosing practice.

Drugs and Therapeutics Committee;

Training for doctors and nurses in

medicines management. Medicines

management policies and

medicines reconciliation service.

Datix reporting of clinical incident

relating to prescribing and dosing

errors. EPMA in place.

CQC inspection

highlighted issues.

Recent CQC Inspection

2016 highlighted some

issues associated with the

safe storage of

medications in maternity

Enforcement notice lifted.

Management of

medicines audit planned

2015/16.

Actions to address the issues

highlighted in the verbal

feedback by the CQC at the

time of the inspection have

been completed.

Green

(19) To develop a culture of

continuous improvement,

supporting clinical teams to

improve their quality, safety

and efficiency


services everyday





(20) To look within our

organisation and ensure

services are joined up and

integrated across specialities

to the benefit of the patient

13

BAF

of 132


Board Assurance Framework - as at end March 2017Not meeting the performance

requirements in the NHS

Standard Contract or Monitor

Risk Assessment Framework

will distract focus onto

operational recovery.

J Pearce

Divisional performance framework

in place. Performance framework to

be reviewed to align with NHS-I

appraoch

Regular report to SMT and Board of

Directors. Performance during Q3

improved for ED and cancer

standards; under-performance in

RTT and diagnostic standards

FPC, Trust Board &

Contract monitoring

meetings

Review of Divisional

governance

arrangements has

been undertaken by

PwC . Final Report

received and action

plan being developed

to address the

recommendations.

Under-performance of

key national standards

during Q1 and Q2, Q3

recovery plans in

place. Recovery

trajectories submitted

to CCG and NHS-I;

Action plans in place to recover

any performance issues.

Recommendations from the

PwC review has highlighted

areas where governance can

be strengthened. A proposal to

standardise processes

currently being developed.

Project team identified to take

forward the recommendations

from the governance review.

External support from NHS-I

has been agreed in relation to

ED performance on 4 hour

standard. Q2 appeal on RTT

successful; appeal for Q3 RTT

being prepared.

Amber

From the Francis report

actions not owned by

individuals and therefore not

delivered.

N Lucey

Quarterly review by the Quality

Committee, clinical governance

committees and trust board of the

action plan including assurance

mechanism.

Internal audit planned

April 2016. Internal audit

completed, final report to

be signed off with internal

audit

No external assurance,

PWC review of

divisional governance

will look at elements of

the Francis action plan

to look for embedded

changes

Scope of internal audit

discussed and awaiting draft

terms of reference. Terms of

reference agreed and audit will

take place during Q1. Audit has

taken place, draft report

suggests appropriate

assurances in place, final

changes to the report to be

agreed.

Green

Access and quality of services

reduces due to inadequate

emergency preparedness and

business continuity plans.

J Pearce

Major incident and business

continuity plans revised in 2013/14.

Members of the local Resilience

Forum and Executive attendance at

the Local Health Resilience

Partnership Forum.

Live testing of plans 3 yearly.

EMERGO exercise

undertaken in May 2014.

Annual review of Major

Incident Plan completed

and signed of by the

Board, CCG & NHS

England. Programme of

testing the robustness of

the emergency plans in

place. Additional training

available for key people.

Internal audit planned for

September 2016

NHS-E revised

standards framework

for 2016/17, gap

analysis to be

undertaken and any

gaps identified.

Business continuity plans for

DCH revised and updated.

Revisited Emergency planning

and business continuity policy

and plan submitted to the

Board in June 2016 and was

ratified. Testing of BCP on a

rolling programme during

2016/17.Green

(21) To implement a

comprehensive and robust

governance approach across

the organisation


services everyday





(20) To look within our

organisation and ensure

services are joined up and

integrated across specialities

to the benefit of the patient

14

BAF

of 132


Board Assurance Framework - as at end March 201721a) To achieve 'Good -

Outstanding' CQC rating as

part of our strategic excellence

ambition

Failure to complete actions as

identified in the CQC action

plan to meet the required

regulation standards in the

timescales identified

N Lucey

Action plan and tracking of actions.

Governance framework to provide

assurance on performance and

clinical/corporate governance

refined to enable delivery of the

actions. Internal inspections and

assurances processes: Mock

internal CQC inspections;

monitoring of divisional governance

and actions; Board sub-committees;

partnership Dorset Vanguard

additional good practice sharing and

development of pathway standards

CQC action plan

assurance evidence; Sub-

board committee

assurance reports to

board; Divisional

governance minutes;

CCG assurance visits

reports; internal 'mock'

inspections and deep

dives. Internal audit mock

CQC inspection against

action plan: significant

assurance.

Governance

framework needs

refreshing to enable

stronger assurance

monitoring on internal

governance. Gaps in

divisonal robust

governance and

assurance to clinical

governance and

perforamnce reviews..

Redesign of the Trust

Governance framework -

proposal by December 2016

for implementation April 2017.

On track for delivery. Divisional

performance reviews increased

to provide additional scrutiny of

governance until new divisional

structure, new performance

framework and revised

governance framework are

implemented and embedded.

Amber

(22) To develop an excellent

administrative care pathway


services everyday





15

BAF

of 132

Title of Meeting

Board of Directors

Date of Meeting

31 May 2017

Report Title

Committee Work Plans

Author

Lindsey Perryman, Trust Secretary


Patricia Miller, Chief Executive

Purpose of Report (e.g. for decision, information) To present to the Board the proposed work plans for Quality Committee, Finance and Performance Committee and Risk and Audit Committee for approval.

Summary Although committees have previously had annual work plans these have not in the past been approved by the Trust Board. For 2017/18 work plans have been reviewed by the Committee Chairs, Trust Chair and relevant executives to ensure that the work plans are robust and provide appropriate assurance.

Paper Previously Reviewed By Finance and Performance Work Plan – reviewed by Finance and Performance Committee on 21 March 2017. Risk and Audit Committee Work Plan – reviewed by Risk and Audit Committee on 18 April 2017. Quality Committee Work plan – reviewed by Quality Committee on 23 May 2017.

Strategic Impact Failure of the Trust to have robust governance arrangements could impact on the ability to achieve its Strategic Objectives.

Risk Evaluation Low

Impact on Care Quality Commission Registration and/or Clinical Quality The work of the Board committees provides assurance to the Board in respect of the quality of care and patient experience.

Governance Implications (legal, clinical, equality and diversity or other):

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Robust governance arrangements enable appropriate decision making.

Financial Implications The Finance and Performance Committee provide assurance to the Board in respect of the Trust financial plan.


Yes

Recommendations To approve the work plans.

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Quality Committee Work plan 2017/18

The Quality committee work plan reflects the Board Assurance Framework (BAF) strategic

objective ‘Outstanding: Delivering outstanding services every day’. The Priorities included in this

are 18,19, 20,21, 21(a), and 22.

Quality Committee work plan support the effective organisation management of clinical

governance including:

- Risks management relating to quality and safety, including risk management processes and

application; incident and serious incident reporting, learning and monitoring of harm.

- Assurance and identification of any gaps in control in improvement to deliver the strategic

objective

- Lessons learnt that aid improvement and learning to benefit quality, safe care and best

practice including clinical audit.

- Clinical adherence to national guidelines or standards such as NICE

- Patient and public feedback including complaints, plaudits, surveys and patient involvement

in services (such as volunteers experience and carers experience).

- Policies that apply to quality and safety principles.

The detailed reporting work plan informs sub groups of their agendas and reporting lines, as

outlined in the governance framework for the Trust.

To support the detailed reporting work plan Quality committee have agreed the following

overarching work plan priorities:

Work plan priorities CQC

1. Mortality surveillance in line with national

guidance

CQC domain: SAFE, EFFECTIVE (Regulation

12, 13, 16, 17, 20)

2. Sepsis and the deteriorating patient CQC domain: SAFE, EFFECTIVE (Regulation

12, 20

3. Board triangulation via quality visits –

board visibility and assurance

CQC domain: WELL-LED (Regulation 17)

4. Quality impact assessment of new

models for DCHFT as part of the STP

CQC domain: WELL-LED, RESPONSIVE

(Regulations 17,

5. Governance ward to board to be an

exemplar of well-led domain

CQC domain: WELL-LED (Regulation 17)

Underpinning fundamental CQC standards (Regulation8)

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April May June July August September October November December January February March

Frequency

Quality aspect of integrated performance

report: Patient Safety, Effectiveness and

Experience Report - including safer staffing Mthly

Divisional exception reports Mthly

CQC Inspection action plans, exception reportTwice a QRT

CQC Inspection deep dive action plansQRTLY Deferred as

covered in April

Quality Accounts Quarterly ReportsQRTLY

Medicines Committee exception report (meets

first wed)BI-MTHLY

Deferred

Safety Group exception report: including

Learning from Serious Incidents, claims and legal

cases (meets first Friday)MTHLY

New start -

here

Clinical effectiveness and Innovation Group

exception reports: e.g NICE Compliance &

Clinical Audit Annual Report & Research and dev

(meets second wed)

MTHLYNew start -

here

Infection Prevention and Control Group

exception reports (meets first wed)BI-MTHLY

End of Life Care Group exception reports (meets

second wed)BI-MTHLY

Patient Experience Group exception reports

(meets third Tues): INCLUDING PATIENT

ENVIRONMENT (plus PLACE)

BI-MTHLY New -starts

here

Mortality Group exception reports (meets third

Wed) BI-MTHLY

Safeguarding Adults and Children Group

exception reportsQRTLY

TBC TBC TBC TBC TBC TBC TBC TBC TBC TBC TBC TBC

Detailed Mortality Report QRTLY

Annual Quality Report - draftANNUAL

Annual Quality Report - finalANNUAL

Committee Annual Review of Effectiveness,

Review of ToRsANNUAL

Safeguarding Children Annual ReportANNUAL

Deferred update

Safeguarding Adults Annual ReportANNUAL

update

Infection Prevention and Control annual reportANNUAL

TBC

RISK management strategy update ANNUAL

CLINICAL AUDIT plan ANNUAL

Annual patient surveys ANNUAL

Clinical Audit Annual Report ANNUAL

Information Governance Annual Report ANNUAL

Medicines Safety Annual Report ANNUAL

PLACE Annual Review ANNUAL

Complaints Annual Report ANNUAL

Annual Work Plan for Quality Committee 2017/18

SAFETY & QUALITY

ANNUAL ASSURANCE

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1

To: Finance and Performance Committee From: Libby Walters, Director of Finance and Resources Subject: Proposed Finance and Performance Committee Work Plan 2017/18 Date: March 2017 1.0 Purpose of the Paper

The Trust Board has the responsibility to put in place governance structures and processes to:

Ensure that the organisation operates effectively and meets its statutory and strategic objectives; and

Ensure that this is the case. The Finance and Performance Committee supports the Board in fulfilling this role by:

On the ability of the Trust to meet its financial and operational performance requirements.

Ensuring performance manager processes are robust.

Providing assurance to the Board by undertaking deep dives on high risk performance issues.

Challenging relevant managers when controls are not working or data is unreliable.

To ensure the Finance and Performance Committee can fulfil its role effectively it must have in place a work programme that covers each of its responsibilities.

The purpose of this paper is to propose a work plan for the Finance and Performance Committee for 2017/18.

2.0 Current gaps in the Finance and Performance Committee Work Plan There are a number of areas that the Finance and Performance Committee are responsible for providing assurance to the Board on that they are not always covered in sufficient detail, in addition there are also opportunities to further enhance the effectiveness of the committee. The table below proposes how these gaps / enhancements are included in the work plan.

Gap in Work Plan Proposed action

Reviewing operational performance at a divisional level.

Focussing on the delivery of divisional business plans.

Divisional Managers to attend meeting on permanent basis with Divisional Directors on an as and when basis

Bi annual review of divisional business plans.

Gaining assurance from the committees/ Groups reporting to the FPC i.e.

Workforce & Resources Strategy Group

Medical Devices Group

Access & Flow Group

Template reviewed at each meeting for these 3 groups that show when last met, was meeting quorate, issues discussed, areas to escalate.

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2

Continual opportunities to deep dive into high risk areas.

Post development appraisals not undertaken.

Increased focus on service line reporting data.

No detailed scrutiny on estates statutory compliance.

Increased focus on trend analysis and switching more time from retrospective reviews to more forward looking

Work plan to include dedicated time for deep dives on alternative agendas.

FPC to get assurance that post development appraisals are undertaken and undertake some themselves for significant developments.

Divisions to report their service line reporting to the Committee on a quarterly basis.

Head of Estates and Facilities Management to attend annually.

Monthly Finance, Operational & HR updates to include more trend analysis

3.0 Proposal

The attached work plan is a proposal for how the Finance and Performance Committee can effectively fulfil its duties in 2017/18.

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

Performance Reporting

Operational Performance x x x x x x x x x x x x

HR x x x x x x x x x x x x

Finance x x x x x x x x x x x x

Finance - SLR detail to be reported by divisions x x x x

Financial assurance

Business planning guidance to approve x

Draft Budgets to be approved x

Final budgets to be approved x

NHSI Draft Operational Plan to be approved x

NHSI Final Operational Plan to be approved x

Review of post investment appraisal process x x

Report from Procurement Board and Head of

Procurement attends - assurance reviewx

Report from Better Value Better Care - assurance

reviewx x

Review of cash flow reporting and borrowing

requirements - Head of Financial Accounts to attend

x x

Deep dives where required

Operational Performance assurance

Division A to attend to discuss business plans x x

Division B to attend to discuss business plans x x

Deep dives into assurance and performance issues as

and when requiredx x x x x x

Report from Access and Flow Group. Access Manager

to attendx

HR Assurance

Report from Workforce Resources Strategy Group -

assurance reviewx x

Report from Education/learning development group -

Head of Training and Education to attend.x


Estates and Facilities Assurance

Report from Medical Devices Group - Chair of Group to

attendx

Review of Estate and Capital Planning to include

reports from- Space utilisation, sustainability and

capital planning. Head of EFM to attend

x

Report on Estates Statutory compliance and travel

working group. Head of EFM to attend.x


Governance

Review meeting templates from all reporting in

committees. x x x x x x

Approval of business cases as and when

Other

Review of Terms of reference x

Review of Effectiveness of FPC x

Finance and Performance Committee Proposed Work plan -2017/18

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1

To: Audit Committee From: Libby Walters, Director of Finance and Resources Subject: Proposed Audit Committee Work Plan 2017/18 Date: March 2017 1.0 Purpose of the Paper

The Trust Board has the responsibility to put in place governance structures and processes to:

Ensure that the organisation operates effectively and meets its statutory and strategic objectives; and

Ensure that this is the case. The Audit Committee supports the Board in fulfilling this role by:

Obtaining assurances about controls and whether that are working as they should;

Seeking assurances about the underlying data (upon which assurances are based) to ensure that it is robust, reliable and accurate;

Challenging poor and/or unreliable sources of assurance; and

Challenging relevant managers when controls are not working or data is unreliable.

To ensure the Audit Committee can fulfil its role effectively it must have in place a work programme that covers each of its responsibilities.

The purpose of this paper is to propose a work plan for the Audit Committee for 2017/18.

2.0 Current gaps in the Audit Committee Work Plan There are a number of areas where the Audit Committee must provide assurance on and currently does not spend adequate time reviewing. The table below proposes how these gaps are included in the work plan.

Gap in Work Plan Proposed action

Ensuring the risk management system and process for developing the assurance framework (BAF) is robust.

Head of Risk Management attends audit committee annually to present the risk management process.

Time on the agenda for reviewing the BAF process

Review the internal audit report on Risk Registers at the same meeting as above.

Gaining assurance from the committees reporting to Audit Committee i.e.

Information Governance Group

Information Assurance Group

Health Informatics Programme Board

Template reviewed at each meeting for these groups that show when last met, was meeting quorate, issues discussed, areas to escalate.

IG lead to attend annually to present

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in more detail the IG processes

Providing assurance that data used has undergone quality checks to ensure it is robust

Head of BI to attend annually to present how assurance is gained on this.

Ensure effective whistle blowing arrangements are in place

Review annually the process for whistleblowing.

Noting business of other committees and reviewing inter relationships

FPC and QC chair’s attend to present how getting assurance from committees they provide assurances on.

There are a number of areas where the Audit Committee could reduce its workload as follows:

Review of tenders awarded: The audit committee needs to provide assurance that effective financial systems are in place. This can be done through the internal audit plan and does not need all tender activity to be reported to the Audit Committee. It is recommended that an annual report on tender activity is provided.

Counter Fraud: Good practice states that Counter Fraud attend Audit Committee meetings at least twice a year. Currently the Counter Fraud Service attends every meeting. This could be halved and therefore they could attend three times a year.

3.0 Proposal

The attached work plan is a proposal for how the Audit Committee can effectively fulfil its duties in 2017/18.

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14-Feb 18-Apr 22-May 18-Jul 19-Sep 21-Nov Jan March

Governance

Review the BAF x x x x x x x

Review the significant risk register x x x x x x x

Review the assurance framework process x

- Head of Estates present x

Review of risk management system including

attendance of Head of Risk x

Review work of other committees x

Review reports from IGC, IAG and HIPB x x x x x x x

IG lead attends x

BI lead attends x

Auditors Annual Governance Report including letter of

representation x

Draft Annual Account, Quality Report and Governance

Statement x

Auditors Report on the Quality Account 2016/17 x

Review annual report and accounts x

Review whistle blowing arrangements x

Review changes to standing orders, SFI's, Scheme of

delegation x

Review losses and special payments x x

Review tender activity x

External Audit

Agree final annual report and accounts timetable and

plans x

Review audited annual accounts including the external

audit opinion x

Agree external audit plans and fees x

Review the effectiveness of external audit x

Review external audit progress reports x x x x x x x

Receive the external auditors report to those charged

with governance x

Receive/consider the external auditors annual audit

letter x

LCFS

Approve the annual work plan 2017/18 x

Progress Report x x x

Review the effectiveness of counter fraud x

Review the annual report on counter fraud x

Internal Audit

Review and agree Work plan 2017/18 x

Progress Report x x x x x x x

Recommendations Tracker x x x x x x x

Internal audit reports

-Well led review x

- Review of risk registers x

- Quality accounts/KPI quality x

- Main accounting systems x

- Financial systems - IT control x

- ICT infrastructure x

- Patient experience x

Audit Committee Proposed Work plan -2017/18

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14-Feb 18-Apr 22-May 18-Jul 19-Sep 21-Nov Jan March

- Equality and diversity x

- Follow up x

- Quality audit tbc

Review the annual effectiveness of internal audit x

Receive the Head of Internal Audit Opinion x

Clinical Audit

Receive the annual clinical audit work plan x

Review clinical audit progress reports x x

Other

Audit Committee Annual Report x

Review of Terms of reference x

Review of Effectiveness of Audit Committee x

Register of gifts and hospitality x x

Declarations of interest x x

Draft Minutes of Quality Committee x x x x x x x

Auditors meet members without management IA IA & EA

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Title of Meeting

Board of Directors

Date of Meeting

31 May 2017

Report Title

Board Self-Assessment of Effectiveness

Author




Purpose of Report (e.g. for decision, information) To present to the Board the outcome of the recent self-assessment of Board effectiveness for discussion and agreement of next steps.

Summary The report contains a summary of the responses received to the Board’s self-assessment questionnaire. Responses were received from 12 Board members. Key points:

Generally there was a good consensus of opinion

Nine people said that there were sometimes surprises at Board meetings with one person stating that there were often surprises

Particularly high scores were received to the following two questions where all respondents rated the Board in the top two categories:

To what extend do Board members’ own standards of behaviours uphold these values (Trust values) and adhere to the Nolan principles?

How would you assess the balance of the Board in terms of the ranges of skills and knowledge available?

Low scores were received in respect of the following two questions: Do partners have the opportunity to influence the longer term direction

of the Trust? How would you assess the performance of the Board in assuring its

accountability to local government?

How would you rate the process for staff having a voice within the Board and access to raise their concerns and feedback?

A wide spread of answers was seen for the following questions: Do senior managers and senior clinicians have the opportunity to

contribute to the development of the strategic direction of the Trust? Do partners have the opportunity to influence the longer term direction

of the Trust? Do all Board members challenge each other in a way which can be

considered constructive? How would you assess the performance of the Board in assuring its

accountability to patients and the wider public? How would you assess the performance of the Board in assuring its

accountability to local government?

How would you rate the process for staff having a voice within the Board

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and access to raise their concerns and feedback?

What proportion of the Board’s time would you estimate is spent on forward looking plans; historic performance; other?

Paper Previously Reviewed By Chair and Chief Executive.

Strategic Impact None related to this report. However, failure by the Board to operate effectively could have an impact on achievement of its strategic objectives.

Risk Evaluation Low.

Impact on Care Quality Commission Registration and/or Clinical Quality None directly related to the paper.

Governance Implications (legal, clinical, equality and diversity or other): It is considered good governance practice for Boards to carry out an annual review of their effectiveness.

Financial Implications Potential financial impact if further external facilitation or development work was considered necessary to improve Board performance and effectiveness.


Yes

Recommendations To discuss the outcome of the self-assessment. To identify any actions required to improve effectiveness.

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Board Effectiveness Self Assessment Questionnaire – Collated Results

March 2017

Focus on purpose and strategy

1 How effective has the Board, as a whole, been in defining and expressing a clear purpose for the Trust?

Not Effective

0

Somewhat effective

0

Moderately effective

4

Effective

7

Highly effective

1

Unable to comment

2 How effective and transparent are the Board’s processes for developing a strategy aimed at delivering the agreed purpose?

Not Effective

0

Somewhat effective

0


5

Effective

7

Highly effective

0

Unable to comment

3 Do senior managers and senior clinicians have the opportunity to contribute to the development of the strategic direction of the Trust?

Never

0

Sometimes

2

Often

0

Almost always

7

Always

2

Unable to comment

1

4 Do partners have the opportunity to influence the longer term direction of the Trust?

Never

0

Sometimes

6

Often

1

Almost always

4

Always

1

Unable to comment

Promoting values and good governance

5 How effective is the Board in establishing and promoting values for the Trust and its staff?

Not Effective

0

Somewhat effective

0


2

Effective

5

Highly effective

5

Unable to comment

6 To what extent do Board members’ own standards of behaviours uphold these values and adhere to the Nolan principles?

Never

0

Sometimes

0

Often

0

Almost always

5

Always

7

Unable to comment

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7 How effective are the Trust’s arrangements for ensuring sound clinical quality governance?

Not Effective

0

Somewhat effective

0


5

Effective

7

Highly effective

0

Unable to comment

8 What proportion of the Board’s time would you estimate is spent on:

Forward looking plans: Range 5% - 50% Mean 32 Review of historic performance: Range15% - 75% Mean 48 Other: Range 0% to 45% Mean 20

Skills and decision making

9 How would you assess the “balance” of the Board in terms of the ranges of skills and knowledge available?

Not Effective

0

Somewhat effective

0


0

Effective

7

Highly effective

5

Unable to comment

10 Overall, how effective is the Board at managing organisational performance to deliver the strategy?

Not Effective

0

Somewhat effective

0


5

Effective

7

Highly effective

0

Unable to comment

11 How rigorous and transparent are the Board’s decision making processes, including the information available to support their decisions?

Not rigorous

0

Somewhat rigorous

0

Moderately rigorous

2

Rigorous

9

Very rigorous

1

Unable to comment

12 What is your view of the quality of information currently received by the Board?

Very poor quality

0

Poor quality

0

Reasonable quality

8

Good quality

4

Excellent Quality

0

Unable to comment

13 Does the Board make effective use of available external information which might enhance performance?

Never

0

Sometimes

3

Often

6

Almost always

2

Always

0

Unable to comment 1

14 How effective is the Board at assuring itself that the organisation is operating effectively, efficiently

Not Effective

Somewhat effective


Effective

Highly effective

Unable to comment

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and economically?

0 0 4 8 0

15 How effective are the Board and organisational arrangements in respect of the management of risk?

Not Effective

0

Somewhat effective

0


6

Effective

6

Highly effective

0

Unable to comment

16 How effective are the Board and organisational arrangements in respect of the management of clinical safety?

Not Effective

0

Somewhat effective

0


5

Effective

7

Highly effective

0

Unable to comment

17 Is sufficient time spent at Board meetings discussing and understanding key decisions so that consensus can be reached?

Never

0

Sometimes

0

Often

2

Almost always

9

Always

1

Unable to comment

18 Do all Board members leave meeting with a clear understanding of what decision has been reached, who is responsible for implementing it and how the Board will next be updated on its progress?

Never

0

Sometimes

0

Often

1

Almost always

7

Always

3

Unable to comment

1

19 Do all Board members challenge each other in a way which can be considered constructive?

Never

0

Sometimes

2

Often

3

Almost always

6

Always

1

Unable to comment

20 Are there ever surprises at Board meetings? Never

2

Sometimes

9

Often

1

Almost always

0

Always

0

Unable to comment

21 Do you think the Board is adequately trained and developed to fulfil and meet its responsibilities?

Not at all

0 Slightly

0 Partially

2 Mostly

6 Fully

4

Unable to comment

Managing and listening to stakeholders

22 How would you assess the performance of the Board in assuring its accountability to:

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Patients and the wider public Not Effective

0

Somewhat effective

1


2

Effective

8

Highly effective

1

Unable to comment

Commissioners and other NHS Providers Not Effective

0

Somewhat effective

0


0

Effective

11

Highly effective

1

Unable to comment

Staff Not Effective

0

Somewhat effective

0


1

Effective

10

Highly effective

1

Unable to comment

Local Government Not Effective

½

Somewhat effective

½


3

Effective

5

Highly effective

1

Unable to comment

3

Regulators Not Effective

0

Somewhat effective

0


1

Effective

7

Highly effective

4

Unable to comment

23 How would you rate the Board’s working relationships with its partner organisations?

Not Effective

0

Somewhat effective

0


8½

Effective

3½

Highly effective

0

Unable to comment

24 How would you rate the process for staff having a voice within the Board and access to raise their concerns and feedback?

Not Effective

1

Somewhat effective

4


5

Effective

2

Highly effective

0

Unable to comment

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Title of Meeting

Board of Directors

Date of Meeting

31 May 2017

Report Title

Use of Trust Seal

Author




Purpose of Report (e.g. for decision, information) To inform the Board of the use of the Trust Seal during the period 1 January 2017 to 31 March 2017.

Summary The Trust Standing Orders require that the use of the Trust’s seal is reported to the Board on a quarterly basis. During the period 1 January 2017 to 31 March 2017 the seal has been used on to May 2013 the seal was used on five occasions as set out below:

Seal number

Date of signing Description of Document Signed by

11 27 Jan 2017 Agreement for Lease and Tenant’s Works relating to the Main Entrance at Dorset County Hospital

Patricia Miller Nick Johnson

12 31 Jan 2017 Damers Road Agreement Patricia Miller Libby Walters

13 22 March 2017 Dorset Care Record Deed of Variation to Partnering Agreement

Patricia Miller Libby Walters

14 29 March 2017 Compass – Licence to carry out works relating to units at ground floor main entrance


15 29 March 2017 Compass – Lease relating to retail unit at ground floor entrance


Paper Previously Reviewed By N/A

Strategic Impact None

Risk Evaluation None


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None

Governance Implications (legal, clinical, equality and diversity or other): Reporting of the use of the seal is a requirement under Trust Standing Orders

Financial Implications None


Yes

Recommendations To note the report.

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Title of Meeting

Trust Board

Date of Meeting

31st May 2017

Report Title

Safe Staffing Return (March 2017)

Author

Neal Cleaver (DDoN and Quality)


Nicky Lucey (Director of Nursing and Quality)

Purpose of Report (e.g. for decision, information)

To report the submission to UNIFY on planned Nurse/Midwife staffing against actual hours and to provide assurance that safe staffing is managed, monitored and any gaps are mitigated to ensure patient safety.

Summary

As part of the requirement by NHS England to submit information to NHS Choices relating to planned and actual staffing levels, Trusts are required to report any areas which have a lower staffing level than planned and any specific impacts on the quality of care provided as a consequence. In the absence of clear national guidance on the thresh-hold for reporting, DCHFT Trust Board agreed that where actual registered staffing was less than 90% of the planned staffing that this should be reported to the Board with an assessment of any adverse impacts on quality that may have occurred. During this reporting period it should be noted that:

- Abbotsbury/Barnes/Day Lewis– During this period the trust saw a decrease in activity and acuity

- SCBU– Staff in this area flex up and down or are redeployed to other areas dependent on the acuity of their patients and the demand for their services.

Paper Previously Reviewed By Quality Committee on May 23rd 2017.

Strategic Impact

There is a requirement from NHS England for Trust Boards to receive this information

Risk Evaluation Staffing levels are reviewed on a daily basis, along with a review of the patient needs. If there are staffing gaps then a clinical review and effective distribution of staffing resources is applied. The National shortage of both Nursing and Midwifery registered staff continues to cause concern, and the introduction of agency caps has not yet seen the anticipated rise in nurses/midwives entering substantive posts.


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There is national debate as to how the information may identify a lack of clinical quality, and extra information has been included to clarify the position of DCHFT. This this information is monitored by the CQC as part of the Safe, Responsive, Effective and Well-Led domains.

Governance Implications (legal, clinical, equality and diversity or other):

Staffing shortages could lead to patient safety and experience incidents and negative reputational impact.

Financial Implications There are costs and financial benefits associated with the recommendations of the full establishment review.


Yes

Recommendations

a) To note and agree the contents for publication on the Trusts website. b) To receive assurance that safe staffing is monitored and managed to ensure safe care.

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Title of Meeting

Trust Board

Date of Meeting

May 31st 2017

Report Title

Annual Complaints Report 2016/2017

Author

Neal Cleaver, Deputy Director of Nursing Becky Protopsaltis, Head of Public and Patient Engagement


Nicky Lucey, Director of Nursing and Quality

Purpose of Report (e.g. for decision, information) The annual complaints report complies with the Local Authority Social Services and National Health Service Complaints Regulations 2009, which requires each NHS Trust to produce an annual report regarding complaints received. This is also a mandated requirement of NHS Improvement in the production of the annual quality account.

Summary The paper covers the period 1st April 2016 to 31st March 2017

During this period the Trust received 283 formal complaints, an increase from 217 for 2015/16

There were 588 recorded informal issues resolved in real time during this reporting period

The Trust received 427 formal compliments during this period, a substantial increase of 41% from the previous year

Complainants have received a feedback questionnaire based on the experience based design approach in order for us to be able to understand the complaints process from a complainants perspective

There were 4 (1.4%) complaints refereed to the Parliamentary and Health Service Ombudsman (PHSO), a decrease from the previous year of 8 (4%)

A timeliness of responses action plan has been developed to be implemented in conjunction with the new governance structure and divisional restructure

Timeliness of responses to complaints remains a Quality Priority for the Trust for 2017-2018.

Paper Previously Reviewed By This paper was reviewed by the Quality Committee on 23rd May 2017 prior to providing assurance to the Trust Board. Timeliness of responses and communication/attitude themes from complaints were discussed in detail and will be monitored through the Quality Committee

Strategic Impact The delivery of improved complaints processes will require cross boundary working, MDT working and strengthened processes within the new divisional governance structure.

Risk Evaluation Improved timeliness of responses to complaints was identified as part of the quality account priorities for 2016-17. As no significant improvement has been demonstrated, this has been continued as a priority for 2017/18.

Impact on Care Quality Commission Registration and/or Clinical Quality As feedback is designed to enhance and improve both patient safety and experience, non-

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delivery of improvement may result in a detrimental consequence on the quality and experience of our patients.

Governance Implications (legal, clinical, equality and diversity or other): Inability to achieve progress or sustain set standards could lead to a negative reputational impact and inability to improve patient safety, effectiveness and experience.

Financial Implications None currently identified


Yes

Recommendations 1. Note the report 2. Gain assurance of the scrutiny performed by the Quality

Committee

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1

Title of Meeting

Quality Committee

Date of Meeting

23rd May 2017

Report Title

Annual Complaints Report 2016/17

Author

Becky Protopsaltis, Head of Public and Patient Experience Nicola Lucey, Director of Nursing and Quality Neal Cleaver, Deputy Director of Nursing and Quality

INTRODUCTION

1.1 The annual complaints report complies with The Local Authority Social Services

and National Health Service Complaints (England) Regulations 2009, which

requires each NHS Trust to produce regular reports about complaints received,

including an annual report.

1.2 This annual report includes an overview of the number and nature of complaints

received, how complaints are handled,

2.0 NUMBER OF COMPLAINTS RECEIVED

2.1 The total number of formal complaints received by the Trust for this year was 283 which has increased (30%) from the previous year. There were also 588 recorded contacts for PALS informal issues resolved, a decrease (3%) on the previous year.

2.2

373

544

352411

345

478428 452

385459

217

608

283

588

0

100

200

300

400

500

600

700

Formal complaints PALS (informal issues)

Number of Complaints and Concerns

2010/11

2011/12

2012/13

2013/14

2014/15

2015/16

2016/17

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2

2.3 Each formal complaint is treated as well-founded in order to investigate and a response is

provided to the complainant outlining the findings of the investigation.

3.0 PROCESS FOR COMPLAINTS HANDLING

3.1 The Trust informs patients and carers how to raise concerns in the bedside folders, on the

website and in the “Comments, Complaints, Concerns & Compliments” leaflet.

3.2 All feedback, concerns and complaints are co-ordinated centrally and upon receipt are

screened and triaged according to the seriousness of the issues raised. The focus is to

consider each complaint from the complainant’s perspective and every complainant is

offered the opportunity to discuss the way in which their complaint is handled.

3.3 The responsibility for investigating complaints is devolved to the Divisions and their

respective teams, who are required to provide a comprehensive response within an agreed

timeframe. This outlines the response to the investigation and recommendations or actions

taken for improvement where appropriate. The final response to every formal complaint is

agreed and signed by the Chief Executive.

3.4 The complaints process allows the Trust flexibility in arranging local resolution meetings

with complainants. These meetings usually include the relevant healthcare professionals

including the Consultant or Matron in order that questions can be answered by the clinicians

delivering care and a personal apology given where appropriate. This has proved to be a

very positive and helpful process with the openness of the meetings being well received by

all participants.

3.5 Dorset County Hospital NHS Foundation Trust has been part of the NHS England

development group for the “Protocol for the Handling of Inter-Organisational Complaints in

Wessex” (Hampshire, Dorset and IoW) which will replace the “Joint NHS Complaints Policy

for Dorset”. This protocol is between NHS England (Wessex) and the NHS Trusts, CCGs,

Local Authorities and Ambulance Trusts in the Wessex area.

4.0 TIMELY AND COMPASSIONATE RESPONSE TO COMPLAINTS

4.1 This year again our task was to improve the timeliness of responses to complaints so that complainants are responded to within mutually agreed timescales and to improve the compassion in the response so that it responds to the emotions of the complainant.

4.2 We believe that when our patients or their families have cause to complain, the response

they receive should be within an agreed timescale and acknowledge the experience of the patient through their own eyes. We believe that the response should cover all the concerns that are raised, should not cause any further distress, and that our patients/families should have an identified lead who will keep them updated on the progress of any investigation.

4.3 In order to achieve improvements in this area, we:

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4.3.1 Reviewed the Complaints Policy and Standards which includes the standards for

the complaints process and agreements of timescales for responding to complaints for non-complex complaints and concerns involving one area.

4.3.2 Met with Divisions (as per Division capacity /resource) on a weekly basis to

highlight complaints response times, and complaints in need or urgent response.

4.3.3 Sent out a weekly report highlighting which complaints and concerns are outstanding and complaint timeframes to Divisions and senior management team, Director of Nursing/ Quality, Deputy Director of Nursing/Qualityand Chief Operating Officer.

4.3.4 Put request for timescales included in complaint email from PALS. 4.3.5 Process mapped the complaint journey for the development of the Complaints

module on Datix.

4.3.6 Participate in a quarterly deep dive review from the Clinical Commissioning Group to quality check processes and responses and action any improvements identified in their report.

4.3.7 The Patient & Public Experience Lead reviews all responses to ensure compassion and timely response.

4.4 Divisions report that: 4.4.0 All complainants now receive a personal telephone call from the relevant

Manager. 4.4.1 The purpose of the call is to reassure the patient and try to deal with the matter

there and then if possible and to find out whether a written response or meeting is required in the first instance. A timescale for response will also be agreed at this time. A short confirmatory letter then is sent as a follow up.

4.4.2 If the patient wants a full and formal response this is provided and is read and signed by the CEO.

4.4.3 If this response does not meet the needs of the patient, then the patient is offered

a meeting with an appropriate person (usually the Divisional Manager). At this meeting every attempt will be made within reason to meet the patient’s needs.

4.4.4 A follow up letter is then sent after the meeting.

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5 LEARNING FROM COMPLAINTS

5.1 Staff from across the Trust regularly reflect on complaints at divisional and departmental

meetings, in grand rounds, during junior doctors training, sisters and matrons meetings

and porters & housekeeping briefings. The training and support provided by the PALS

team enables them to understand the emotional experience from the complainant and

staff perspective and reflect upon improvements in relational aspects of care.

5.2 Patients have assisted in making videos narrating their experience of the care that they

received, and also their feelings about the complaints process. These videos are shown

to the relevant divisional leads and are available for presentation at Board when required.

The creation of patient video stories remains ongoing.

5.3 Feedback from clinicians into the delivery of complaints training and education by the

PALS team is very positive, with clinicians reporting that they have changed their practice

to deal with complaints more effectively, understand the emotions in complaints and feel

confident when dealing with them.

5.4 Complaints are an integral element of improving the patient’s overall experience of health

care and help to ensure that safe, high quality care is provided within the hospital.

5.5 The quality improvement or learning outcome following investigation of a complaint is

identified and action taken by the respective Division. This is monitored through the

Learning from Patients Committee (now Patient Experience Group) which continues to

meet quarterly. This framework enables the information gained from patient and public

feedback to be owned locally whilst providing a strategic overview with a clear focus on

improving service quality, ensuring that lessons are learnt and processes are changed to

prevent situations recurring.

6.0 FEEDBACK FROM COMPLAINANTS

Complaints Experience Questionnaire Report 2016-2017

6.1 The following charts show the responses received from the Complaints Experience Questionnaire that is sent out with each complaint response. This will be used to improve the complaint handling processes.

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Getting complaint information

Further comments received around obtaining complaint information:

Difficult; I was not given details despite requesting a few times.

I had to ask various staff at various times to get the information I requested

Making a complaint

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Further comments received around making a complaint:

Simple enough. I just wrote what happened and quoted when I could.

Emotionally draining and very upsetting. Only because it took me all weekend to put together all of the dates/information about the things that had gone wrong and the delays. Each department helpful in their own way but not communicating well with each other.

Staying informed

Further comments about staying informed:

Kept informed by the hospital about what was happening.

I had to chase response several times.

Unhelpful, never kept informed.

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Response

Further comments about the complaint response:

Extremely good letter. Helpful and positive and should prevent similar situation in the future. Thank you.

Feel pacified by response. Not sure if it will make any difference as pressure on service is immense.

Frustrating. The response was full of apologies and procedural improvements; all easy to say leaving me helpless and frustrated with no compensation for the poor service.

I would make a complaint again if I needed to

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Further comments about complaining again in future:

Without receiving complaints complacency is more likely.

To not complain only lets the NHS deteriorate further.

If people don’t speak out nothing will ever change.

The complaint was handled fairly

Further comments about the complaint being handled fairly:

Undecided. Don’t feel that the issue was dealt with in depth.

Procedurally yes. But I had no assurance that the service will improve.

7.0 REPORTING & MONITORING

7.1 The Trust Board receives a monthly summary of the number of complaints

received and the issues raised as part of the Integrated Operational Report. A

further report which contains a more in depth analysis of the issues raised in

complaints is provided quarterly to the Board.

7.2 Complaints are coded on the Datix system under a variety of categories.

Although the subject matter may vary, the root causes which result in a

complaint being raised can be associated to three main themes:

communication, staff attitude and delays.

7.3 The five main themes are shown in the graph below.

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9

7.4 The graph below shows a breakdown of the largest theme of consent, communication

and confidentiality in more detail.

34

4245

62

80

0

10

20

30

40

50

60

70

80

90

Patient care - Ongoingmonitoring and review

Treatment, procedure

Diagnostic scans and tests

Access, admission, transfer,discharge (inc. missing patient)

Consent, communication,confidentiality

38

2

5

33

2

0

5

10

15

20

25

30

35

40

Employee Attitude

Breach of confidentiality

Communication failure (team)

Communication failure withpatient, parent/carer

Communication or advicegiven incorrectly

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8.0 COMPLAINTS BY STAFF GROUPS

9.0 TIMELINESS OF COMPLAINT RESPONSES

9.1 The following chart shows the percentages achieved per division for sending a timely

complaint response (from September 2016 the target was 95%).

0

20

40

60

80

100

120

140

160

180

200

Consultant Nurse - Grade not known Administrative/Clerical

April May June July Aug Sep Oct Nov Dec Jan Feb March

Medicine

14% 83% 73% 50% 55% 46% 50% 41% 50% 38% 83% 50%

Surgery 80% 60% 68% 66% 50% 57% 41% 40% 20% 60% 60% 50%

Family n/a n/a 80% 100% 50% 0% 43% 100% 33% 50% 0% 33%

Clinical

&

Scientific

n/a n/a 0% 100% 100% 100% 50% 0% 50% 66% 0% 33% A

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10.0 PARLIAMENTARY AND HEALTH SERVICE OMBUDSMAN

10.1 Contact information for the Parliamentary and Health Service Ombudsman is provided

to all complainants should they remain unhappy with the outcome of the Trust’s

investigation and response.

Complaints referred to the Ombudsman

2010/2011 2011/2012 2012/2013 2013/14 2014/15 2015/16 2016/17

Total

number of

complaints

373 352 345 428 385 217 283

Total

number

referred to

ombudsman

13

(3%)

16

(5%)

8

(2%)

1

(0.25%)

7

(2%)

8

(4%)

4

(1.4%)

Further

action

required

through

local

resolution

7 10 3 0 5 1 2

No action

required

5 3 0 1 2 3 0

Awaiting

outcome

1 3 1 0 0 4 2 A

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11.0 COMPLIMENTS

11.1 The graph below shows the number of compliments received by the Trust in recent

years, with the number of compliments received this year being 427, up by 41% and a

significant increase on the usual numbers received.

12.0 CONCLUSION

12.1 Timely and compassionate response to complaints remains within the Trust’s Quality

Account Priorities for the forthcoming year as the required improvements have not been

delivered.

12.2 A detailed improvement plan is due to be presented to the May Quality Committee for

assurance on the actions required.

12.3 The new governance structure implementation which commenced in May 2017 has

identified a ‘quality’ lead position for each division. The Divisional Heads of Nursing and

Quality are also due to commence in post in June 2017, both of which will be

instrumental in delivering the improvements required.

12.4 A comprehensive action plan has been developed to implement required change and a

plan for improvement, as shown below.

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ACTION: COMPLETION

BY:

1 To update current system used for inputting and recording complaints

(Datix Rich Client) to a web based reporting system (DatixWeb) for

complaints management.

June 2017

2 Creation of toolkit for complaints investigation to go onto intranet.

Development of toolkit to include:

How to write a statement

How to interview staff

Guidance on holding meetings with complainants

Draft response templates

Lessons learnt template

May 2017

3 Process mapping to reflect updated management of

complaints/divisional restructure to be developed and adapted as

DatixWeb rolls out to ensure continuity, accuracy and flow.

May 2017

4 On-going monthly monitoring of response timeliness. A monthly report

is already provided to reflect progress and numbers received. To be

continually monitored for improvement progress.

On-going

5 Complaints investigation training to be provided for all relevant staff.

Next steps:

• Prepare training materials for workshops.

• Identify staff requiring training.

• Trust Complaints Officer to provide 1:1 small group training as

and when required.

June 2017

6 Full quarterly report to reflect on-going progress. An on-going quarterly

report to include:

• Executive summary

• Breakdown of complaints received

• Emerging themes

July 2017 (end of

Q1)

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• Breakdown of outcome/resolution

• Ombudsman update

• Complaints process satisfaction survey update

• PALS update

• Lessons learnt

7 Monthly complaints update meetings to be attended by Complaints

Officer and Quality Managers for each Division.

On-going from

May 2017

8 Quarterly meetings with Patient & Public Engagement Lead and

Divisional Managers to review progress and track improvement made.

On-going from

July 2017

9 Weekly report to be sent out highlighting which complaints and

concerns are outstanding and complaint timeframes to Divisions and

senior management team, Director of Nursing, Deputy Director of

Nursing and Chief Operating Officer.

Already in place;

to continue

monitoring

10 Divisional Managers and Patient & Public Engagement to review all

draft responses – the purpose of this is to check for clarity and

accuracy, as well as to ensure that the reply is sufficiently

compassionate in tone.

April 2017

13.0 RECOMMENDATIONS

13.1 The Trust Board is requested to receive and note the contents of this report.

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