the meeting of the board of directors to be held on ......action notes meeting: board of directors...

The meeting of the Board of Directors

To be held on Tuesday, 23 October 2018 at 10.00am

in the Boardroom, DRI

AGENDA Part I

Enclosures Time

1. Apologies for absence

(Verbal) 10am

2. Declarations of Interest Members of the Board and others present are reminded that they are required to declare any pecuniary or other interests which they have in relation to any business under consideration at the meeting and to withdraw at the appropriate time. Such a declaration may be made under this item or at such time when the interest becomes known.

(Verbal)

3. Actions from the previous meeting

Enclosure A

Presentation slot

4. Clinical research in the older population Professor Lynda Wyld, Professor of Surgical Oncology at University of Sheffield & Honorary Consultant Breast Surgeon, the Jasmine Breast Centre, DBTH

Presentation 10.05am

Reports for decision

5. Use of Trust Seal Matthew Kane – Trust Board Secretary

Enclosure B 10.40am

Reports for assurance

6. Progress Against Corporate Objectives Richard Parker – Chief Executive

Enclosure C 10.45am

7. Chairs Assurance Logs for Board Committees held 22 October 2018 Neil Rhodes – Chair of Finance and Performance Committee Linn Phipps – Chair of Quality and Effectiveness Committee

Enclosure D (to follow)

11.00am

8. Strategy and Transformation Update Marie Purdue – Director of Strategy and Transformation

Enclosure E 11.10am

BREAK

11.30am

9. Finance Report - September 2018 Jon Sargeant – Director of Finance

Enclosure F 11.40am

10. Performance Report – September 2018 Led by David Purdue – Deputy Chief Executive & Chief Operating Officer

Enclosure G

12.00noon

11. Estates & Facilities Q2 Dr Kirsty Edmondson-Jones – Director of Estates and Facilities

Enclosure H (to follow)

12.20pm

12. Corporate Risk Register & Board Assurance Framework Q2 Matthew Kane – Trust Board Secretary

Enclosure I 12.30pm

Reports for information

13. Chair and NEDs’ Report Suzy Brain England – Chair

Enclosure J

12.40pm

14. Chief Executive’s Report Richard Parker –Chief Executive

Enclosure K

15. Minutes of Charitbale Funds Committee – 31 July 2018 Sheena McDonnell – Chair of Caritable Funds Committee

Enclosure L

16. Minutes of Management Board, 17 September 2018 Richard Parker – Chief Executive

Enclosure M

17. To note: Board of Directors Agenda Calendar Matthew Kane – Trust Board Secretary

Enclosure N

Minutes

18. To approve the minutes of the previous meeting held 25 September 2018

Enclosure O

19. Any other business (to be agreed with the Chair prior to the meeting)

20. Governor questions regarding the business of the meeting

12.50pm

21. Date and time of next meeting

Date: 27 November 2018 Time: 10.00am Venue: Boardroom, Bassetlaw Hospital

22. Withdrawal of Press and Public

Board to resolve: That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

1.00pm

Suzy Brain England Chair of the Board 17 October 2018

Action Notes

Meeting: Board of Directors

Date of meeting: 25 September 2018

Location: Boardroom, DRI

Attendees: SBE, RP, KB, PD, MH, DP, AA, LP, JP, JS, PS, KS

Apologies: SS, NR

No. Minute No Action Responsibility Target Date Update

1. 18/4/44 Presentation to be given to Board on work in theatres and outpatients.

DP/MK Autumn 2018 Timetabled for a future Board.

2. 18/6/47 18/7/27 18/7/64 18/9/23

Workshops to be organised on:

Digitising A&E

LEAN

Values based recruitment

Freedom to Speak Up Strategy

KB/MK Autumn 2018 Included in board development schedule.

3. 18/9/3 Board development work with Karl George to be brought into an action plan.

KB November 2018 Not yet due.

No. Minute No Action Responsibility Target Date Update

4. 18/9/51 QEC to deep dive cancelled operations.

DP December 2018 Not yet due.

Date of next meeting: 23 October 2018 Action notes prepared by: M Kane Circulation: SBE, AC, NR, KB, MH, KS, PD, DP, JS, SS, RP, LP, SM

Title Use of Trust Seal

Report to: Board of Directors Date: 23 October 2018

Author: Matthew Kane, Trust Board Secretary

For: For approval

Purpose of Paper: Executive Summary containing key messages and issues

The purpose of this report is to advise of use of the Trust Seal in accordance with section 14: Custody of Seal and Sealing of Documents of the Standing Orders of the Board of Directors:

Seal No.

Description Signed Date of sealing

99 Integrated health projects contract project (II) – Stage 3: Completion of design construction and handover of the works service infrastructure upgrade at DRI. P21 + 337. (This refers to the electrical contract previously approved at Board in August)

Richard Parker Chief Executive

22 August 2018

Jon Sargeant Director of Finance

100 Contract project (II) DRI/HG0016/S4 – Confirmation of agreement to complete multiple integrated health projects (again refers to electrical contract previously approved at Board in August)


22 August 2018


101 Agreement for provision of sterile services 2018-2033 between DBTH and Steris Ltd


12 September 2018


Recommendation(s)

The Board is requested to approve use of the Trust Seal.

Title Corporate Objectives 2018/19

Report to Board of Directors Date 23 October 2018

Author Matthew Kane, Trust Board Secretary

(to be presented by Richard Parker, Chief Executive)

Purpose Tick one as appropriate

Decision

Assurance X

Information

Executive summary containing key messages and issues

The corporate objectives for 2018/19 were agreed at Board in June 2018 following the appraisals process. Progress for each objective in relation to Q1 and Q2 is provided in the attached paper along with a RAG rating.

Key questions posed by the report

Is the Board sufficiently assured by progress in relation to the objectives for each director?

How this report contributes to the delivery of the strategic objectives

This paper contributes to all strategic objectives.

How this report impacts on current risks or highlights new risks

Relevant risks are highlighted in the appendix.

Recommendation(s) and next steps

The Board is asked to note the paper for assurance.

OBJECTIVE EXPECTED OUTCOME Q1 & Q2 UPDATE Q3 UPDATE Q4 UPDATE CURRENT RAG RATING Chief Executive

Establish a Trust wide vision, values and commitment to achieve a step change in performance across a range of key quality and performance metrics.

Across a range of measures agreed with the Board of Directors and Council of Governors. Demonstrate improved performance and outcomes including, but not exclusive to achieving a CQC Outstanding assessment by 2020/ 2021 and a Single Oversight Assessment of 1 by 2020/ 2021

Preliminary work in establishing vision and values through the NHSI improvement practice work has been undertaken. CQC outstanding action plan in progress.

Ensure a Trust wide commitment to high quality services delivered through robust financial management. Leading the delivery of an improved financial position, ensuring improved statutory and regulatory compliance.

Achieve a break even, or better, financial position by 2020/ 2021

The cumulative position at Q2 is an £11.9m deficit, £1k favourable to plan. The Trust needs to achieve a £6.6m deficit to deliver the year end control total but is currently forecasting achieve a deficit of £9.5m. Actions are underway to rectify this situation.

Lead the delivery of the vision, values and benefits identified in the Trusts Strategic Direction.

Achieve the key milestones identified in the Trusts Strategic Direction

In Q2, 44 of the milestones were completed and seven were off track. Four remain off track from the previous quarter.

Ensure that the Trust builds upon the quality Improvement and Innovation strategy to ensure Trust wide engagement and benefit from the NHSI Lean Programme. Removing all forms of ‘waste’ at every level of the Trust.

Following the visioning event ensure a Trust focus and engagement on the ‘True North Statement’, ensuring a detailed plan and expected outcomes for year 1.

Exec Team up to date on improvement practice training and positive VSA events held on 2ww and with trauma and orthopaedic pathways.

Maintain strong, open and honest relationships to maximise the Trusts influence within the Integrated Care System and Accountable Care Partnerships to achieve the maximum benefits for the Trust, Place and Integrated Care System.

Ensure appropriate representation at relevant ICS and ACP meetings and events, including where appropriate taking lead roles on behalf of the ICS and ACPs.

CEO commenced secondment within ICS on 1/10/2018. Members of Executive Team regularly attending system-wide meetings or sending deputies.

Deputy Chief Executive & Chief Operating Officer

Complete the Divisional management structures, strengthening the COO team and the Senior Management Teams to enable sustained improvements in key performance metrics.

Achieve trajectory, or national performance standards; Emergency Admissions, RTT ( within the CCG contracted performance levels) Cancer services Diagnostic waits

Improvements in Cancer performance following restructure of the Cancer teams. RTT performance trajectory agreed with plans to address increases in waiting list size. 4hr access below trajectory partially due to overall 6.7% increase in attendances and staffing issues in ED.

In collaboration with the Director of People and Organisational Development support the leadership development and succession planning programme, leading the work to develop the new Divisional Senior Management Teams.

Identify the learning and development needs of the Divisional Senior Management Teams establishing a sustainable leadership programme with measurable outcomes linked to improvements in the Trusts capacity and capabilities.

Divisional Directors have leadership development plans. Coaches agreed. Shadowing plans agreed. Awaiting confirmation of Shadow Board Programme from the Leadership Academy.

Support the Trusts partnership working by taking lead responsibility for identified programmes of work.

Take a lead role within the two ACPs for agreed work programmes

Leading Urgent and Emergency Care for DCCG and BCCG. Working with SCH to improve Paediatric pathways. RDASH to review therapy and rehab pathways.

Lead and deliver the identified Effectiveness and Efficiency Programmes:

Deliver the identified E&E programmes within plans and timeframes. Identifying additional opportunities to deliver the Trusts 2018/ 2019 financial plans.

Length of Stay project slightly behind plan but with mitigation plans in place. Admin structures agreed, will have agreed plans with Care Groups by end of Q2 Strategy, Plans in place for joint work with RDASH. Elective work-stream changes agreed.

Leading by example, Support the successful implementation and delivery of the Trusts Transformation and Lean Programmes.

Actively participate in the Trusts Lean Programme. Demonstrating the required leadership and assuming lead responsibilities where required.

Personal A3 completed. VSA of 2 week wait completed. Launched VSA for T&O.

Medical Director

Sustain improvement in care quality as evidenced by a range of metrics

Deliver improvement in the quality of clinical care as evidenced by quality indicators agreed with the Quality and Effectiveness Committee, Clinical Governance Committee and Board of Governors.

On a range of metrics, care quality has been maintained. The digital quality dashboard has been populated and is being shared with all staff to facilitate quality improvement activity.

Lead and deliver the identified Effectiveness and Efficiency Programmes: Theatre and pre assessment Medical Productivity


Most consultants’ job plans are up to date. There remain one or two specialties where the process is ongoing. Revised pre-op process has gone live. We continue to work to optimise theatre utilisation.

Complete the maternity services transformation and improvement programme

Deliver all of the outcomes on the Royal College of Obs and Gynae Review, CQC recommendations, strategic objectives and Hospital Services Review. Demonstrating Improvements in maternity staff survey feedback and maternity quality indicators.

The only outstanding actions from the RCOG action plan relate to improving staff morale and implementing cross-site working. Work is in train on the former and is planned for the latter.

Leading by example, support the successful implementation and delivery of the Trusts Transformation and Lean Programmes.


The Trust’s Quality Improvement programme will shortly be used to revise and augment our maternity service.

In conjunction with the DNMAHP and Director of People and Organisational Development identify a plan to achieve CQC Outstanding by 2020/ 2021

Establish an appropriate plan to ensure that the Trust is able to demonstrate the standards required to achieve an Outstanding rating by 2020/ 2021.

Sessions are planned to map our path to achieving a CQC rating of outstanding.

Director of Nursing, Midwifery & Allied Health Professionals

In conjunction with the Director of

People and Organisational

Development review governance

arrangements in relation to education

and research to oversee and support

the development and implementation of

academic directorate

Agree a structure for education and

research by December 2018 to

deliver a strategy for the

development of academic

Directorates as part of phase 2 of

Teaching Hospital status.

Research now reporting into Workforce, Education and Research Committee. R&D strategy includes development of academic directorates.

Review and implement recruitment and

retention strategies to minimise

registered and non-registered

vacancies across the organisation.

Identifying strategies to implement new

and changing roles.

Ensure that the Trust has a Nursing,

Midwifery and Allied Health

Professionals workforce plan which

reduces workforce gaps to minimise

the use of temporary workforce.

Workforce plan in development. Meeting planned with ICS CN’s/HEE 26 Oct to focus on ICS workforce. Agency HCA discontinued with only NHSP providing temp non-registered staff.

Implement improvements in patient

experience and engagement

Implement the patient experience and engagement strategy in line with agreed milestones, which improves the Trusts patient survey and friends and family results.

PE&E Strategy due to update at December Management Board and QEC.

Lead on the public health agenda in

relation to smoking cessation and

enforce a smoke free site by October

18 and achievement of the CQUIN by

March 19.

Implementation of a revised strategy to establish a smoke free site and improved compliance with CQUIN requirements

CQUIN in relation to tobacco control on target to deliver. Main entrance work delayed to December 2018.



Plans on track.

In conjunction with the MD and Director of People and Organisational Development identify a plan to achieve CQC Outstanding by 2020/ 2021


Plan to deliver outstanding in progress. Meeting with Divisions and corporate departments planned 19 October 2018.



A3 for patient supporting cell completed. Patients contributed to first VSA. Personal A3 in development.

Director of Finance

Complete the production of the Year End

accounts 2017/18

The 2017/ 2018 annual accounts are approved by internal and external audit and accepted at the 2018 Annual General Meeting.

Delivered on time with a clear audit report. COMPLETED

Complete the restructuring of information services producing a ward to Board information scorecard to support assurance and a revised performance management framework.

Complete the restructuring of information services to deliver an enhanced service and a new ward to Board information scorecard and performance management framework.

Passed to DoF In Q2. Work started with a review of current reporting and the initial performance reporting to Board/F&P to be completed in Q2.

Manage and maximise the Capital allocation and bids Processes

Improved management of the 2018/ 2019 capital programme to maximise benefits.

Capital Budgets signed off by Trust Board before year start. Capital Governance paper agreed at Management Board and Trust Board. All meetings and groups meeting and working to agreed processes. Minutes being shared at F&P. Capital Budget being monitored routinely at F&P. Cash and Capital Cash Forecast being reviewed monthly at cash committee.

Set Annual Financial Plans, monitor and recommend actions to ensure delivery

Delivery of the Trusts financial plan Forecast shared with F&P and Board. Recovery plan being produced by executive.

Develop the PMO to support the delivery of the 2018/ 2019 Effectiveness and Efficiency programmes and progress towards a break even or better financial position in 2020/ 2021

Actively support the delivery of the Trusts 2018/ 2019 Effectiveness and Efficiency programme and plans for 2019/ 2020.

Permanent Efficiency Director appointed and audit report giving significant assurance on Governance processes achieved. Initial total outline CIP identified however a number of schemes will require mitigation to deliver the full plan.



Effectiveness and Efficiency Committees taking place. Accountability architecture in place. Regular reports to F&P and Board on CIP delivery.



Working through lean programme accreditation with other Executives.

Director of People and Organisational Development

Implement a Trust Leadership Development framework including our approach to coaching, talent management and succession planning. Delivering improved training and development across the Trust.

Implementation of a Trust wide framework to deliver coaching, talent management and succession planning, including establishing a robust Board development programme with a combination of knowledge acquisition and team building.

Coaching proposition refreshed. Head of Leadership & OD commenced September. Refresh of management skills passport underway. Board development programme identified, and a number of sessions undertaken.

Implement systems and processes to ensure all areas of the Trust maximise workforce productivity. Including strategies to maximise the opportunities created by improved partnership working and the application of family friendly policies and flexible working.

Ensure the maximum use of e-roster systems, model hospital portal, grip and control processes and use of workforce information and technology to maximise workforce productivity.

Grip and control meetings in place. Internal audit review undertaken – action plan identified. Interface between NHSP and Allocate being implemented along with Safecare which will enable greater visibility of staffing requirements. ESR self-service introduced for employees including access to on line payslip.

Establish and implement a robust and reliable workforce plan. Identifying robust recruitment and retention strategies and maximising the use of new and emerging roles.

All areas of the Trust will have effective workforce plans to ensure safe and sustainable staffing levels which reflect the changing needs of the Trust and minimising the use of temporary workforce.

Care group workforce plans developed as part of business planning process. Reviewed as part of internal audit plan. Profession specific templates being completed by Divisions.

Establish and implement a Trust staff involvement and engagement plan to deliver improved staff survey results.

Re-launch of Trust’s values to demonstrate the importance placed on staff by the leadership teams of the Trust.

Action plan in place; link in with Sharing how we care bulletin and health and wellbeing initiatives. Regular articles in Buzz. Included within management skills passport.

In conjunction with the Director of Nursing , Midwifery and Allied Health Professionals review governance arrangements in relation to education and research to oversee and support the development and implementation of academic directorate

Agree a structure for education and

research by December 2018 to

deliver a strategy for the

development of academic

Directorates as part of phase 2 of

Teaching Hospital status.

R&D now forms part of the Workforce, Education & Research Committee to ensure appropriate governance and alignment of R&D with Education.



Management & corporate workstream on plan.

In conjunction with the MD and DNMAHP identify a plan to achieve CQC Outstanding by 2020/ 2021


P&OD representatives will be attending clinical governance workshop. Discussions scheduled with P&OD senior leadership team.



Attended Executive team training modules. Commenced personal A3 coaching. Reviewing the process for conducting investigations. P&OD cell being developed.

Director of Strategy and Improvement

Lead on co-ordinating visioning event with the Executive Team to develop “True North” statement and ensure alignment of strategic priorities with further development of processes for monitoring implementation and assurance.

Working with NHSI, organise and lead the visioning event, identifying the Trusts ‘True North Statement’. Developing a detailed year one plan to identify and secure the expected outcomes1.

Preliminary work in establishing vision and values through the NHSI improvement practice work has been undertaken. CQC outstanding action plan in progress. Purpose pyramid developed and shared with stakeholders. First Value Stream Analysis undertaken.

Develop the innovation and horizon scanning elements of Strategy & Transformation Team to inform strategic direction.

Ensure that the Trusts Strategic Direction reflects new and emerging policies, procedures and practices and remains fit for purpose.

Ongoing – horizon scanning in areas affected by VSA – feedback from Expo obtained

Actively contribute to the NHSI lean Improvement Programme and lead the successful implementation in DBTH. Have measurable evidence of improvements as a result of this within the first year.

Identified detailed outcomes for the programme in year one with draft work programmes for years two and three.

Contributed to workshops to develop NHSI Improvement practice model. Implementing as agreed with NHSI National Director of Lean Transformation. First VSA undertaken – improvement work commenced in Trauma & Orthopaedics and plan developed for 2018/19.

Work with partners to support joint working where there are quality and financial benefits and support projects when “commissioned” by Executive colleagues Lead and deliver the identified Effectiveness and Efficiency Programmes:

Enhanced collaboration and partnership working to support quality improvements in patient pathways and improved productivity, efficiency and effectiveness.

Developed Strategic Change Manager role for Urgent & Emergency Care, hosted by DBTH, to support all stakeholders in Doncaster ACP. Commenced work with RDASH on Neuro Rehab and OPMH.

Director of Estates and Facilities

Deliver the 2018/ 2019 capital and revenue budgets spend within agreed financial limits by end of March 2019

Improved management of revenue and capital budgets to maximise the benefits to the Trust.

Budgets circa £200k over YTD, underspend on pay, revenue overspends contained to uncontrolled central costs such as utilities. Capital programme delayed start due to need for NHSi confirmation of treatment of £3m. Programme now catching up and looking to deliver in year.

Develop Site Strategies with the aim of divesting of poor estate with high levels of backlog.

Renewal or upgrade of existing estate; accessing ICS funding, identifying and developing commercial and public sector partnerships, and via internally generated Capital.

Disposals achieved 5 Highland Grove and MMH Nurses Home Plot. £130m bid submitted June to ICS Inc. partnership with DMBC Working with CCG on relocation of service form Chequer Rd. Accommodation identified for 2 of 3 service form Chequer Rd at Devonshire House. Need to agree costs neutral rental with CCG and for 200m2 for Audiology Master planning BDGH delayed due to complexity of financial model – report due to Exec Q3

Increase Statutory Compliance by building upon improved performance against NHS Premises Assurance Model (PAM) 17/18

Enhancing the profile and actions of the Trusts Health & Safety Committee to ensure improved compliance and resilience of key services.

H&S Committee developing KPI’s. Second 6 monthly H&S report to ANCR in September. Feedback to expand to cover more risks and include EFM Risk Register. Review of EFM risk register complete and to be circulated to Exec team in October ahead of next ANCR meeting. Estates staff training was agreed as £20k cost pressure – training for CP/AP’s in progress.

Increase Staff Engagement Building upon improved Staff Survey scores 2017/18 to improve scores to the Trust average, in addition to increasing uptake. Staff Survey action plan reviewed monthly at the Estates and Facilities Committee (DoEFM Chair).

Staff Survey Action Plan in progress. Trust-wide Director Drop-ins continue. PADR levels maintained above 90%. Staff Surveys for 18/19 will be available as paper based to increase uptake.



On track and exceeded in some areas, list being developed for 19/20.



Director attended NHSi LEAN training as part of Exec Team learning and development. NHSi LEAN combined within Leadership/Culture training undertaken by senior EFM team. EFM have become early adopter of NHSi LEAN with Visual management Boards in Place, 5 Wastes, SIPOC, and A3’s for three workstreams SI/NHSi keeping track on work. T&O will visit Estates to see tools being used. NHSi Productivity Team to utilise DoEFM for Best practice films.

Chief Information Officer

Deliver the 2018/ 2019 capital and revenue budgets spend within agreed financial limits by end of March 2019

Improved management of revenue and capital budgets to maximise the benefits to the Trust

Official M5 figures show £220k overspend on revenue. Changes anticipated to M6 to include CIG approved revenue and budget transfers for staff. Expect M6 and rest of year to deliver on track. Capital on track.

Deliver the 2018/19 activities defined in the IT Digital strategy

Ensure projects stay within capital limits and deliver to a satisfactory level of quality within the allocated resources.

Approved and funded projects on track. Bed management at Bassetlaw live October 2018. Portal live with 1200+ users. Further planned rollout activities for portal in rest of FY.

Deliver a satisfactory IT service for existing infrastructure and software demonstrating at least 99.9% availability.

Develop additional balanced scorecard and KPI’s to demonstrate upper quartile performance against the rest of the Trust departments and, if feasible, against other Trusts within the ICS.

Service availability at 99.9%+. Outages subject to Root Cause analysis and feedback to operational procedures and vendors. Friendly Fridays introduced to support clinical directorates IT needs.

Deliver GDPR readiness by May 2018. Continue to monitor effective information, data governance and cyber security controls

Ensure that the Trust achieves a Significant Assurance rating within the new DSP framework (replaces IG toolkit) by March 2019

GDPR Complete. DSP artefacts being delivered. Full DSP not yet defined so status is AMBER until this is known and workload understood.

A significant contribution to the development of technology at ACP, ICS or internally within the Trust that supports the transformation of the wider organisation.

Ensure appropriate representation at relevant ICS and ACP meetings and events, including where appropriate taking lead roles on behalf of the ICS and ACPs.

CIO is deputy ICS CIO and part of regional panels for funding. Fully supporting iDCR at Doncaster CCG and including activities and requirements for Bassetlaw CCG in portal in support of social and community care. DBTH a significant influencer at both ICS and ACP level.



Departmental CIP’s largely on track. Supported iFIT changes to contracts and functionality in support of ED. All developments have benefits that aim to increase overall trust efficiencies.



Active participation.

Title Chair’s Assurance Logs – October 2018


Author Neil Rhodes & Linn Phipps


Decision

Assurance X

Information


Attached as appendices are the reports from the chairs of the two board committees held 22 October 2018: - Finance and Performance Committee - Quality and Effectiveness Committee The reports set out assurances obtained during the meetings plus any new risks and escalations to Board.


Is Board able to take confidence from the various assurances given in the attached document?


N/A


As highlighted in the paper.


(1) To note the reports.

(2) QEC requests that the Board agrees to sign off the HEE self-assessment, which has

been scrutinised by QEC, and provide QEC with delegated powers to sign off the document in future years.

Chair’s Log - Finance and Performance Committee 22.10.18

Overview

This was principally a financially focused meeting, which took place the day before the Board meeting which receives this report. There was a broadly encouraging financial picture presented, albeit with significant caveats in relation to the journey ahead. We had a deep dive into Agency Spend and the internal and external controls we operate with – which is discussed in more depth under the workforce management item below. Performance was reassuring, with additional information provided around ambulance handover times. The Director of Estates presented an overview of progress with Sodexho in improving the quality and timeliness of patient meals. Issues clearly still remain to be resolved and the committee will monitor progress closely. In such a sensitive area it is important that tangible progress is made swiftly and that the committee is able to receive strong reassurance.

The committee received for information, a paper setting out our bid to obtain funding for components of the Trust IT Strategy from the recently announced Health Service-Led Investment (HSLI) Public Dividend Capital (PDC) fund. It also received an update on the progress across the enabling strategies that underpin overall direction that broadly indicated satisfactory delivery.

Assurance area – Performance

Performance Report The Board meeting will receive a separate performance report which will give a more detailed appreciation of the picture. In broad terms Trust performance once again remains sound. At F+P, when monitoring performance we try to achieve perspective by tracking our relative position, not only against targets, but also against a similar comparator group of trusts and nationally. When considering the performance paper presented to the Board, members are encouraged to note that very often if the national target has not been achieved, then DBHT has performed better than average and better than most comparator trusts, such as in A and E four hour waits, where 93.8% was achieved against a 95% target, however this was better than the 88.9% national average and significantly better than the 82.43% peer average. (See at a glance table on the performance paper) As previously reported, NEDs are to meet with the Director of Finance and his performance staff on Thursday 25 October to discuss recrafting the performance report to better align with NHSi requests for activity, and also presenting a commentary with an

independent perspective, whilst still utilising the core ‘Ward to Board’ Business Intelligence Report as its foundation.

Assurance area – Workforce Management

We considered the Workforce report that addressed –

The profile of vacant posts

Agency spend

Staff sickness

Appraisals and SET The report itself continues to develop, with more analysis and comparisons. Improved disaggregated sickness data left us with particular concern at the inability to share with confidence consultant and senior medical sickness levels. We have asked for work to be done to improve this position, which may involve culture change as well as improved data capture. F+P spent over an hour in a deep dive into Agency spend with a particular focus on Medical and Dental performance. This month we continue to spend more than target £1070k in month compared to £975k target. We were impressed by the depth and breadth of management information now available and the overview of the current position shared in relation to systems and processes now deployed. As we have frequently reported, agency spend is a critical driver of cost for the Trust and a real concern for F+P. The Trust is subject to a range of external NHSi controls and has recently firmed up its own internal controls. A theme emerging throughout the wider meeting and of particular relevance to this issue is the bedding down of the new management structure of four divisions. Achieving culture change and developing and growing senior clinical managers into very capable organisational managers who routinely understand and push the boundaries of their role in performance managing both within their divisions and as part of the collective senior Trust team, will be critical to success. The delivery of change and performance improvement over the next few months is essential if the Trust is to meet its control total whilst sustaining quality and this will be threatened by any performance lag associated with the changes. The committee were reassured by the internal grip and control regime that has been reasserted and an assurance that all divisions were now holding meaningful meetings on a regular basis.

Assurance area – Overall Financial Picture and Closing the Financial Gap

A more detailed picture of finances is set out in the separate finance paper.

However, F+P heard with approval that the Trust could confidently meet PSF thresholds for Quarter 2. This is a significant achievement made possible by a number of factors including: an indication of a relaxation of A&E targets to recognise our achievement of year to date performance overall; prudent and proper release of reserves to the value of £1.5m following discussions with CCGs in relation to block contract delivery; and adequate performance in some other areas. The challenge moving forward remains, as the Director of Finance summarised –

Delivery of CIP which has been back loaded in the plan and significant savings still required to be identified and delivered. Whilst work continues the gap in the plan is not being closed quickly enough. The Trust needs to implement NHSI quality improvement findings at pace and scale.

Robust plans are required from Divisions to maximise income that deliver in line with plan for elective and outpatients. The Trust has seen growth in the waiting list position over the first half of the year.

Control and reduction of agency and additional sessions spend linked to robust capacity plans and challenging grip and control meetings.

The next quarter’s delivery will be critical and winter pressures will add an additional layer of challenge.

Assurance area – Governance and Risk

F+P received and noted the current risk register.

Assurance area – Strategy and Planning

F+P, as set out in the overview section, received an update on the progress across the enabling strategies that underpin overall direction that broadly indicated satisfactory delivery.

Neil Rhodes Chair – Finance and Performance Committee

1

DBTH Board 23.10.18

DBTH Quality & Effectiveness Committee (QEC) 22.10.18 - Chair’s report

OVERVIEW Welcome: to Antonia and Eki, two of our new Divisional Directors, and Willy, Deputy

Medical Director, all observing QEC.

Appreciation: Matt Kane, Trust Board Secretary, who is moving to Sheffield.

Escalation: No new items for escalation to QEC; or from QEC to the Board.

Enabling strategies: QEC reviewed the People & OD Strategy and the Clinical

Governance & Assurance Strategy, for assurance on progress against milestones. QEC

discussed what actually is a milestone and how we are assured on underpinning activities.

Pat proposed that we should focus on exception reporting going forwards. Sewa

described key outcomes from the recent workshop on getting to outstanding in CQC

ratings, and the recognition of the key role of patient feedback in guiding this. Clive

supported the importance of using feedback. Sheena emphasised the interlinkages

between strategies in delivering the cultural change needed. Peter raised the fact that

whilst there had been 59 CQC inspections of Duty of Candour, there had been no

prosecutions (HSJ article).

Health Education England Education & Training Self-Assessment Report: Health

Education England has developed a quality framework against which placement and

education providers are assessed to ensure that learners have a high quality learning

environment. As a placement provider we are required to undertake a self-assessment

against the various domains of that framework. This self-assessment requires sign off by

the Board or a committee of the Board. The self-assessment demonstrated a high level of

assurance of our learners experience at DBTH. Recommendation: QEC requests that

the Board agrees to sign off the HEE self-assessment, which has been scrutinised by

QEC, and provide QEC with delegated powers to sign off the document in future

years.

ASSURANCES

QEC probed its standing Assurance reports on:

Workforce and Education Assurance Report, which included further detail on

capability management – noting the wide range of activities being undertaken to

address this, Linn suggested asking for further ideas from any Trusts which have

been on a similar journey and found ways to achieve reductions in stress related

absence

Quality Assurance Report (Quality Dashboard; Nursing Workforce Quality

Metrics Assurance Report (Hard Truths), and Clinical Governance Report),

noting the importance of emphasising learning, and that no Ward had triggered

2

“red” for quality in August or September. Linn highlighted the concerns about

radiology and it was agreed that this would be risk assessed by ET.

A patient story and learning therefrom.

QEC probed reports for assurance on:

Maternity Staff Morale – QEC probed the areas of negative feedback and noted

that many mitigatory actions are in hand. Linn suggested establishing

milestone(s) for where we want to be /when

Learning from Deaths – Q1 (2018/19) – it was clarified that all “unexpected”

deaths are put through the SJR process. Noted that there is not a current milestone

for the % of deaths that will be screened, and the Chair asked the Medical

Director to reflect on setting a target for this.

Key issues examined at QEC Sub-Committees

Examples of Trust process to assess the quality and clinical impact of proposed

cost improvement plans – the Divisional Directors find this process

comprehensive and assuring

RISK & GOVERNANCE

Confirmed that the Executive team had risk-assessed all concerns raised in the

August QEC.

The Medical Director is reviewing all Quality risks with a view to rationalisation

No new risks..

FUTURE ASSURANCES needed for:

How Divisional Directors can each best share their Quality vision with QEC

SIs and what has been learnt

Appointment cancellations

Complaints trends – assurance that performance is bouncing back

Quality risks related to estates

Organ donation – annual report, including the 3 missed opportunities

Governor questions

Peter Abell felt assured by the Trust’s commitment not to reduce quality due to finances.

Clive Tattley raised questions around whether the proposed 3-month period until

radiology update was too long; F&FT targets in A&E; and the NHSLA premium in

relation to claims history/ forecast.

Meeting reflections

What was good?

Opportunity to appreciate the positives eg recruitment and work to develop

maternity staff culture

Discussion of “milestones”

Involvement of DDs and their very helpful contribution already

Focus on patient feedback

3

“The discussion is on the page and hits the mark”

What can we improve?

As ever, timekeeping to keep within 3 hour target – ran 15 mins over time

Opportunity to learn from what’s gone well.

Linn Phipps

Chair, Quality & Effectiveness Committee 22 10 18

Appendix 1

The core scope and structure of Assurance Reports and data reports is:

1. What is the data telling us (where are we now)? How are we triangulating data to give

a richer picture of what is happening (e.g. staff and quality data)?

2. What are our good practices and achievements?

3. What are the causes for concern (what are the problem issues, “the red areas”?)

4. Where there are concerns, are we assured on having action plans to address these/

improve and to monitor these?

5. What assurances are there on progress with mitigatory actions on the causes of

concern, and on next steps?

6. What is the future trajectory, better or worse?

Source: QEC meeting 22.8.17, minutes, Appendix 1.

1

Title Strategy & Transformation Update

Report to Board of Directors Date 23rd October 2018

Author Marie Purdue, Director of Strategy & Transformation


Decision

Assurance X

Information


The first section of this report highlights the progress made with implementation of the Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust (DBTH) Strategic Direction 2017 – 2022 (including enabling strategies). A second section of the paper provides an update on the involvement of DBTH with the NHSI programme, an update on Quality Improvement (Qi) practice incorporating implementation of the NHSI Vital Signs Improvement programme.

Key questions posed by the report Is the board assured that sufficient progress is being made to develop improvement practice in DBTH?


This report outlines the contribution being made by Qi to progress made with the delivery of the strategic objectives.


The main risk is that we will not robustly implement the transformation required at local, or system level, to ensure we can sustain high quality services in line with our revised Strategic Direction.


The Board of Directors is asked to note the content of the report.

2

1. Introduction The first section of this report highlights the progress made with implementation of the Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust (DBTH) Strategic Direction 2017 – 2022 (including enabling strategies). A second section of the paper provides an update on Quality Improvement (Qi) practice incorporating implementation of the NHSI Vital Signs Improvement programme which supports implementation of the Strategic Direction. 2. Implementing the Strategic Direction

2.1 Enabling Strategies Exception reporting – Quarter 2

To be able to implement the Trusts Strategic Direction, a number of Enabling Strategies are being implemented. Exception reports to document these have been discussed at Finance & Performance Committee and Quality & Effectiveness Committee. Where a milestone has not been achieved, mitigation was provided by the lead for that Enabling Strategy. Scheduled presentations to allow for a deep dive into enabling strategies have continued according to plan. 2.2 Strategy Delivery Steering Groups The Terms of Reference (ToR) for the groups overseeing implementation of the clinical site strategy (Urgent & Emergency Care Steering Group, the Elective Steering Group and the Childrens & Families Board) have been amended to reflect changes to the management structure to establish divisions and in response to the Internal Audit Feedback on inclusion of aims and objectives.

The revised ToR have been discussed at the relevant strategic delivery group and were subsequently ratified by Management Board in October 2018.

3. Qi Practice Update The Qi team has continued to implement training and events in line with the NHSI programme, Vital Signs – An Improvement practice for the NHS, to further develop the practice of improvement at DBTH. Previous updates have described the development of a purpose pyramid which identifies the vision, mission and goals of the improvement work ensuring it is aligned to the DBTH Strategic Direction and ties it down to one year and five year goals. The graphics for this have now been finalised and is included as Appendix 1. A communication plan has been developed and is being implemented to ensure implementation of Qi work is widely shared and the purpose understood across the organisation.

3

The vision for Improvement above is underpinned by quality improvement practice. Following a visioning event with the Executive Team, two Value Stream Analysis (VSA) events were planned to identify the plan the annual quality improvement work undertaken as part of the NHSI programme. These were planned in the areas of Trauma & Orthopaedics (T&O) and Maternity. A date to undertake the Maternity VSA is currently being agreed in line with recruitment timescales for the permanent Head of Midwifery and initial scoping work will commence. The T&O VSA event was undertaken in September, this was slightly later than initially reported to Board (August) to ensure that adequate notice could be provided to minimise disruption to patients and ensure opportunity for clinicians to attend. Attendance was good and we were fortunate in receiving support and insight from a number of people who had experienced the service. Patient feedback from this event will inform work being undertaken with the Qi and Patient Experience teams on how to increase levels of patient and service user engagement with the programme. Engagement and support from the T&O specialty, leadership team and other supporting services was positive. Multidisciplinary teams who provide the services worked together to process map the current state for certain patient pathways and then identified issues and countermeasures. A future state was then developed and an initial plan to map the future improvement work in T&O. Following the event, areas of initial focus have been agreed with the Speciality:

Scheduling – incorporating rotas and bed management

T&O Emergency Department

Inpatient Orthopaedics

Surgery (including theatres and Pre-operative assessment) It is recognised that work is already underway in some of these areas, for example per-operative assessment and this programme will work to complement work already progressing, avoiding any duplication. Support areas were identified in the future state, for example logistics, IT and Information and leads for these are involved in the improvement work in the areas identified above. Feedback from the event had been collected and is being used to inform future VSA events. Further updates will be provided to Board as the programme develops.

4

Appendix One - DBTH Improvement Journey Purpose Picture

Title Financial Performance – Month 6 - September 2018

Report to Trust Board Date 23rd October 2018

Author Jon Sargeant - Director of Finance

Alex Crickmar – Deputy Director of Finance


Decision

Assurance

Information X


The Trust’s deficit for month 6 (September 2018) was £1.1m, which is a favourable variance against plan in month of £1.1m. The cumulative position to the end of month 6 is an £11.9m deficit, which is £1k favourable to plan. However the Trust needs to achieve a £6.6m deficit to deliver the year end control total, and therefore needs to essentially achieve a better than break even position for the rest of the year. The forecast at Month 6 scenarios indicates a range of potential year end positions, with the realistic case showing the Trust missing the control total by £2.9m (before PSF risk). Therefore the Trust needs to take immediate action to close the financial gap and deliver the Trust’s financial plan. Some of the significant risks to delivery of the forecast and the financial control total include:

Delivery of CIP which has been back loaded in the plan and significant savings are still required to be identified and delivered. Whilst work continues the gap in the plan is not being closed quickly enough. Also some of the deliverability of the CIPs (e.g. block contracts) will potentially be impacted by the funding available from CCGs. The Trust needs to implement NHSI quality improvement findings at pace and scale.

Robust plans are required from Divisions to maximise income that deliver in line with plan for elective and outpatients. The Trust has seen growth in the waiting list position over the first half of the year.

Control and reduction of agency and additional sessions spend linked to robust capacity plans and challenging grip and control meetings.

A release of funds from the balance sheet relating to aged accruals of £1.4m was required to ensure delivery of the Q1 control total. A further £1.5m of centrally held

reserves was required to ensure delivery of the Q2 control total.

The Trust has assumed full achievement of PSF in its position. Whilst the Trust did not achieve its Q2 A&E performance target, the Trust did achieve the target YTD and therefore it is expected that PSF will have been achieved for Q2. There however remains a risk in achieving PSF through the second two quarters of the year.

The Trust is currently assuming 95% achievement of CQUINs in the position, when historically the Trust has achieved 90%. CQUINs achievement for Q1 has still not been confirmed with CCGs requesting further evidence.

Following a maternity audit in the previous year this identified a potential income risk of c850k. This risk is not assumed in the month 6 financial position, but is identified in the forecast.

The Trust has identified a historical depreciation risk of £3.9m as previously reported to the F&P Committee. The position has been discussed with external audit who are currently reviewing the accounting treatment. Current expectation is that this is a prior period or opening balances adjustment.


Is the Trust Board assured by actions taken to bring the financial position back in line with plan?


This report relates to strategic aims 2 and 4 and the following areas as identified in the Trust’s BAF and CRR.

F&P 1 - Failure to achieve compliance with financial performance and achieve financial plan and subsequent cash implications

F&P 3 - Failure to deliver Cost Improvement Plans in this financial year

F&P 19 - Failure to achieve income targets arising from issues with activity

F&P 13 - Inability to meet Trust's needs for capital investment


Update on risk relating to delivery of 2018/19 financial plan.


The Board is asked to note:

The Trust’s deficit for month 6 (September 2018) was £1.1m, which is a favourable variance against plan in month of £1.1m. The cumulative position to the end of month 6 is an £11.9m deficit, which is £1k favourable to plan.

The progress in closing the gap on the Cost Improvement Programme.

The forecast scenarios presented including the risks set out in this paper.

1

FINANCIAL PERFORMANCE

P6 September 2018

3

The Trust’s deficit for month 6 (September 2018) was £1.1m, which is a favourable variance against plan in month of

£1.1m. The cumulative position to the end of month 6 is an £11.9m deficit, which is £1k favourable to plan. However

the Trust needs to achieve a £6.6m deficit to deliver the year end control total, and therefore needs to essentially

achieve a better than break even position for the rest of the year.

The YTD income position at the end of Month 6 is £2,846k adverse to plan, (including the pay award funding of

£2,112k in both plan and actual). In month 6, NHS Clinical Income (including Non-PbR drugs) was £680k behind plan

(£2,933k adverse YTD). Doncaster CCG has an adverse variance against the Trust’s plan of £668k (favorable variance

against contract of £1,401k) and Bassetlaw CCG has a favorable income variance of £679k against plan (£1,326k

favorable against contract). Non NHS Clinical Income and Other Income is £231k ahead of plan in month 6 and YTD

£88k favorable to plan (excluding the impact of pay award funding). PSF is assumed at 100% in the position and

CQUIN achievement at 95%.

The YTD expenditure position at Month 6 was £2,826k lower than budgeted levels. Non-PbR drugs were significantly

lower than planned levels (c.£1.9m which is offset by underperformance on income). Please note that the YTD

position reflects the release of non-recurrent monies in Month 3 of £1.4m (against reserves) following the review of

prior year accruals being held. This mainly relates to accruals for agency doctors (through Holt). The YTD position

also reflects the part release of two centrally held reserves in Month 6 which were previously being accrued for. The

two amounts released from reserves relate to outsourcing of £1.1m and contingency reserve of £0.4m.

Capital expenditure YTD is £1,980k against the YTD plan of £4,330k (£2,350k behind plan). The cash balance at the end of September was £9.1m against a plan of £3m. This is largely due to the receipt of Q4

STF funds (£8.4m), delayed capital expenditure and movements in trade receivables and payables.

In September CIPs of £1,673k (last month £569k) were delivered against the NHSi plan of £821k. YTD savings are £3,687k, which is a favourable variance against the NHSi plan of £433k. The significant change in month 6 was the release of the elective outsourcing reserve of £1.1m. An objective assessment of the likely out-turn of schemes by year end has been undertaken with c.£12m deemed achievable at this stage. This leaves c. £6m of high risk ‘red’ schemes that need urgent attention if to be part of the 2018/19 CIP Programme and support delivery of the Trust’s year end Control Total.

Income GroupAnnual Budget

In Month

Budget

In Month

ActualYTD Budget YTD Actual

Commissioner Income -312,482 -25,321 -25,070 251 A -155,035 -154,008 1,027 A

Drugs -24,089 -2,222 -1,794 429 A -12,277 -10,370 1,907 A

PSF -16,238 -1,083 -1,083 0 F -5,683 -5,683 0 F

Trading Income -39,121 -5,017 -3,488 1,529 A -19,520 -19,607 -88 F

Grand Total -391,930 -33,643 -31,434 2,209 A -192,514 -189,668 2,846 A

Pay Award Adjustment 4,224 2,112 352 -1,760 F 2,112 2,112 0 F

-387,706 -31,531 -31,082 449 A -190,402 -187,556 2,846 A

YTD VarianceIn Month

Variance

1. Executive Summary

4

The Trust’s year to date financial position at Month 6 is £1k favourable compared to plan (£1.1m favourable in

month). The forecast at Month 6 scenarios indicates a range of potential year end positions, with the realistic case

showing the Trust missing the control total by £2.9m (before PSF risk). Therefore the Trust needs to take immediate

action to close the financial gap and deliver the Trust’s financial plan. These actions are being taken forward

following a meeting to agree steps between the CEO, Deputy CEO and DoF.

Some of the significant risks to delivery of the forecast and the financial control total include:

Delivery of CIP which has been back loaded in the plan and significant savings are still required to be

identified and delivered. Whilst work continues the gap in the plan is not being closed quickly enough. Also

some of the deliverability of the CIPs (e.g. block contracts) will potentially be impacted by the funding

available from CCGs. The Trust needs to implement NHSI quality improvement findings at pace and scale.

Robust plans are required from Divisions to maximise income that deliver in line with plan for elective and

outpatients. The Trust has seen growth in the waiting list position over the first half of the year.

Control and reduction of agency and additional sessions spend linked to robust capacity plans and

challenging grip and control meetings.

A release of funds from the balance sheet relating to aged accruals of £1.4m was required to ensure delivery

of the Q1 control total. A further £1.5m of centrally held reserves was required to ensure delivery of the Q2

control total.

The Trust has assumed full achievement of PSF in its position. Whilst the Trust did not achieve its Q2 A&E

performance target, the Trust did achieve the target YTD and therefore it is expected that PSF will have been

achieved for Q2. There however remains a risk in achieving PSF through the second two quarters of the year.

The Trust is currently assuming 95% achievement of CQUINs in the position, when historically the Trust has

achieved 90%. CQUINs achievement for Q1 has still not been confirmed with CCGs requesting further

evidence.

Following a maternity audit in the previous year this identified a potential income risk of c850k. This risk is

not assumed in the month 6 financial position, but is identified in the forecast.

The Trust has identified a historical depreciation risk of £3.9m as previously reported to the F&P Committee.

The position has been discussed with external audit who are currently reviewing the accounting treatment.

Current expectation is that this is a prior period or opening balances adjustment.

The committee is asked to note:

The Board is asked to note:

The Trust’s deficit for month 6 (September 2018) was £1.1m, which is a favourable variance against plan in

month of £1.1m. The cumulative position to the end of month 6 is an £11.9m deficit, which is £1k

favourable to plan.

The Trusts current forecast would mean that the Trust misses its control total by c£3m before PSF losses.

Action plans to address this position are being drawn up following and are being shared with the F&~P

Committee in the first instance.

The progress in closing the gap on the Cost Improvement Programme.

The forecast scenarios presented including the risks set out in this paper.

3. Recommendations

2. Conclusion

Title Performance Report

Report to Board of Directors Date 23rd October 2018

Author David Purdue, Chief Operating Officer

Sewa Singh, Medical Director

Moira Hardy, Director of Nursing, Midwifery and AHPs

Karen Barnard, Director of People and Organisational Development


Decision

Assurance x

Information


This report highlights the key performance and quality targets required by the Trust to maintain NHSI compliance. The report focuses on the main performance area for NHSi compliance: Cancer 62 day classic, measured on average quarterly performance 4hr Access, measured on average quarterly performance 18 weeks measured on monthly performance against active waiters, performance measured

on the worst performing month in the quarter Diagnostics performance against key tests Infection control measures, C Diff and MRSA Bacteraemia The Quality report highlights the ongoing work with Care Groups and external partners to improve patient outcomes and a focus on mortality rates. The Workforce report identifies vacancy levels, agency spend and usage, sickness rates, appraisals and SET training. The performance report contains a deep dive in to the work undertaken by System Perfect

looking into the reason for the increase in attendances to ED.


Is the Trust maintaining performance against agreed trajectories with NHSi? Is the Trust providing a quality service for the patients? Are Governors assured by the actions being taken to maintain a quality service?


This report supports all elements of the strategic direction by identifying areas of good practice and areas where the Trust requires improvements to meet our expectations.


The corporate risks supported by this report are related to NHSi single oversight framework, especially in line with quality, patient experience, performance and workforce.


That the report be noted.

Performance Executive Summary Board of Directors October 2018

The performance report is against operational delivery in July, August and September 2018.

Provide the safest, most effective care possible

Monitor governance compliance is rated against 3 National targets, 4hr Access, Referral to

Treatment, which includes diagnostic waits and Cancer Targets. The targets are all monitored

quarterly, both 4hr access and cancer are averaged over the quarter but referral to treatment is

monitored each month of the quarter and must be achieved each month.

The report also highlights key local targets which ensure care is being provided effectively and safely

by the Trust.

Referral to Treatment

The Referral to Treatment Target, active waiters below 18 weeks set at 92%, the Trust has been

commissioned to achieve 89.1% by the end of March with no growth to the waiting list size.

Though performing above the National average, the Trust position remains below the target at 88%.

The total number of Incomplete Pathways has increased by 415 between August and September,

however the number of incomplete pathways over 18 weeks increased by 218 hence the

performance has dropped. The total number of Incomplete Pathways with a decision to admit for

treatment is virtually unchanged between August and September 2018. The number of new RTT

periods in September was 796 fewer than in August meaning the proportion of short waiters in the

month have also gone down. There were 23 more admitted and 39 more non-admitted clock stops

in September than in August, even though September had fewer working days.

The specialty groups with the largest increase in the number of waiters over 18 weeks are:

T&O – increase of 139 over 18 weeks

General Surgery – increase of 42 over 18 weeks

Others – increase of 41 over 18 weeks

Rheumatology – increase of 31 over 18 weeks

Urology – increase of 30 over 18 weeks

At the end of September 2018 there were 3 Incomplete Pathway over 52 Weeks (T&O Bassetlaw

CCG, 2 x Urology – Doncaster CCG).

DBTH have developed an action plan to deal with the rise in the waiting list size, focussed on 7

specialities with the largest growth. This plan has been given low risk, high confidence by NHSE. At

the end of September the waiting list had reduced by 240.

Diagnostics

The Trust has achieved the Diagnostic performance standard of 99% in September at 99.4%, with 47

breaches from 7789 waiters.

4hr Access

The target is based on the number of patients who are treated within 4hrs of arrival into the

emergency department and set at 95% and reported quarterly as an average figure. This target is for

all urgent care provided by the Trust for any patient who walks in. We have 2 type 1 facilities, ED at

BDGH and DRI and 1 type 3 facility at MMH.

September Performance

Trust 93.73%

Quarter 2 92.8%

Year to date 93.39%

PSF for quarter 2 was achieved following a National change to 4hr access funding which is now

based on either quarter performance or year to date performance.

The Trust saw 14227 attendances in September, which is 509 more than in September 2017 and 104

more than August 2018. 892 patients failed to be treated in 4hrs, with the main breach reason was

wait to see ED doctor/ ED review which accounted for 506 of the 892 breaches. 103 breaches were

due to bed pressures.

System Perfect

System Perfect brings partners together from all health and social care organisations to improve

and develop Urgent and Emergency Care across Doncaster and Bassetlaw.

During System Perfect this October, we set out to better understand peoples’ health needs and

choices, and to raise awareness about local services available in the area.

One of the main aims of this System Perfect was to talk to people directly to ask firstly, what they do

when they are unwell and secondly, whether they are aware of the options available to them

locally. We particularly wanted to understand why people choose to go to our A+E departments.

We have engaged with the people of Doncaster and Bassetlaw in a number of ways:

An online survey was posted across social media and was also

completed face to face

A series of videos of clinicians has been shared, informing people

about the different options for advice and treatment

The Health bus visited local town centres in Doncaster, Thorne,

Mexborough with plans to go to Worksop

The team undertook visits to local large employers with teams

spending time at DMBC, NEXT distribution centres and Greencore

The team spoke with staff and patients on our Doncaster and

Bassetlaw sites

The response to social media has been extremely positive; from a DBTH perspective, we have reached 80,000 people in total. Adding to this, we have received approximately 2,000 responses to the survey.

The survey requires further analysis, however, initial findings are as follows.

99% are aware of GP practices 97% are aware of the Emergency Department (I’d suggest the discrepancy in this not being 100% is terminology – Emergency Department to Accident and Emergency and people simply leaving this blank by accident) 59% have heard of the Doncaster Same Day Health Centre 72% have heard of the Minor Injuries Unit 97% have heard of pharmacies and chemists 91% have heard of NHS 111 56% have heard of NHS Choices 85% have heard of GP Out of Hours

The commonest reason given for people attending the Emergency Department (ED) is a perceived lack of GP capacity, difficulty in making an appointment or an individual not being registered with a GP. An instantaneous service is described as being provided in the ED, compared with other services where you would need to wait for an appointment. The ED is seen as a catch-all service which, importantly, is available 24/7. There is also a general feeling of health anxiety described by respondents, which appears to be fed by Google symptom searches with a visit to ED acting to reassure that there is nothing serious. Surprisingly, a number of respondents describe a visit to the ED as dramatic, as an event to post on

Facebook, essentially feeding into the culture of likes, comments and attention. The Trust has continued to see high attendance within the ED on both Doncaster and Bassetlaw Teaching Hospital’s main sites. As a system, it is important that we continue to share key messages and information about local services with the public. The findings from the survey will be analysed in more details and the intelligence used to help develop our Urgent and Emergency care services over the forthcoming months.

Streaming

Doncaster FDASS

The number of patients streamed directly from the front door in September was 12.4%.

NHSI Additional Reporting Requirements

18.2% of all of DRI discharges take place at a weekend and 15.3% at BDGH

If the rest of the week was at the same level as Mondays then we would see an extra 173 patients a

week at DRI and an extra 110 patients at BDGH

A&E attendances on a Monday at DRI account for 15.6% of weekly activity rising to 16.0% at BDGH

Non Elective Admissions on a weekday that GP admissions account for is 20.6% of all Emergency

Admissions on a weekday at DRI but only 7.9% at BDGH.

When we move into the weekend this drops to 11.2% at DRI and 2.3% at BDGH

Cancer Performance

August

62 day performance 86.2%

The 62 day standard was achieved by the Trust in August at 86.2%, this maintains performance seen in July. Key issue was in the urology pathway, 6 local breaches and 3 shared care. The One Stop Prostrate Clinic is on target to commence at the end of October to coincide with the latest guidance release for 2 week wait. A pilot of Straight to test for colonoscopy has been partially funded by the Cancer Alliance for lower GI cancers, which will commence in April 2019. Two Week Wait Performance 87.1% The August position for two week wait was 87.1% which was not compliant with the national target of 93%. The key areas of breaches were dermatology and urology due to clinic cancellations in the final 2 weeks of August. The Capacity and Demand tool continues to be developed, providing a planning tool based on previous referral trends, activity and capacity. Care groups are now using the tool proactively in order to plan two week wait capacity. Since April there has been an overall increase of referrals for 2 week wait of 12%.

Stroke Performance

July stroke discharges 45

Direct admission 69.4%

CT within 1 hour 71.4%

In terms of exceptions, there were 5 patients originally admitted at Bassetlaw who had long waits for

transport to DRI. The transfer of stroke patients has been escalated to EMAS to ensure timely

transfer.

David Purdue Chief Operating Officer October 2018

DBTH PERFORMANCE REPORT – September 2018

FL/ DP 17/09/18

1

Cancer Performance The following information relates to Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust performance in August. The Trust has updated the action plan to improve 62 day and 2 week wait performance. August Performance

Standard Local Performance % Position from Previous Month

TWW 87.1%

31 day 100%

62 day 86.2 %

31 day Sub – Surgery 100%

31 day Sub – Drugs 100%

31 day Sub – Other 100%

62 day Screening 90%

62 day Con Upgrades 73.7%

Breast Symptomatic 93.2%

62 day Cancer performance The 62 day standard was achieved by the Trust in August at 86.2%, this maintains performance seen in July. The One Stop Prostrate Clinic is due to commence at the end of October to coincide with the latest guidance release for 2 week wait. The key issues remain around complex pathways and shared breaches. The local pathway issues remain in Urology. Additional monies are available to be applied for in quarter 3 and 4 to improve the urology position. Bids are being developed for additional MRI capacity and additional CNS to support follow up reviews.


FL/ DP 17/09/18

2

The graphs below compare 62 day performance up to August at Doncaster and Bassetlaw compared with National performance.

Two Week Wait Performance

The August position for two week wait was 87.1% which was not compliant with the national target of 93%. The position from a booking perspective was improved but in the last week of August a large number of clinics were cancelled due to a locum leaving unexpectedly in dermatology and emergency leave in urology Work with the Capacity and Demand tool continues to be improved. Care groups are now using the tool proactively in order to plan two week wait capacity. Weekly PTL meetings with each specialty are ongoing to jointly track patient booking, pathways and to review breaches. These meetings now focus on both 2ww and 62 day breaches.


FL/ DP 17/09/18

3

TWW Performance by specialty for August

2ww

Non 2ww Symptomatic

Breast Referrals

31 Day -

Classic

31Day Sub -

Surgery

31 Day

Sub - Drugs

31 Day Sub -

Palliative

62 Day -

Classic 62 Day

Screening 62 Day Consultant

Upgrades Operational

Std 93% 93% 96% 94% 98% 94% 85% 90% TBA

Breast 98.3% 93.2% 100% 100%

97.4% 100% 100% Gynaecology 88.5% 100%

85.7%

100%

Haematology 100% 100%

100%

100% Head & Neck 88.9% 100%

33.3%

Lower GI 81% 100% 100%

100% 85.7% 66.7% 100% Lung 94.9% 100%

100%

50%

Sarcoma Skin 76.9% 100%

100%

Upper GI 90.9% 100%

83.3%

100% Urological 78.4% 100% 100% 100%

55.9%

66.7% EXCEPTIONS 62 DAY There were delays in Head and Neck, Upper GI, Urology and Lung with reasons for the breaches predominantly due to shared care pathways, complex diagnostic pathways or patient choice. TWO WEEK WAIT Head and Neck, Upper and Lower GI, Skin, Gynaecology and Urology did not achieve the standard in August. Capacity issues were predominantly the issues Dermatology and Urology as a result in a continued increase in referrals and clinic cancellations. The current process for oral/maxillary/facial cancers is being reviewed with Sheffield Teaching Hospital due to ongoing capacity issues. Administration delays are being addressed within the new Cancer management processes.


FL/ DP 17/09/18

4

The reasons for breaches in relation to two week wait appointments can be seen in the table below: CWT Standard Tumour Group Performance

against CWT

standard

High Level View

Two Week Wait Gynae 88.5% 13 Patients – 11 patient choice, 2 administrative delay

H&N 88.9 % 7 Patients – all patient choice

Lower GI 81% 35 Patients – 20 patient choice, 4 capacity, 9 hospital

cancellation, 2 administrative delay

Skin 76.9% 46 Patients – 15 patient choice, 16 capacity, 10

administrative delay, 5 clinic cancellations

Upper GI 90.9% 15 Patients – 9 patient choice, 2 capacity, 4

administrative delay

Urology 78.4% 35 Patients– 12 patient choice, 12 capacity, 8

administrative delay, 3 clinic cancellations 62 day H&N 33.3% 4 patients – All shared care - 3 complex pathway, 1

patient choice

Upper GI 83.3% 3 patients – all shared care – 3 Complex diagnostic

pathway

Urology 55.9% 9 patients – 6 local pathways and 3 shared care . Local 3

patient choice , 2 capacity issues , 1 complex pathway.

Shared Care – 2 elective capacity (STH), 1 pathway delay 62 day

Screening Lower GI 66.7% 1 patient –shared care – capacity delay in screening

service 62 day Con

Upgrade Lung 50% 3 patients – all shared care .2 complex pathway, 1

pathway delay

Urology 66.7% 1 patient – local treatment – capacity issue


FL/ DP 17/09/18

5

4hr Access Target In September 2018 the Trust achieved a performance 93.73% against the 4hr access standard of

95%.

The graphs below compare 4 hour access performance at Doncaster and Bassetlaw with

National performance

The Trust managed 14227 ED attendances in September this year, which is 54 more than

August 2018 and 509 more, when compared to September 2017

We are focussed as a system, on understanding reasons for the highest attendance age groups (20-35s and 45-60s) and working on alternative pathways that patients could be streamed to. Work is continuing with both CCGs to understand the recent increases in attendances.

The System Perfect event ran from 2-9 Oct with wide engagement with the public and over 200 responses to a survey, asking about why people attend A+E. Results are currently being evaluated and the published findings will support the future development of UEC services.


FL/ DP 17/09/18

6

Streaming Doncaster FDASS The number of patients streamed directly from the front door in September was 12%. Bassetlaw streaming for September – 12.12% with potential to increase this over time as processes become embedded. EXCEPTIONS

In September, 892 patients failed to be treated in 4hrs; with the key issues being Waits to see

ED doctor and ED doctor reviews. These issues accounted for 506 of the 892 breaches across

sites. 110 breaches were due to bed pressures/ lack of bed capacity.

Streaming pathways have been reviewed at BDGH jointly with Notts Health Care FT and a

proposal developed for commissioners to review to improve front-door streaming alternative

pathways.

Referral to Treatment (RTT) The Referral to Treatment Target, for active waiters below 18 weeks is set at 92%. DBTH

contract for 2018/19 expects the Trust to maintain the March position of 89.1% and the waiting

list size to be lower than it was at the end of March 2018.

Although performing above the National average, the Trust position was 88% in September.

The graphs below and on the next page show Doncaster and Bassetlaw’s performance compared with the National picture:


FL/ DP 17/09/18

7

The total number of Incomplete Pathways has increased by 415 between August and September and the number of incomplete pathways over 18 weeks increased by 218 hence the slight drop in performance. The total number of Incomplete Pathways with a decision to admit for treatment remains largely unchanged from August 2018. Septembers Specialty level RTT performance, against a target of 92%, can be found below:

Specialty Group Under 18 Weeks

18 Weeks & Over Total Percentage

General Surgery 2848 427 3275 87.0%

Urology 1475 198 1673 88.2%

T&O 5335 838 6173 86.4%

ENT 2766 759 3525 78.5%

Ophthalmology 2909 286 3195 91.0%

Oral Surgery 1711 100 1811 94.5%

General Medicine 1681 285 1966 85.5%

Cardiology 1756 263 2019 87.0%

Dermatology 1922 98 2020 95.1%

Thoracic Medicine 793 106 899 88.2%

Rheumatology 749 226 975 76.8%

Geriatric Medicine 222 41 263 84.4%

Gynaecology 1597 97 1694 94.3%

Others 3994 350 4344 91.9%

Trust Total 29758 4074 33832 88.0%

At the end of September 2018 there were 3 patients on Incomplete Pathways over 52 Weeks. No patients came to harm.


FL/ DP 17/09/18

8

Diagnostics In September the Trust achieved 99.4% against the 6ww Diagnostic Performance standard of 99%. There were 47 patient breaches in month, out of a total 7789 patients.

Waiters <6W Waiters >=6W Total Performance

Trust 7742 47 7789 99.40%

NHS Doncaster 4959 28 4987 99.44%

NHS Bassetlaw 1942 9 1951 99.54%

Most exam types achieved the target individually again in September; with 8 of the 13 diagnostic areas achieving more than 99% and 5 of these 8 achieving 100%. EXCEPTIONS: The 99% target was missed in 5 areas:

Audiology; 97.45% (14 breaches out of 549 waiters)

Echo; 98.96% (2 breaches out of 193 waiters)

Nerve conduction; 96.58% (4 breaches out of 117 waiters)

Urodynamics; 77.42% (14 breaches out of 62 waiters)

Cystoscopy; 97.01% (4 breaches out of 134 waiters)

Unreported waits ; GDA and ASD Community Paediatrics Although there is no waiting time target for GDA (General Development Assessments) and following this ASD (Autism Spectrum Disorder) pathways/ assessment, and the numbers of children waiting in the Trust Community Paediatrics pathway has improved, we are aware that this is slow and want to monitor and support further improvements in the numbers of children being seen for both CCG’s.


FL/ DP 17/09/18

9

The National picture shows that it is not unusual for children to be waiting +2 years for the initial assessment (GDA), and then another 2 years for a specialist ASD assessment. The reasons for this are multifactorial; including GP intervention and referrals, sufficiency/ capacity for community Paediatricians, availability and experience of additional support staff, psychologists, therapists etc Doncaster GDA – times in weeks wait

Doncaster April May June July August September October

Longest Wait Of First GDA Attendances 2017-18 40 31 29 18 12 4 4

Longest Wait Of First GDA Attendances 2018-19 14 14 15 14 14

Longest Waits ASD are shown in Days


Longest wait of those children waiting for their first consultation/contact <5 years old ASD 2017-18 367 398 428 431 449 387 488

Longest wait of those children waiting for their first consultation/contact <5 years old ASD 2018-19 308 301 275 292 274


Longest wait of those children waiting for their first consultation/contact =>5 years old ASD 2017-18 656 681 662 630 661 600 589

Longest wait of those children waiting for their first consultation/contact =>5 years old ASD 2018-19 497 470 402 433 464

Bassetlaw Longest Waits for GDA are shown in weeks

Bassetlaw April May June July August September October

Longest Wait Of First GDA Attendances 2017-18 8 4 6 6 6 6 6

Longest Wait Of First GDA Attendances 2018-19 8 8 8 10 10


FL/ DP 17/09/18

10

Longest Waits ASD are shown in Days


Longest Wait Of First ASD Attendances 2017-18 6 8 8 10 10 10 8

Longest Wait Of First ASD Attendances 2018-19 8 8 8 8 8


Longest Wait Of First ADHD Attendances 2017-18 6 8 8 10 10 10 8

Longest Wait Of First ADHD Attendances 2018-19 8 8 8 8 8

Stroke Performance in July The Trust level percentage for Direct Admission to the Stroke Unit was 69.4% against a 90% target.

Against a target of 48%; performance in July was compliant with the 1 Hour to scan standard at 71.4% compared to 62.2% for June and a 1st quarter achievement of 62.1%.


FL/ DP 17/09/18

11

EXCEPTIONS In terms of exceptions, there were 5 patients originally admitted at Bassetlaw who had very long waits for transport to DRI, this has been raised with EMAS as these patients have clinical priority. EMAS are developing protocols for transfer jointly with the DBTH. Direct admissions within 4hrs, target 90%

CCG

Category Sub

Category Total

Direct Admission within 4 Hours Bassetlaw Doncaster Other Total

Organisational Beds

Yes 4 27 3 34

Pathway 11

No 5 10 0 15

Staff

Availability

Grand Total 9 37 3 49

Clinical Patient

Presentation 3

Performance 44.4% 73.0% 100.0% 69.4%

Patient Needs 1

Patient Choice Declined

Awaiting further validation

Scan within 1hr, target 48% CCG

Category Sub Category Total

Scan 1 hr Bassetlaw Doncaster Other Total

Organisational Scanner 1

Yes 4 28 3 35

Pathway 11

No 5 9 0 14

Staff

Availability

Grand Total 9 37 3 49

Clinical Criteria

Performance 44.4% 75.7% 100.0% 71.4%

Patient Needs

Patient Presentation 2

Patient Choice Declined

Awaiting further validation


FL/ DP 17/09/18

12

Stroke Additional Reporting

Discharge with Named Consultant Main issues identified:

Joint Care Plan on discharge – this is given to patients and on completion a stamp is recorded on the patient notes to confirm the JCP has been issued with all relevant details including the named consultant. Issue – stamp is not being put on resultant in lack of evidence to confirm NC is given. Team confident that the JCP with details is given to all patients on discharge from the ward. Therefore issue is recording

Joint Care Plan on discharge – where patients are transferred to MMH there is a risk that the relevant information (as would be given from stroke ward) is not given. Therefore recording of evidence is less likely to happen.

ACTIONS: Issues discussed at the Stroke Governance meeting. Tick Box is being added to the JAC system to mark as plan given. Re-educate teams on completing stamp on discharge and ensure capture of patients slept out to complete necessary discharge details. Alice is leading this.

TIA within 24hours Immediate feedback is the capacity required to meet the 24hour TIA deadline whilst ensuring attention to high priority patients first. Key issues relate to capacity within the service. An additional stroke consultant has been appointed, with plans for a four consultant due to be appointed in April.

Cancelled Operations In September 1.15% of Trust operations were cancelled. This demonstrates an improvement in performance compared with the previous month with 55 patients being cancelled, out of a total of 4801. 47 patients were cancelled for theatre reasons and 8 for non theatre reasons.

Indicator Standard

Jun-18 Jul-18 Aug-18

Cancelled Operations (Total) 1.0% 1.19% 1.46% 1.69%

Cancelled Operations (Theatre)

1.08% 1.23% 1.52%

Cancelled Operations (Non Theatre) 0.10% 0.23% 0.17%

Cancelled Operations-28 Day Standard 0 1 0 1

The reasons for the non-clinical cancellations are displayed in the graph on the following page:


FL/ DP 17/09/18

13

DNA and CNA Rates In September the overall DNA rate across the Trust increased slightly to 9.90% compared with the previous month’s position at 9.70%.

Indicator June

July

Aug

Sept

Outpatients: DNA Rate Total

9.41% 9.78% 9.70% 9.90%

Outpatients: Hospital cancellation Rate 5.19% 5.66% 5.41% 5.41%


FL/ DP 17/09/18

14

Delayed Transfers of Care

Significant work has been underway in Doncaster and Bassetlaw to improve patient discharge processes, and to reduce the number of medically fit patients waiting in hospital. This work will also impact on the number of formally reported Delayed Transfers of Care (DTOCs).

A Length of Stay meeting is planned (this Thursday) for all partners; to strengthen the focus on reduction in delays and prevention of unnecessary long stays in hospital.

National monitoring of LOS is currently focussed on reducing super-stranded LOS and a Long

Stays Dashboard is available to monitor progress.

To date DBTHFT has made very good progress against this as follows:

Revised Operating Guidance for The Integration and Better Care Fund for 2017-19 was published in July; this replaces the Guidance for 2016-17. The Guidance provides a framework for the ongoing requirements of BCF for implementing the two year joint plans that were agreed for 2017-19. For Doncaster the new trajectory is 16.8 days (per day). This compares to a previous trajectory of 17 days; the baseline period used to determine the new trajectory was Q3 2017-18. The new DTOC metric is effective from September 18 and the expectation is that this new trajectory will be met from then; and that this level will be maintained or exceed thereafter.


FL/ DP 17/09/18

15

Whilst the September actual figure is not yet available, performance against DTOCs to date in 18/19 has been under trajectory A revised guide on counting DTOC is expected to be published for implementation in October 18. This will provide greater clarity on the process for recording and attributing delayed transfers with the aim of reducing the variation in recording that currently occurs across the country. This guide is still awaited.

HWB

2017/18 Q3 (Baseline figs) 2018/19 expectations

2017/18 previously agreed

plans

Per day Per day Per day

NHS ASC Joint Total NHS ASC Joint Total NHS ASC Joint Total

Doncaster 6.7 5.5 4.5 16.8 6.7 5.5 4.5 16.8 5.1 6.3 5.6 17.0

Indicator Standard Current Month Month ActualNHS England

%DBTHFT Month Peer Groups % DBTHFT Month Current Month

Month Actual (TRUST)

Month Actual (DRI)

Month Actual (BDGH)

Data Quality RAG Rating

31 day wait for second or subsequent treatment: surgery 94.00% 100.00% 93.80% 100.00% 93.50% 100.00% % of patients achieving Best Practice Tariff Criteria Sep‐18 48.90% 45.70% 60.00%

31 day wait for second or subsequent treatment: anti cancer drug treatments

98.00% 100.00% 99.50% 100.00% 100.00% 100.00%

31 day wait for second or subsequent treatment: radiotherapy 94.00% 100.00% 97.10% 100.00% Not Available 100.00% 36 hours to surgery Performance 64.44% 65.71% 60.00%

62 day wait for first treatment from urgent GP referral to treatment 85.00% 86.20% 79.40% 86.20% 75.90% 86.20% 72 hours to geriatrician assessment Performance 71.11% 68.57% 80.00%

62 day wait for first treatment from consultant screening service referral

90.00% 90.00% 90.10% 90.00% 79.70% 90.00% % of patients who underwent a falls assessment 80.00% 74.00% 100.00%

31 day wait for diagnosis to first treatment‐ all cancers 96.00% 100.00% 97.00% 100.00% 95.50% 100.00% % of patients receiving a bone protection medication assessment 80.00% 77.00% 90.00%

Two week wait from referral to date first seen: all urgent cancer referrals (cancer suspected)

93.00% 87.10% 91.70% 87.10% 89.20% 87.10%

Two week wait from referral to date first seen: symptomatic breast patients (cancer not initially suspected)

93.00% 93.20% 90.60% 93.20% 95.10% 93.20%

Infection Control C.Diff4 Per Month ‐ 45 full year

M

Infection Control MRSA 0 L

HSMR (rolling 12 Months) 100 N Jun‐18

Never Events 0 L Sep‐18

VTE 95.0% N Aug‐18

Avoidable Pressure Ulcers Cat 3&4 21 Full Year L Aug‐18

Ambulance Handovers Breaches ‐Number waited over 15 & Under 30 Minutes

742 Falls that result in a serious Fracture 2 Per Month 23

full YearL

Ambulance Handovers Breaches‐Number waited over 30 & under 60 Minutes

29

Ambulance Handovers Breaches ‐Number waited over 60 Minutes 1

Proportion of patients scanned within 1 hour of clock start (Trust) 48.00% 71.40%

Proportion of patients directly admitted to a stroke unit within 4 hours of clock start (Trust)

90.00% 69.40%

Percentage of eligible patients (according to the RCP guideline minimum threshold) given thrombolysis (Trust)

20.00% 14.30%

Percentage of patients treated by a stroke skilled Early Supported Discharge team (Trust)

40.00% 65.90%

Percentage of those patients who are discharged alive who are given a named person to contact after discharge (Trust)

95.00% 88.60%

Implementation of Stroke Strategy ‐ TIA Patients Assessed and Treated within 24 Hours

60.00% September 52.38%

Cancelled Operations 0.80% 1.15%

Cancelled Operations‐28 Day Standard 0 1

Out Patients: DNA Rate 9.95% 7.62% 9.41% June 6.96% 9.41% June

f


At a Glance September 2018 (Month 6)Doncaster & Bassetlaw Teaching Hospital NHS Foundation Trust

NHS England Benchmarking

Peer Group Benchmarking

Mon

itor C

ompliance Fram

ework

Direction of travel

compared to previous Month

Fractured Neck of Fem

ur

Indicator

August

10.00%

August August

Best Practice Criteria

Sep‐18

A&E: Maximum waiting time of four hours from arrival / admission / transfer / discharge (Trust)

93.80% 88.90%

% of Patients waiting less than 6 weeks from referral for a diagnostics test

99.00% September 99.40% 96.90%

Maximum time of 18 weeks from point of referral to treatment‐ incomplete pathway

92.00% September 88.00% 87.72%

95.00% September

UCL: 796 & LCL: 659

UCL: 122 & LCL: 56

UCL: 29 & LCL: 2

August

Mortality‐Deaths within 30 days of procedure 6.67% 5.70%


Complaints received (12 Month Rolling)

Current Month Month Actual

Sep‐180

93.80% September 82.43% 93.80% September

Safe

88.50% August 83.39%

99.58% 99.58% August

95.0%

1

88.50% August

0

90.89

0

IndicatorStandard (Local,

National Or Monitor)

94.95%

Ambu

lance Han

dover T

imes

July

1

Catheter UTI Snap shot audit

Month Actual

Sep‐18

0.45%

Effective

Emergency Readmissions within 30 days (PbR Methodology) August 6.40%

Stroke

July

Theatres & Outpa

tients

September

Out Patients: Hospital Cancellation Rate 4.95% Clinical Negligence Scheme for Trusts (CNST)

No Benchmarking available

No Benchmarking available ‐ data not submitted to Secondary Uses Service by all Trusts

419

86.0%

11

Complaints Performance

569Complaints & Claim

sWorkforce

Aug‐18

Concerns Received (12 Month Rolling)

SSNAP performance for December to March improved to A rating.


AppraisalsSep‐18

Indicator Current Month

7.20% 6.40% May 8.02% 6.40% May

78.50%SET Training 82.37%

Liabilities to Third Parties Scheme (LTPS) 6

Claims per 1000 occupied bed days 0.49

Indicator Current Month YTD (Cumulative)

Monitor Compliance Framework: Cancer ‐ Graphs ‐ August 2018 (Month 5)

Monitor Compliance Framework: A&E ‐ Graphs ‐ September (Month 6)

Monitor Compliance Framework: 18 Weeks & Diagnostics ‐September (Month 6)

Stroke ‐ Graphs July 2018 (Month 4)

Mr S Singh

Mrs M Hardy

Hospital Acquired Pressure Ulcers: The rate is higher for Q1 and July and has reduced for August compared to 2017/18.

Executive Summary ‐ Safety & Quality ‐ September 2018 (Month 6)

HSMR: The Trust's HSMR for June 2018 is 86.7 giving a roling 12 month HSMR of 90.9, which remains better than expected

Fractured Neck of Femur: For the month of June, BPT was achieved in 60% of patients whilst rolling 12 month HSMR is 89.7.

Serious Incidents: SIs per bed days remains low with no HAPUs reported in month

Executive Lead:

C‐Diff The rate is below that of the same period last year and the national trajectory

Fall resulting in significan harm: The rate is higher for both the month of September and the same YTD

Complaints and Concerns There has been a decrease in the number of complaints and concerns, although still within normal variation. Complaints resolution performance has deteriorated and this is being investigated; but may be due to changes in leadership as part of the restructure.

Friends & Family Test: There has been a slight deterioration in the response rates for inpatients and systems and processes for caturing responses is being reviewed. Positivity of responses continues to be better than the national average for both inpatients and ED.

Executive Lead:

2015 2016 2017 2018January 116.80 99.21 94.86 93.92February 99.94 97.73 105.44 84.21March 90.54 97.37 82.66 87.34April 105.91 88.50 85.36 98.71May 101.15 96.60 82.88 94.06June 80.27 93.67 89.99 86.70July 92.56 97.73 96.09August 100.27 87.52 73.78September 90.26 95.34 87.30October 90.29 88.66 98.57November 88.98 82.30 88.02December 82.30 93.52 99.02

Oct‐17 Nov‐17 Dec‐17 Jan‐18 Feb‐18 Mar‐18 Apr‐18 May‐18 Jun‐18 Jul‐18 Aug‐18 Sep‐18Trust 1.45% 1.46% 1.99% 2.11% 1.52% 1.48% 1.46% 1.23% 1.06% 1.37% 1.35% 1.26%Donc 1.41% 1.42% 2.13% 2.29% 1.63% 1.46% 1.51% 1.33% 1.08% 1.40% 1.47% 1.27%Bass 1.95% 1.90% 1.94% 1.86% 1.45% 1.87% 1.60% 1.19% 1.23% 1.53% 1.10% 1.43%

HSMR Trend (monthly) Crude Mortality (monthly) ‐ Sep 2018 (Month 6)(number of deaths/number of patient discharged)

Hospital Standardised Mortality Ratio (HSMR) ‐ June 2018 (Month 3)

Overall HSMR (Rolling 12 months) HSMR ‐ Non‐elective Admission (Rolling 12 months) HSMR ‐ Elective Admission (Rolling 12 months)

90.89

86

88

90

92

94

96

98

Aug 16

‐ July 17

Sep 16

‐ Au

g 17

Oct 16 ‐ Sep

17

Nov

‐16 ‐ O

ct‐17

Dec 16

‐ Nov

17

Jan 17

‐ De

c 17

Feb 17

‐ Jan 18

Mar 17 ‐ Feb

18

Apr 1

7 ‐ M

ar 18

May 17 ‐ A

pr 18

Jun 17

‐ May 18

Jul 17 ‐ Jun

18

91.12

86

88

90

92

94

96

98

Aug 16

‐ July 17

Sep 16

‐ Au

g 17

Oct 16 ‐ Sep

17

Nov

‐16 Oct‐17

Dec 16

‐ Nov

17

Jan 17

‐ De

c 17

Feb 17

‐ Jan 18

Mar 17 ‐ Feb

18

Apr 1

7 ‐ M

ar 18

May 17 ‐ A

pr 18

Jun 17

‐ May 18

Jul 17 ‐ Jun

18

69.08

40

50

60

70

80

90

100

Aug 16

‐ July 17

Sep 16

‐ Au

g 17

Oct 16 ‐ Sep

17

Nov

‐16 Oct‐17

Dec 16

‐ Nov

17

Jan 17

‐ De

c 17

Feb 17

‐ Jan 18

Mar 17 ‐ Feb

18

Apr 1

7 ‐ M

ar 18

May 17 ‐ A

pr 18

Jun 17

‐ May 18

Jul 17 ‐ Jun

18

1.0%1.2%1.4%1.6%1.8%2.0%2.2%

Oct/17

Nov/17

Dec/17

Jan/18

Feb/18

Mar/18

Apr/18

May/18

Jun/18

Jul/1

8

Aug/18

Sep/18

Crude Mortality(Trust)

0.5%

1.5%

2.5%

Oct/17

Nov/17

Dec/17

Jan/18

Feb/18

Mar/18

Apr/18

May/18

Jun/18

Jul/1

8

Aug/18

Sep/18

Crude Mortality(BDGH)

1.0%1.5%2.0%2.5%

Oct/17

Nov/17

Dec/17

Jan/18

Feb/18

Mar/18

Apr/18

May/18

Jun/18

Jul/1

8

Aug/18

Sep/18

Crude Mortality(DRI)

NHFD Best Practice Pathway Performance ‐ Sep 2018 (Month 6)

Best Practice Criteria Performance 36 Hours to Surgery Performance 72 hours to Geriatrician Assessment Performance

Bone Protection Medication Assessment Falls Assessment Performance

Relative Risk Mortality (HSMR) ‐ Fractured Neck of FemurRolling 12 month

0%

10%

20%

30%

40%

50%

60%

70%

80%

Oct‐17

Nov

‐17

Dec‐17

Jan‐18

Feb‐18

Mar‐18

Apr‐18

May‐18

Jun‐18

Jul‐1

8

Aug‐18

Sep‐18

% achieving best practice tariff criteria (Trust) % achieving best practice tariff criteria (DRI)

% achieving best practice tariff criteria (BDGH)

40%

60%

80%

100%

Oct/17

Nov/17

Dec/17

Jan/18

Feb/18

Mar/18

Apr/18

May/18

Jun/18

Jul/1

8

Aug/18

Sep/18

Trust DRI BDGH

40%

60%

80%

100%

Oct/17

Nov/17

Dec/17

Jan/18

Feb/18

Mar/18

Apr/18

May/18

Jun/18

Jul/1

8

Aug/18

Sep/18

Trust DRI BDGH

60%

70%

80%

90%

100%

Oct/17

Nov/17

Dec/17

Jan/18

Feb/18

Mar/18

Apr/18

May/18

Jun/18

Jul/1

8

Aug/18

Sep/18

Trust DRI BDGH

60%

70%

80%

90%

100%

Oct/17

Nov/17

Dec/17

Jan/18

Feb/18

Mar/18

Apr/18

May/18

Jun/18

Jul/1

8

Aug/18

Sep/18

Trust DRI BDGH

79.4

76.76

89.73

405060708090

100110120130140

Jul/1

7

Aug/17

Sep/17

Oct/17

Nov/17

Dec/17

Jan/18

Feb/18

Mar/18

Apr/18

May/18

Jun/18

Trust DRI BDGH

Current YTD reported SI's (April‐Sep 18) 22 29

Current YTD delogged SI's (April‐Sep 18) 0 16

Serious Incidents ‐ Sep 2018 (Month 6)(Data accurate as at 10/10/2018)

Please note: At the time of producing this report the number of serious incidents reported are prior to the RCA process being completed.

Overall Serious Incidents

Number reported SI's (Apr‐Sep 17)

Number delogged SI's (Apr‐Sep 17)

Themes

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

Oct/17

Nov/17

Dec/17

Jan/18

Feb/18

Mar/18

Apr/18

May/18

Jun/18

Jul/1

8

Aug/18

Sep/18

Pressure Ulcers ‐ Category 3 & 4 (HAPU)

Pressure Ulcers HAPU 3 & 4 per 1000 occupied bed days

0.00

0.05

0.10

0.15

0.20

0.25

Oct/17

Nov/17

Dec/17

Jan/18

Feb/18

Mar/18

Apr/18

May/18

Jun/18

Jul/1

8

Aug/18

Sep/18

Care Issues

Care Issues per 1000 occupied bed days

0

0.01

0.02

0.03

0.04

0.05

0.06

Oct/17

Nov/17

Dec/17

Jan/18

Feb/18

Mar/18

Apr/18

May/18

Jun/18

Jul/1

8

Aug/18

Sep/18

Serious Falls

Serious Falls per 1000 occupied bed days

0

0.1

0.2

0.3

0.4

0.5

0.6

Oct/17

Nov/17

Dec/17

Jan/18

Feb/18

Mar/18

Apr/18

May/18

Jun/18

Jul/1

8

Aug/18

Sep/18

Serious Incidents per 1000 occupied bed days

Reported Si's per 1000 occupied bed days Reported Si's per 1000 occupied bed days ‐ Previous years performance

02468

101214

Oct/17

Nov/17

Dec/17

Jan/18

Feb/18

Mar/18

Apr/18

May/18

Jun/18

Jul/1

8

Aug/18

Sep/18

Number Serious Incidents Reported(Trust & Care Group)

Emergency Care Group MSK & Frailty Care GroupSurgical Care Group Children & Family ServicesDiagnostic & Pharmacy Speciality ServicesChief Operating Officer Number Reported SI'sNumber Reported SI's ‐ Previous years performance Medicine Division

Standard Q1 Jul Aug Sep YTD2018‐19 Infection Control ‐ C‐diff 39 Full Year 6 1 1 0 82017‐18 Infection Control ‐ C‐diff 40 Full Year 8 4 2 2 162018‐19 Trust Attributable 12 0 0 0 0 02017‐18 Trust Attributable 12 1 1 0 0 2

Standard Q1 Jul Aug Sep YTD2018‐19 Serious Falls 10 Full Year 1 0 0 1 22017‐18 Serious Falls 6 Full Year 0 0 1 0 1

Standard Q1 Jul Aug YTD2018‐19 Pressure Ulcers 21 Full Year 7 7 1 152017‐18 Pressure Ulcers 27 Full Year 5 2 4 11

Monitor Compliance Framework: Infection Control C.Diff ‐ Sep 2018 (Month 6)(Data accurate as at 09/10/2018)

Pressure Ulcers & Falls that result in a serious fracture ‐ Sep 2018 (Month 6)(Data accurate as at 15/10/2018)

Please note: At the time of producing this report the number of serious falls reported are prior to the RCA process being completed.

01020304050

Apr

May Jun Jul

Aug

Sep

Oct

Nov Dec

Jan

Feb

Mar

C‐diff 2018‐19

2018‐19 C‐diff Cumulative total 2017‐18 C‐diff Cumulative total Standard

02468

1012

Apr

May Jun Jul

Aug

Sep

Oct

Nov Dec

Jan

Feb

Mar

Falls that result in a serious fracture

2018‐19 Falls Cumulative Total 2017‐18 Falls Cumulative Total Standard

0

5

10

15

Apr

May Jun Jul

Aug

Sep

Oct

Nov Dec

Jan

Feb

Mar

Trust Attributable C‐diff 2018‐19

2018‐19 Trust Attributable Cumulative Total 2017‐18 Trust Attributable Cumulative Total Standard

01020304050

Apr

May Jun Jul

Aug

Sep

Oct

Nov Dec

Jan

Feb

Mar

Pressure Ulcers (Ungradeable, Cat 3 & Cat 4)

2018‐19 Pressure Ulcer Cumulative Total 2017‐18 Pressure Ulcer Cumulative Total Standard

‐202468

Aug

Sep

Oct

Nov Dec

Jan

Feb

Mar Apr

May Jun Jul

Aug

Pressure Ulcers (Ungradeable, Cat 3 & Cat 4)

Mean UCL LCL

Safe Effective Caring Responsive Well Led

Division Matron WardNo of Funded Beds

CHPPD Variance Total score Total score Total score Total scoreQM total score

Work‐force Quality

Surgery & Cancer B5 30.7 7.2 99% 0.0 0.5 0.0 1.5 2.0B6 16 7.5 98% 2.5 0.0 0.5 1.0 4.0

AH St Leger 35 6.7 97% 0.0 1.0 1.0 2.0 4.0AH 1&3 23 9.0 99% 2.0 2.0 0.5 1.5 6.0

20 27 4.8 96% 1.0 0.5 2.0 0.5 4.021 27 4.9 100% 1.5 0.5 0.0 2.0 4.0S10 20 5.3 100% 1.0 1.0 2.5 1.5 6.0S11 19 5.8 106% 0.0 1.5 0.0 1.5 3.0S12 20 5.5 100% 0.0 1.0 2.0 2.5 5.5SAW 21 7.6 98% 0.5 0.0 1.0 2.0 3.5

99%Medicine JC A4 24 6.3 103% 0.0 0.5 2.0 1.5 4.0

JC C1 16 6.6 112% 0.0 0.0 0.0 2.5 2.5JC CCU/C2 18 6.3 100% 1.0 1.5 2.0 2.0 6.5JC ATC 21 8.8 106% 1.0 0.0 0.0 2.0 3.0SS AMU 40 8.4 102% 0.5 1.0 3.0 2.5 7.0MT FAU 16 8.2 99% 0.0 1.5 1.0 1.5 4.0AW 16 24 8.7 108% 1.0 0.5 0.0 1.0 2.5AW 17 24 6.2 96% 0.0 0.0 0.5 3.0 3.5

18 Haem 12 7.7 106% 5.0 2.0 0.0 1.0 8.018 CCU 12 7.1 98% 2.0 0.0 0.0 1.5 3.524 24 5.8 104% 0.5 0.5 3.0 1.0 5.025 16 6.8 113% 0.5 0.5 0.5 1.0 2.5

Respiratory unit 56 6.8 112% 1.5 2.0 2.0 0.5 6.032 18 6.2 94% 1.5 0.5 0.0 2.0 4.0

MT Mallard 16 8.3 101% 2.0 1.5 2.5 1.5 7.5MT Gresley 32 6.0 102% 0.5 1.5 2.0 1.5 5.5MT Rehab 2 19 5.5 98% 2.0 0.0 0.5 2.0 4.5MT Rehab 1 29 4.8 99% 0.0 0.0 0.0 1.5 1.5

104%Clinical Speciality Services ITU DRI 20 26.4 92% 1.5 3.0 2.0 1.5 8.0

ITU BDGH 6 27.6 85% 0.0 3.0 2.0 0.5 5.590%

Children and Families AB SCBU 8 18.0 98% 0.0 0.5 0.0 0.0 0.5AB NNU 18 10.6 100% 0.0 0.0 0.0 0.0 0.0AB CHW 18 10.6 96% 0.5 0.5 0.0 0.0 1.0AB COU 12 10.2 97% 0.5 0.5 0.0 0.5 1.5TB G5 24 7.3 81% 2.0 1.0 1.0 1.5 5.5JH M1 26 9.1 90% 0.0 3.0 1.0 1.0 5.0JH M2 18 9.5 84% 1.0 3.0 1.0 1.0 6.0SR CDS 14 23.1 84% 1.0 1.0 1.0 1.0 4.0JH A2 18 7.2 83% 2.0 4.0 1.0 0.5 7.5KC A2L 6 34.1 95% 1.0 2.0 0.0 1.0 4.0

90%

Hard Truths ‐ Sep 2018 (Month 6)(Data accurate as at 11/10/2018)

Planned v Actual Profile The workforce data submitted to UNIFY provides the actual hours worked in September 2018 by registered nurses or midwives, and health care support workers compared to the planned hours. The Trusts overall planned versus actual hours worked was 99% in September 2018; similar to recent months. There are no wards flagging as red on quality. The data for September 2018 demonstrates that the actual available hours compared to planned hours were;

24 wards within 5% of the planned staffing level, 1 less than last month 8 wards with between 5‐10% of planned staffing levels, 1 more than last month. 3 wards with >10% higher than planned staffing level, 2 less than last month.5 wards with >10% lower than planned staffing level, 2 more than last month.

The wards where there were deficits in excess of 10% of the planned hours are ITU at BDGH, G5, M2, CDS and A2. When there has been lower levels of bed occupancy these areas have supported safe staffing in other departments in order to provide safe staffing levels. ITU at BDGH had a reduced occupancy so staff were redeployed to wards and departments to optimise safe staffing needs. The wards with greater than 10% of actual staffing over planned staffing are Ward C1, the Respiratory Unit and Ward 25. Escalation beds opened due to demand on C1 impacted on staffing plans, with enhanced care needs impacting on 25 and the Respiratory Unit.

Registered midwives/ nurses

Care Staff Overall

5.08 3.54 8.624.47 3.49 7.972.32 2.70 5.024.45 3.45 7.90TRUST

The CHPPD data is similar to the previous month

Care Hours Per Patient Day (CHPPD) ‐ Sep 2018 (Month 6)(Data accurate as at 15/10/2018)

Utilising actual versus planned staffing data submitted to UNIFY and applying the CHPPD calculation the care hours for September 2018 are shown below

Site Name

BASSETLAW HOSPITALDONCASTER ROYAL INFIRMARYMONTAGU HOSPITAL

Month

`2016/17 0

2

1

0

0

3

10

00

0

4

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

2018/19 10 7 9 6 8 12 522017/18 11 8 8 18 11 15 8 9 7 6 6 9 1162018/19 2 6 1 1 7 172017/18 2 3 1 1 1 1 1 3 1 2 2 2 20

Number referred for investigation

YTD

Outcomes YTD

Complaints & Claims ‐ Sep 2018 (Month 6)(Data accurate as at 10/10/2018

Complaints

Complaints ‐ Resolution Perfomance (% achieved resolution within timescales)

Parliamentary Health Service Ombusdman (PHSO)

Number of cases referred for investigation

Number Currently Outstanding

Sep‐18 4 5

8 Outstanding

2017/18 7

Fully / Partially Upheld

Not Upheld

No further Investigation

Case Withdrawn

Not Investigated

Outstanding

2018/19 4

Fully / Partially UpheldNot Upheld

No further Investigation

Case WithdrawnOutstanding

Please note: Performance as a percentage is calculated on the cases replied and overdue, compared to the due date. Any current investigations that have not gone over deadlines are excluded data.

Claims

Clinical Negligence Scheme for Trusts (CNST) Not including Disclosures

Liabilities to Third Parties Scheme (LTPS)

Please note: At the time of producing this report the number of claims reported are provisional and prior to validation

Sep 2018 Complaints ReceivedRisk Breakdown

Low Risk

Moderate Risk

High Risk

Year to DateComplaints ReceivedRisk Breakdown

01020304050607080

Apr 2

014

Jun 20

14

Aug 20

14

Oct 2014

Dec 2014

Feb 20

15

Apr 2

015

Jun 20

15

Aug 20

15

Oct 2015

Dec 2015

Feb 20

16

Apr 2

016

Jun 20

16

42583

42856

43009

43070

43132

43191

43252

43313

Complaints Received

Complaints Mean UCL LCL

0

20

40

60

80

100

120

Apr 2

014

Jun 20

14Au

g 20

14Oct 201

4Dec 201

4Feb 20

15Ap

r 201

5Jun 20

15Au

g 20

15Oct 201

5Dec 201

5Feb 20

16Ap

r 201

6Jun 20

1642

583

4285

643

009

4307

043

132

4319

143

252

4331

3

Concerns Received

Concerns Mean UCL LCL

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct/17

Nov/17

Dec/17

Jan/18

Feb/18

Mar/18

Apr/18

May/18

Jun/18

Jul/18

Aug/18

Sep/18

Complaints Resolution Performance

0.000.200.400.600.801.00

Oct/17

Nov/17

Dec/17

Jan/18

Feb/18

Mar/18

Apr/18

May/18

Jun/18

Jul/1

8

Aug/18

Sep/18

Number of Claims per 1000 Occupied bed days

Claims per 1000 occupied bed days Claims per 1000 occupied bed days ‐ Previous years performance

Accident & Emergency

Please note: At the time of producing this report no further benchmarking data is available from NHS England.

Friends & Family ‐ Sep 2018 (Month 6)(Data accurate as at 08/10/2018)

Inpatients

Please note: At the time of producing this report no further benchmarking data is available from NHS England.

0%5%

10%15%20%25%30%35%

Oct/17

Nov/17

Dec/17

Jan/18

Feb/18

Mar/18

Apr/18

May/18

Jun/18

Jul/1

8

Aug/18

Sep/18

Response Rates (%)

Trust Rate NHS England Yorkshire & the Humber

0.930.940.950.960.970.980.99

1

Oct/17

Nov/17

Dec/17

Jan/18

Feb/18

Mar/18

Apr/18

May/18

Jun/18

Jul/1

8

Aug/18

Sep/18

Likely to recommend (%)


0%2%4%6%8%10%12%14%

Oct/17

Nov/17

Dec/17

Jan/18

Feb/18

Mar/18

Apr/18

May/18

Jun/18

Jul/1

8

Aug/18

Sep/18

Response Rates (%)


0.80.820.840.860.880.9

0.920.940.96

Oct/17

Nov/17

Dec/17

Jan/18

Feb/18

Mar/18

Apr/18

May/18

Jun/18

Jul/1

8

Aug/18

Sep/18

Likely to recommend (%)


Executive summary ‐Workforce ‐ August 2018 (Month 5)

Sickness absence Following a reduction in rates in August rates have reduced further in September to 3.96% which is below the same period last year) with a cumulative figure of 4.15%. Absences in excess of 6 months absence have stabilised following the reduction last month with a small reduction in the number of absences over 28 days.

AppraisalsThe Trusts appraisal completion rate has maintained at 78.85% as at the end of September 2018 following the end of the appraisal season. Following the move to the new Divisional structure discussions will take place with those areas where improvements are required.

SET SET compliance is currently 82.37% as at the end of August. Specific focus continues on topics where compliance rates are lower and with the new Divisions where compliance rates are low and is included in the CQC action plans.

Staff in post Please see attached tab covering staff in post by staff group. Vacancy rates are provided to both Finance & Performance and Quality & Effectiveness Committees.

Workforce: Sickness Absence ‐ September (Month 6)

CG & Directorate Sickness Absence - September 2018 (Q2)

RAG: Below Trust Rate - Above Target - Above Trust Rate

Abs Rate = 3.96% LT Abs Rate =2.58% Days Lost =6,462.26

Sickness Absence Occurences

0%

1%

2%

3%

4%

5%

6%

7%

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

Target - 3.50% % 17/180

5

10


Over 12 mths12 Months+ 17/18

0

10

20

30


Over 6 Months6 Months+ 17/18

0

100

200

300


Over 28 Days28Days - 6mths 17/18

0

100

200

300


BF +1000BF +1000 17/18

Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % Rate Days Lost % RateDoncaster & Bassetlaw Teaching Hospitals NHS FT 6966.07 4.30% 6852.91 4.09% 6610.26 4.08% 7244.35 4.34% 6993.67 4.16% 6462.26 3.96% 41,129.51 4.15%Chief Executive Directorate 14.00 2.67% 27.76 5.12% 18.80 3.58% 0.00 0.00% 2.00 0.36% 0.91 0.17% 63.47 1.97%Children & Families Division 840.01 4.65% 851.44 4.60% 608.47 3.43% 769.74 4.21% 843.46 4.62% 666.99 3.77% 4,580.10 4.22%Clinical Specialist Division 1932.19 4.51% 1682.42 3.81% 1650.39 3.88% 2000.43 4.57% 1854.48 4.22% 1768.63 4.16% 10,888.54 4.19%Directorate Of Strategy & Improvement 0.00 0.00% 2.00 1.72% 0.00 0.00% 1.00 0.80% 0.00 0.00% 0.00 0.00% 3.00 0.40%Estates & Facilities 818.11 5.76% 772.80 5.24% 745.79 5.21% 878.47 5.94% 811.97 5.57% 895.99 6.37% 4,923.12 5.68%Executive Team Board 0.00 0.00% 1.00 0.08% 2.00 0.16% 0.00 0.00% 0.00 0.00% 0.00 0.00% 3.00 0.03%Finance & Healthcare Contracting Directorate 80.84 2.96% 42.00 1.52% 72.54 2.74% 31.07 1.16% 15.60 0.58% 12.00 0.48% 254.04 1.58%IT Information & Telecoms Directorate 71.46 2.22% 113.84 3.46% 143.69 4.46% 141.81 4.20% 125.97 3.72% 162.66 4.91% 759.43 3.83%Medical Director Directorate 3.60 0.64% 21.14 3.62% 23.40 4.22% 23.15 4.15% 23.15 4.15% 10.45 1.94% 104.89 3.12%Medicine Division 1901.44 4.53% 1967.12 4.49% 1750.43 4.14% 1832.66 4.20% 1783.53 4.07% 1655.56 3.90% 10,890.73 4.22%Nursing Services Directorate 74.84 4.27% 58.53 3.27% 86.20 4.97% 87.04 4.81% 73.20 3.98% 39.60 2.27% 419.41 3.93%People & Organisational Directorate 118.60 3.97% 124.76 4.00% 112.95 3.79% 93.69 3.01% 2.65 0.09% 6.60 0.21% 459.25 2.49%Performance Directorate 236.65 4.47% 161.87 2.99% 301.99 5.79% 277.01 5.17% 200.33 3.81% 186.43 3.66% 1,364.28 4.31%Surgery & Cancer Division 874.34 3.29% 1026.23 3.72% 1093.61 4.07% 1108.29 4.01% 1257.34 4.54% 1056.45 3.93% 6,416.25 3.93%

Sep-18Aug-18May-18Apr-18 Jun-18 Jul-18 Cumulative

Workforce: SET Training ‐ September (Month 6)

Workforce: Staff in post ‐September (Month 6)

FTE Headcount FTE Headcount FTE Headcount FTE Headcount FTE Headcount FTE Headcount FTE Headcount FTE Headcount FTE Headcount FTE Headcount FTE Headcount FTE HeadcountStaff GroupAdd Prof Scientific and Technic 171.90 187.00 171.47 187.00 170.77 185.00 173.47 189.00 172.47 189.00 172.21 189.00 168.86 187.00 160.58 177.00 169.69 187.00 170.63 188.00 172.02 190.00 172.07 190.00Additional Clinical Services 1,123.63 1,361.00 1,118.74 1,357.00 1,106.22 1,340.00 1,128.45 1,364.00 1,126.47 1,363.00 1,131.05 1,367.00 1,145.20 1,384.00 1,133.01 1,370.00 1,158.83 1,401.00 1,171.05 1,414.00 1,172.67 1,415.00 1,179.29 1,421.00Administrative and Clerical 1,085.93 1,323.00 1,067.20 1,300.00 1,057.48 1,287.00 1,068.60 1,301.00 1,060.57 1,291.00 1,064.98 1,296.00 1,058.77 1,289.00 1,034.25 1,261.00 1,046.56 1,275.00 1,047.67 1,278.00 1,045.17 1,272.00 1,045.71 1,274.00Allied Health Professionals 333.98 385.00 334.55 386.00 333.48 385.00 333.95 386.00 336.83 389.00 331.95 385.00 329.92 381.00 311.78 360.00 324.52 377.00 321.56 375.00 323.12 376.00 322.84 375.00Estates and Ancillary 567.59 826.00 569.05 828.00 564.44 820.00 492.84 701.00 492.83 701.00 488.71 695.00 483.68 688.00 478.88 680.00 485.34 692.00 480.84 686.00 476.40 680.00 474.36 678.00Healthcare Scientists 125.30 139.00 124.90 139.00 122.70 137.00 126.30 141.00 129.10 143.00 125.70 141.00 125.50 141.00 121.30 137.00 124.92 141.00 122.66 139.00 120.78 137.00 122.78 139.00Medical and Dental 505.78 637.00 504.89 628.00 500.29 597.00 504.54 598.00 509.05 601.00 509.11 600.00 510.17 600.00 500.36 574.00 510.07 583.00 508.07 581.00 554.01 633.00 551.15 633.00Nursing and Midwifery Registered 1,580.79 1,831.00 1,577.99 1,829.00 1,559.68 1,809.00 1,603.22 1,862.00 1,598.79 1,859.00 1,598.70 1,861.00 1,591.07 1,856.00 1,530.70 1,792.00 1,578.72 1,846.00 1,573.47 1,840.00 1,564.47 1,828.00 1,570.41 1,835.00Students 8.36 9.00 6.56 7.00 5.56 6.00 3.92 4.00 1.92 2.00 1.92 2.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 8.80 9.00Grand Total 5,503.26 6,698.00 5,475.34 6,661.00 5,420.61 6,566.00 5,435.28 6,546.00 5,428.03 6,538.00 5,424.31 6,536.00 5,413.18 6,526.00 5,270.87 6,351.00 5,398.65 6,502.00 5,395.95 6,501.00 5,428.64 6,531.00 5,447.40 6,554.00

Nov-17Oct-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18

Title Q2 Estates & Facilities Performance Report


Author Kirsty Edmondson-Jones


Decision

Assurance X

Information


The Quarter 2 Estates and Facilities Performance report provides Board of Directors with

the second quarterly review of performance for 2018/19.


Are Board of Directors assured of progress made during Q2 to improve the performance of Estates and Facilities services?


The paper relates to the wider Trust objective around: We will ensure our services are high performing, developing and enhancing elective care facilities at Bassetlaw Hospital and Montagu Hospital and ensuring the appropriate capacity for increasing specialist and emergency care at Doncaster Royal Infirmary.


The paper relates to the following risks on the BAF and CRR (all rated ‘extreme’):

F&P4 - Failure to ensure that estates infrastructure is adequately maintained and upgraded in line with current legislation, standards and guidance.

F&P12 - Failure to ensure that estates infrastructure is adequately maintained and upgraded in accordance with the Regulatory Reform (Fire Safety) Order 2005 and other current legislation standards and guidance

F&P19 & QEC12 - Risk of critical lift failure


Board of Directors are asked to note the content of this paper and progress made.

Quarter 2. July-Sept 18 Estates and Facilities Performance Report

Estates and Facilities Q2 Performance Report July - September 2018 1. Executive Summary

This performance report provides Board of Directors with a quarterly update against the

performance of Estates and Facilities Services (E&F) for Quarter 2, July to September

2018. The report also includes an overview of national benchmarked scores from this

year’s Patient Led Assessment of the Care Environment (PLACE) which were published

during the period.

The report provides assurance to Board of Directors of the performance of Estates &

Facilities services in line with the Trust’s objectives.

At A Glance

2. Management Information

2.1 Appraisal

The Directorate has maintained and improved upon its performance in the first two months

of Q2, July and August, against the Trust target of 90% achieved by the end of 17/18 and in

Q1. Whilst September data is not yet available, the percentage of appraisals completed at

the end of August was 94.07%, an increase compared to the end of Q1.

2.2 Statutory and Essential Training (SET)

Work continues to ensure E&F achieve 90% SET having experienced significant churn with a

number of staff falling out of compliance in Q2, leaving the end of Q2 with only a 0.03%

increase as compared to Q1. Whilst SET booklet training is being completed against the

Trust target, difficulties are being experienced accessing Conflict Resolution training. This

delays the competition of the full package of SET training and the ability of the Directorate

to exceed to 90% Trust target. Work is underway to identify how access can be increased to

Conflict Resolution training in terms of increasing the frequency of courses and assessing

course length.

93.38

94.07

93

93.2

93.4

93.6

93.8

94

94.2

Q1 18/19 Q2 18/19

Tru

st T

arge

t 9

0%

EFM Appraisal Rates

2.3 Sickness The Directorate ended 17/18 as an outlier with an overall cumulative total of 6.56% against

a Trust target of 3.5%. Work to resolve long-term sickness and to effectively manage short-

term sickness has been underway throughout quarters 1 and 2, and despite a sharp rise in

September to 6.37%, the cumulative total is 5.68% at the end of the quarter.

3 PLACE Inspections

PLACE is used as part of external monitoring and features in CQC Insights reports and

historically in data packs produced by CQC for inspection and monitoring.

Following very disappointing results in the annual PLACE assessment for 2017, there was a

very significant improvement in PLACE scores from the inspections carried out in May this

year, as can be seen in the tables below showing the overall Trust scores.

Our performance nationally was not known until publication of the results in August where

it was revealed that DBTH leads the region and is one of the top 20 Trusts nationally for

cleanliness out of 270 Trusts. The Trust is also in the top 50 for Condition, Appearance and

Maintenance.

Overall Trust Scores 2017 % 2018 % Variance %

Cleanliness 91.49 99.99 +8.5

Food 80.11 90.20 +10.09

76.8 76.8

0

10

20

30

40

50

60

70

80

90

Q1 18/19 Q2 18/19

Tru

st T

rage

t 9

0%

EFM SET Training

Organisation Food 75.67 85.16 +9.49

Ward food 81.47 91.24 +9.77

Privacy & Dignity 75.35 85.78 +10.34

Condition, Appearance & Maintenance 91.33 97.81 +6.48

Dementia 76.62 85.05 +8.43

Disability 81.06 88.39 +7.33

4 Facilities Performance

4.1 Hospital Cleanliness

All Trust sites acheived an average of 90% cleanliness target over the quarter, with DRI

achieving an average of 96%, and both BDGH and MMH achieving an average of 90%. BDGH

dropped by 1% in the month of August to 89%.

75%

80%

85%

90%

95%

100%

July August September

Doncaster Royal Infirmary Cleanliness %

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Bassetlaw Cleanliness %

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Montagu Cleanliness %

4.2 Portering Response

In the second quarter MMH has reduced movement request completed within 30 minutes

by 16% from the average of 80% at end of Q1, BDGH has reduced by 2%, and DRI has

reduced by 7%. There are a number of contributing factors that have adversely affected

performance in this area including patients not being ready for collection, no wheelchair,

sickness absence, lift availability at DRI, and vacancies. Values based cohort recruitment

commences w/b 29th October, and a lift refurbishment programme commenced at DRI on

15th October. The department is also working with IT on the use of RFID for equipment and

wheelchairs, and a ‘Find My Wheelchair’ app.

64%

36%

Total Completed Movement Requests MMH 2nd QTR 2017/2018

Completed requests in under30 mins

Completed requests in over 30mins

55%

45%

Total Movement Requests Completed DRI 2nd QTR 2018/2019

Completed requests in under30 mins


88%

12%

Total Movement Requests Completed BDGH 2nd QTR 2018/2019

Completed requests in under 30mins


5 Estates Performance 5.1 Planned Preventative Maintenance (PPM) DRI/MMH

The completion of PPM’s ensures the aged estate is being maintained appropriately, and

where risks have been identified, PPM’s are increased as mitigation to manage the risk.

Whilst a similar number of jobs were completed within the quarter at DRI/MMH compared

to Q1, an additional 209 jobs were programmed for this period. This resulted in an increased

number of jobs completed late, 393, or not completed at all, 419, but saw a decrease in the

number of jobs not yet issued of 587. This decline on completion rates is as a result of the

increased jobs programmed for the period, together with the cumulative effect of the 703

jobs missed in Q1.

Work is now progressing to commence a review of the Estates workforce across all sites

which will utilise NHSi LEAN methodology and receive support from regional EFM NHSi

leads. Certain LEAN tools have already been adopted by the Department and are proving

effective in streamlining processes. The aim of the review is to improve overall Estates

performance including PPM and reactive maintenance.

5.2 Reactive Maintenance DRI/MMH

Completion of Reactive Maintenance tasks improved in Q2 with 100% of Cat1 jobs being

competed on time. The data also shows that 97% of Cat2 jobs were completed within the

required timeframe.

2,957 624

307 1,122

Q2 DRI/MMH PPM

Completed as Scheduled Completed LateNot Yet Issued Missed

5.3 Planned Preventative Maintenance BDGH

There were no missed PPM’s at BDGH within this quarter, a reduction of 241, however 79

are yet to be issued. The completion of PPM’s ensures the aged estate is being maintained

appropriately, and where risks have been identified, PPM’s are increased as mitigation to

manage the risk.

2

0

0 0

DRI/MMH Q2 Reactive Performance - Cat 1

Completed in Target Completed Late

Backlog In Progress

1115

392

4 15

DRI/MMH Q2 Reactive Performance - Cat 2


Backlog In Progress

5.4 Reactive Maintenance BDGH

Within this period 100% of Cat1 jobs were completed on time. The data shows that 99.07%

of Cat2 jobs were completed, with only 5 jobs in backlog.

584 232

79

BDGH Q2 PPM

Completed as Scheduled Completed Late Not Yet Issued

2

0 0 0

BDGH Q2 Reactive Performance - Cat 1


Backlog In Progress

6 Medical Technical Services (MTS) At the end of 2017/18 a new target was identified by the MTS team of completion of

Corrective Repairs tasks within 4 days. Previously the average completion rate was between

8 and 14 days, and by the end of Q1 this had been reduced significantly to just 3 days.

However, as a result of vacancies the average completion rate has increased to 8 days in Q2

and work continues to stabilise the position to ensure consistency, alongside a skill mix

review which should lead to an increase in support staff.

Qtr2

Month Corrective repairs Average completion time Inspection /preventative maintenance jobs logged

July 183 11 days 628

August 149 9 days 234

Sept 188 5 days 626

Total number of new assets commissioned and entering service this quarter 253

Total number of assets condemned and disposed of this quarter 141

6.1 Inspection/Preventative Maintenance Program for Medical Devices

There are 109 wards/departments encompassing the Trust sites including outlying areas at

Retford tri health of which 85 (78%) areas are up to date and 24 (22%) are yet to be

completed.

396

54

5 10 BDGH Q2 Reactive - Cat 2


Backlog In Progress

There continues to be a challenge in accessing busy clinical areas, as a result these areas are

being fast tracked out of normal working hours. The bulk of Bassetlaw departments are due

in November. The department is setting a target for 12 monthly inspections dropped from

the previous 18 monthly inspections. The figures shown represent the position against a 12

month target for 18/19.

6.2 Re-Turn Centre

The innovative ‘Re-Turn Centre’ run by Medical Technical Services is an in-house ‘e-bay’ for

goods and items that would have previously been disposed of. The disposal of goods and

items costs the Trust significant expenditure in the removal of waste in skips, and in the

purchase of new equipment which could have been avoided. Soft launched in April, the

momentum is gradually building and the department is becoming more able to manage

supply and demand and the storage of surplus assets.

Recent publicity has increased the utilisation of the Re-Turn centre which to date has Re-

Turned 168 assets back to use with an estimated value of £31,131 on cost avoidance at the

end of Q2. Chairs and desks remain the most requested item.

IPM

complete

outstanding

Site % still in date or

complete in 18/19

MMH 100

DRI 82

BDGH 54

7 Conclusion and Recommendations

The data presented shows the performance achieved in Q2 of 18/19, such as significantly

improved national performance for PLACE scores, a further increase to appraisal rates,

alongside the successful introduction of the Re-Turn centre. Performance within portering

response targets is a focus for Q3 in terms of recruitment and continued work to reduce

ward and equipment based delays. The data also demonstrates the backlog of Planned

Preventative Maintenance tasks that is building at the DRI site, and supports the work due

to commence to undertake a comprehensive review of the Estates workforce with the

support of NHSi EFM and LEAN specialists.

The Board of Directors is asked to note the content of this E&F Q2 Performance report.

Title Board Assurance Framework & Corporate Risk Register Q2


Author Matthew Kane, Trust Board Secretary


Decision

Assurance X

Information


The attached Corporate Risk Register and Board Assurance Framework have been reviewed by executive and corporate directors for Q2. The following risks on the BAF have seen changes to their ratings:

Ref Risk Previous score Current score Direction

Q&E7 Failure to adequately prepare for CQC inspection.

L2 x I3 = 6

L2 x I2 = 4

Q&E8 Failure to achieve complaint reply performance standards.

L3 x I2 = 6

L2 x I2 = 4

F&P19

Failure to achieve income targets arising from issues with activity.

L3 x I5 = 15

L2 x I5 = 10

F&P16

Uncertainty over ICS financial regime including single financial control total.

L3 x I4 = 12

L2 x I4 = 8

There was one change to the corporate risk register:

• Failure to achieve income targets arising from issues with activity (de-escalated from 15 to 10)

Further to discussion at QEC, the BAF has been revised to include a ‘direction of travel’ column which relates to the likely direction of the risk in the following quarter, based on information we hold at this time. An upward arrow denotes a likely increase in risk rating. Two ratings are upward rated: • Failure to adequately treat patients due to unavailability and lack of supply of medicines

due to potential concerns about medicine stocks arising from the UK’s withdrawal from the EU from April 2019.

• Commissioner plans do not come to fruition and do not achieve the required levels of

acute service reduction, which would be particularly acute during winter pressures. The Medical Director together with the Deputy Medical Director and Clinical Governance Coordinator are in the process of assessing all quality risks on departmental risk registers to determine whether some require escalation and others can be removed. Discussions took place at Management Board on 15 October over two potential risks including the continuing one around Brexit and preparations for a potential ‘no deal’ scenario. The Accountable Officer for emergency planning is in the process of putting together a Brexit Plan based on nine workstreams and an assurance report was also presented at that meeting. Key Brexit issues around medicines supply, information governance and workforce are picked up elsewhere on the board assurance framework and corporate risk register. A separate Brexit risk is therefore not considered necessary at this time.


N/A


The attached BAF highlights the key risks to the strategic objectives.


The report highlights all corporate and strategic risks to the Trust.

Recommendations

The Board is asked to note the attached Corporate Risk Register and Board Assurance Framework for Q2 2018/19.

Source

(Lack of….Failure to ….)

Consequences

(Results in ….Leads to ….)

Like-

lihoodImpact

Like-

lihoodImpact

Like-

lihoodImpact

F&P1 Failure to achieve compliance with financial

performance and achieve financial plan

(i) Adverse impact on Trust's financial position

(ii) Adverse impact on operational

performance

(iii) Impact on reputation

(iv) Regulatory action

Director of

Finance

Finance & Performance

4 5 20

(i) Business and budget planning processes.

(ii) Financial governance policies and procedures.

(iii) Monthly monitoring of financial performance.

(iv) Data analysis of trends and action to address deterioration.

(v) Continued liaison with budget holders to identify risks to delivery.

(vi) Demand and capacity planning proccesses.

(vii) Detailed monitoring by Finance and Performance Committee.

(viii) Budgets set on recurrent outturn resulting in a more robust financial plan.

(ix) Budgets signed off by care groups and corporate departments.

(x) Monthly monitoring at Board and directorate level.

(xi) Uncommitted general contingency reserve.

(xii) Regular finance meetings with budget holders.

(xiii) Performance review meetings with NHSI.

(xiv) All directorates signed up to control total.

(xv) Support from BDO.

(xvi) Appointment of suitably quaified Efficiency Director.

4 4 16 2 5

(i) Additional grip and conrol

mechnaisms.

(ii) Discussions at ET regarding closing

the CIP gap.

Each month

F&P3 Failure to deliver Cost Improvement Plans in

this financial year

(i) Negative impact on Turnaround

(ii) Negative impact on Trust's financial

positon

(iii) Loss of STF funding

Director of

Finance


4 5 20

(i) Full Quality Risk Assessment and operational deliverability assessment of plans.

(ii) Regular consideration of schemes by Management Board and Executive Team.

(iii) Collaboration with other providers, to identify joint opportunities.

(iv) CIP tracker developed to provide visibility of progress agianst plan.

(v) Engagement in working together programme.

(vi) PMO led by new Effeiciecy Director, with associated management processes, key

deliverables, risk logs and reporting to Finance and Performance Committee.

(vii) Implementation of innovation from external reviews.

(viii) Regular meetings with NHSI to track progress.

(ix) Regenerated E&E Committee.

(x) CIP reovery meetings (fortnightly) with each group.

4 4 16 1 5

(i) Additional grip and conrol

mechnaisms.

(ii) Discussions at ET regarding closing

the CIP gap.

Each month

F&P4 Failure to ensure that estates infrastructure is

adequately maintained and upgraded in line

with current legislation, standards and

guidance.

Note: A number of different distinct risks are

contained within this overarching entry. For

further details please consult the E&F risk

register.

(i) Breaches of regulatory compliance and

enforcement

(ii) Claims brought against the Trust

(iii) Inability to provide safe services

(iv) Negative impact on reputation

(v) Reduced levels of business resilience

(vi) Inefficient energy use (increased cost)

(vii) Increased breakdowns leading to

operational disruption

(viii) Restriction to site development

Director of

Estates and

Facilities


5 5 25

(i) Annual business plan supports identification of issues by Care Groups / Directorates

(ii) Risk-based capital investment plans

(iii) Maintenance and support service contracts

(iv) Independent Authorising Engineers appointed for key services, providing annual

audits and technical guidance

(v) Revised business planning process for all capital investments

(vi) Estate condition and backlog maintenance assessment undertaken via 6-7 facet survey

(vi) Progress and monitoring of actions undertaken through compliance committees e.g.

health and safety committee

(vii) Board level health and safety training undertaken, October 2017

(viii) Completion of in-depth high voltage scheme (June 2017)

4 5 20 2 5

(i) Test buisness continuity and disaster

recovery plans

(II) Rolling programme of training

DP - Autumn 2018

KEJ - ongoing

F&P5 Failing to address the effects of the medical

agency cap

(i) Negative patient and public reaction

towards the Trust

(ii) Impact on reputation

Director of

People and OD/

Chief Operating

Officer/Medical

Director


5 4 20

(i) Teaching hospital status communicated through recruitment.

(ii) Care Group to escalate recruitment difficulties to MD/COO.

(iii) Use of Trust staff in first instance to address gaps wherever possible.

(iv) Signed memo of understanding between all Trusts in the WTP to abide by a standard

set of principles.

(v) P&OD / Workforce reports to BoD.

(vi) Workforce and Education Committee.

(vii) Agency spend and breaches going to Exec Team and Finance and Performance.

(viii) Better system around rate-to-fill and fill rates.

(ix) Use of social media to attract new candidates.

(x) Relationships with universities.

(xi) GMC Survey.

(xii) Medical agency locum panel.

(xiii) BDO Grip & Control work.

(xiv) Use of alternative workforce.

4 4 16 3 2

(i) Develop new service model to

mitigate medical staff shortage.

(ii) Develop and progress workforce

from using alternative workforce for

service delivery.

KB/SS/DP - ongoing

As above

No. Exec owner

Doncaster & Bassetlaw Teaching Hospitals Corporate Risk Register

Relevant committeeOverall

Original

Risk Score

Original Risk Score

1:Low…5:Extreme

Controls

Current Risk Score

1:Low 5:ExtremeOverall

Current

Risk Score

Target Risk Score

1:Low 5:Extreme

New and developing controls Owner and target date

Description of Risk

F&P6 Failure to achieve compliance with

performance and delivery aspects of the Single

Oversight Framework, CQC and other

regulatory standards

(i) Regulatory action


Chief Operating

Officer


(impact on performance)

Quality & Effectiveness

(impact on quality)

5 4 20

(i) Performance Management and Accountability Framework.

(ii) Business planning processes

(iii) Relevant policies and procedures.

(iv) Daily, weekly & monthly monitoring of targets.

(v) Regular monitoring of compliance.

(vi) Data analysis of trends and action to address shortfalls.

(vii) Continued liaison with leads to identify risks to delivery.

(viii) CQC Compliance Governance and Assurance Process.

(ix) External reviews policy.

(x) Monitoring at monthly Care Group accountability meetings.

(xi) A&E QAT process.

(xii) Demand and capacity planning proccesses.

(xiii) Weekly review of A&E Action plan in accountability meeting chaired by COO.

(xiv) Licence to Operate linked to SOF

4 4 16 3 3

(i) Review of front door streaming

(ii) New accountability framework to go

live

DP - Summer 2018

F&P8 Inability to recruit right staff and have staff

with right skills

(i) Increase in temporary expenditure

(ii) Inability to meet FYFV and Trust strategy

(iii) Inability to provide viable services

Diretcor of

People & OD


5 4 20

(i) HR policies and procedures.

(ii) Monitoring of use of agency staff through robust processes to stay within cap.

(iii) Medical staff recruitment action plans.

(iv) Care Group Business Plans – workforce plans.

(v) E-Rostering processes.

(vi) VCF processes - bolstered.

(vii) Consultant appointment approval processes.

(viii) NHS Professionals processes & management information.

(ix) Pilot of Assistant Practitioner role.

(x) Links with universities, increasing local placements.

(xi) Developing bands 1-4 nursing roles.

(xii) Nurse associate roles - exploration.

(xiii) Increasing the attractiveness of the website, social media and open days.

4 4 16 2 4

(i) Agency report development

(ii) Care group management

development

(iii) Relaunch of Trust values

(i) Autumn 2018

F&P11 Failure to protect against cyber attack (i) Trust becoming non-operational

(ii) Inability to provide clinical services

(ii) Negative impact on reputation

Chief

Information

Officer


5 5 25

(i) Penetration test of systems to identify gaps and risks;

(ii) Firewalls, passwords, anti-virus equipment.

(iii) Policies and reinforcement through communication to staff;

(iv) Staff awareness through Certified Security Professional course and other training;

(v) Trigger alerts;

(vi) Care Cert system at NHS Digital

(vii) All servers and systems patched to appropriate level

(viii) Computers and network infrastructure get security patches automatically applied

(ix) Monthly cyber security report

(x) Pilot trust for NHS Digital work

(xi) Digital garage work

(xii) Regular returns to the centre

3 5 15 1 4

Controls proposed by recent cyber

security audit including ongoing changes

to systems and new patches being

applied

SM - Autumn 2018

F&P12 Failure to ensure that estates infrastructure is

adequately maintained and upgraded in

accordance with the Regulatory Reform (Fire

Safety) Order 2005 and other current

legislation standards and guidance.

Note: a number of different distinct risks are

conatained within this overarching entry. For

further details please consult the EF risk

register.

(i) Breaches of regulatory compliance could

result in Enforcement or Prohibition notices

issued by the Fire and Rescue Services




Director of

Estates and

Facilities


5 5 25

(i) Regular external inspections from SYRS and Notts Fire Service

(ii) Improved fire safety risk assessments and evacuation strategies

(iii) Improved Fire Safety Training

(iv) Programme upgrade of fire detection systems

(v) Programme upgrade of structural fire precautions (compartments)

(vi) External Audit Fire Authorised Engineer

(vii) Fire safety training Trust Board and Exec Team

(viii) Further Development of Fire Safety Response Team structure

(ix) Risk based Capital Investment plans identified by estate condition and backlog

maintenance assessments via 6 - 7 facet surveys

(x) Progress and monitoring of actions undertaken through compliance committees eg

health and safety committee

3 5 15 2 5

(i) Ongoing training on fire safety with

staff

(ii) Seek additional funding to rectify

condition and backlog maintenance

issues

KEJ - Autumn 2018

F&P13 Inability to meet Trust's needs for capital

investment

(i) Inability to sustain improveemnts in Trust's

estate.

(ii) Negative impact on patient safety.

(iii) Negative impact on reputation.

Director of

Finance


5 4 20

(i) Finance reports to Board and Finance and Performance Committee.

(ii) Capital governance governance structure - Corporate Investment Group and Capital

Monitoring Group.

(iii) Guidance and templates for investment and disinvestment.

(iv) Proactive prioritiation of schemes.

(v) Range of capital groups established and led by directors.

4 4 16 1 4

Clarity around process over STP capital

projects.

Autumn 2018

Q&E1 Failure to engage and communicate with staff

and representatives in relation to immediate

challenges and strategic development

(i) Deterioration in management-staff

relationships

(ii) Negative impact on performance

(iii) Negative impact on reputation

Diretcor of

People & OD


5 4 20

(i) Process to engage with LNC.

(ii) Process to engage with Partnership Forum.

(iii) HR policies and procedures.

(iv) Staff engagement project strands.

(v) Staff experience group.

(vi) Listening events by CEO.

(vi) E&E Committee communications plan.

(vii) One-page strategy summaries.

4 4 16 2 4

Proactive communications around

particular issues

Ongoing

Q&E9 Failure to adequately treat patients due to

inavilability and lack of supply of medicines

(i) Impact on safety of patients

(ii) Impact on patient experience

(iii) Potential delays to treatment

(iv) Impact on trust reputation

(v) Increased workload in pharmacy

procurement

Chief Operating

Officer


5 4 20

(i) Support from Regional Procurement Team

(ii) Arrangement of substitute drugs and medicines

(iii) Databse of supply issues managed by RPT

(iv) Daily updates on shortages

(v) Holding to account of wholesalers for non-delivery of their contractual obligations and

monitoring the performance of wholesalers in the region

(vi) Local holding to account through account business managers

(vii) Escalation measures to Deputy Chief Pharmacist for persistent and acute issues

(viii) Logistics team communicating shortages to the ward and pharmacy team if stock not

available for supply

5 3 15 2 3

(i) Adoption of a regional procurement

online tool to track, manage and

communicate supply shortages

(ii) Updated workflows, process and

procedures to ensure that internal

communication and engagement is

optimised, collaboration is enhanced

and action plans and solutions are

documented better

(iii) Support sought from Regional QA

teams to help quality assure imported or

unlicensed medicines.

Autumn 2018

F&P17 /

Q&E12

Risk of critical lift failure (i) Reduction in vertical transportation

capacity in the affected area

(ii) Impact on clinical care delivery

(iii) General access and egress in the affected

area

Director of

Estates and

Facilities


(impact on performance)


(impact on quality)

4 4 16

(i) Reporting to Estates Committee and Clinical Governance Committee

(ii) PLACE assessments

(iii) Contract monitoring arrangements

(iv) Issues raised through Governor Forum and Patient Experience Committee

(v) Issues and complaints statistics

(vi) Service contract with Lift service provider which includes X 2 resident lift engineers on

site permanently

4 5 20 2 4

(i) New lift scheme (i) October 2018

RISKS LINK TO CRR EXEC CURRENT RR

DIRECTION

OF TRAVEL Q1 Q2 Q3 Q4 GAPS IN ASSURANCE ACTION TO ADDRESS GAPS TARGET RR

Failure to sustain a viable specialist and non-

specialist range of services

leading to



F&P7 Medical

Director/Chief

Operating Officer

L2 x I3 = 6 6 6

(i) Review of vascular services

(ii) Joint working with SCH and

RDaSH

(i) MD leading review of vascular (Autumn

2018)

(ii) Meetings to take place with SCH and RDaSH

(Autumn 2018)

L2 x I2 = 4

Failure to protect against cyber attack

leading to

(i) Trust becoming non-operational

(ii) Inability to provide clinical services


F&P11 Chief Information

Officer

L3 x I5 = 15 15 15

(i) Progress against Internal Audit

action plan to be presented to

ANCR every six months

(ii) Change to Data Security &

Protection toolkit

(i) Phishing exercise (Autumn 2018).

(ii) Paper to ANCR re DSP (November 2018).

L3 x I4 = 12

Failure to ensure adequate medical records

system

leading to

(i) Impact on safety


Q&E4 Chief Operating

Officer

L2x I3 = 6 6 6

(i) Elecrtonic Patient Record System

(ii) Development of Business Case

for EPR

(i) Progress towards EPR System (ongoing)

L2 x I2 = 4

Failure to engage with patients and staff around

the quality of care and proposed service changes

leading to

(i) Negative patient and public reaction towards

the Trust


(iii) Impact on staff morale

(iv) Risk of long-term recruitment issues

(v) Risk of delay to any service changes

Q&E5 Director of

Nursing, Midwifery

and AHPs/ Medical

Director

L3 x I3 = 9 9 9

(i) Improve patient engagement and

listening activities to strengthen

patients and public voice

(ii) Adopt ReSPECT process Trust

wide

(iii) Launch and embed

#hellomynameis

(iv) Implementation of "Always

events"

(v) Identify opportunities for quality

improvement through feedback

(vi) HSR consultation

(vi) Outcomes of improvement

practice work.

(i) Increase engagement activities Q1-Q4 2018-

19

(ii) Process adopted Trust wide Q1 2019

(iii) hellomynameis relaunched and embedded

Q4 2017-18 - Q4 2018-19

(iv) Increased activities 2019 onwards

(v) Increased opportunities for feedback Q1-4

2018-19

(vi) Finalisation of improvement practice work

(commenced Q3)

L2 x I2 = 4

Failure to adequately prepare for CQC inspection

leading to

(i) Sub-optimal performance in inspection

(ii) Risk of regulatory involvement


Q&E7 Diretcor of

Nursing, Midwifery

and Allied Health

Professionals

L2 x I2 = 4 6 4

(i) Action plan to move to

'outstanding'

(ii) Mock inspectons

(i) Action plan in development (Autumn 2018)

(ii) LEAN work informing True North statement

(Autumn 2018)

L1 x I2 = 2

Strategic Aim 1 - We will work with patients to continue to develop accessible, high quality and responsive services.

CONTROLS ASSURANCE

(i) Consultations on major service changes

(ii) CCC report to Board

(iii) Friends and Family Test

(iv) Monitoring through Patient Engagement & Expderience Committee

(including CCG & Healthwatch membership)

(v) Training on communication

(vi) Work on learning from deaths

(vii) Governor walkabouts

(viii) Ward QAT

(ix) Picker national surveys

(x) Social media e.g. Facebook, Twitter

(xi) Media & social media policy

(xii) Governor/ NED briefings

(xiii) MP briefings/ meetings

(xiv) Governor training

(xv) Meetings with local journalists

(xvi) Face to face briefings with services

(xvii) Staff engagement events, briefings and workshops

(xviii) Communications with staff on Hospital Services Review

(xix) Internal staff surveys

(i) Consultation on HASU and children's tier 2 surgery

(ii) Consultation on new strategic direction

(iii) Bassetlaw Governors engagement work with the public

(iv) Case law and advice taken in respect of service changes

(v) F4H Strategy special, September 2017

(vi) Strategy stand at AMM

(vii) Communications team is responsive on traditional and social media

(viii) New, engaging website

(ix) Invested in strong relationships with local journalists and MPs

(x) Ensuring internal and external communications are aligned and staff

engagement is considered in external comms process

(xi) Communications Strategy approved by Board, October 2017

(x) Ongoing meetings with commissioners and primary care across the patch

(xi) Medical Director's discussions with governors

(i) Review of bays and action plans in place

(ii) RFID business case agreed

(iii) Plans to make DRI a closed library

(iv) RFID System operational

(v) IM&T Strategy

(i) Storage bays reviewed

(ii) Presentation before Board in August 2017 on RFID

(iii) RFID installed, October 2017

(iv) Draft information strategy in place

(v) Presentation from Nervecentre at ET and Governor Forum, October 2018

(i) Participation in WTP and Hospital Services Review

(ii) Commissioner engagement

(iii) Involvement/influence NHSE commissioning intentions

(iv) R & D support for specialist services

(v) Quarterly Executive discussions with STH

(vi) Contribution to reconfiguration discussions

(i) Peer review programe outcome (9 June 2016)

(ii) Patient outcome and service quality as published by National Registries

(iii) Agreement with Sheffield over vascular services

(iv) Publication of Hospital Services Review workstreams (September 2017)

(v) Hospital Services Review published (May 2018)

(vi) Particpation in review of specialist services

(vii) Decision on HASU

(i) Penetration test of systems to identify gaps and risks;

(ii) Firewalls, passwords, anti-virus equipment.

(iii) Policies and reinforcement through communication to staff;

(iv) Staff awareness through Certified Security Professional course and other

training;

(v) Trigger alerts;

(vi) Care Cert system at NHS Digital

(vii) All servers and systems patched to appropriate level

(viii) Computers and network infrastructure get security patches automatically

applied

(ix) Monthly cyber security report

(x) Pilot trust for NHS Digital work

(xi) Digital garage work

(xii) Regular returns to the centre

(i) Trust unaffected by cyber attack in May 2017

(ii) Governors briefing June, 2017

(iii) Cyber maturity audit and action plan reported via ANCR to Board,

September 2017 and updated March 2018

(iv) Annual IT audit

(v) Report to Audit Committee on IT Security - Penetration Test of Trust sites

update, September 2018

(i) Self-assessment and mock inspection processes

(ii) Engagement meetings with CQC

(iii) Nottinghamshire Looked after Children and Safeguarding monitored by

Trust Safeguarding People's Board

(iv) Action plans montiored by Clinical Governance Committee

(i) IRMER inspection and action plan in place

(ii) Reports to Board and QEC

(iii) CQC Insights

(iv) Positive mock inspections

(v) CQC report received July 2018

(vi) Board and QEC consideration of action plans

(vii) Action plan following inspection sent to CQC

Failure to achieve complaint reply performance

standards

leading to

(i) Impact on reputation


Q&E8 Diretcor of

Nursing, Midwifery

and Allied Health

Professionals

L2 x I2 = 4 6 4

(i) Consistent improved

performance in complaints handling

(i) Reports to PEEC and QEC (Autumn 2018)

L2 x I1 = 2

Failure to deliver GDPR mandated subject access

requests due to increased demand against existing

resource

leading to

(i) ICO intervention

(ii) Regulatory fines

(iii) Reputational impact

F&P17 Chief Information

Officer

L4 x I3 = 12 12 12

(i) As set out in action plan sent to

Board, May 2018

(ii) Internal audit (to be scheduled

later in 2019).

(iii) Change to Data Security &

Protection toolkit.

(i) DPO taking forward actions and reporting

into IG Committee (2018/19).

(ii) Paper to ANCR re DSP (November 2018).

L2 x I2 = 4

Failure to adequately treat patients due to

unavailability and lack of supply of medicines

leading to

(i) Impact on safety of patients


(iii) Potential delays to treatment

(iv) Impact on trust reputation

(v) Increased workload in pharmacy procurement

(vi) Financial impact for the Trust


Officer

L5 x I3 = 15 15 15

(i) Longer term improvements to

supply chain

(ii) Awareness amongst relevant

staff

(iii) Set out in QEC risk interogation

report, reported April 2018

(i) Gaps to be added to database (ongoing)

(ii) Action plan as set out to QEC during risk

interrogation (Autumn 2018)

L2 x I3 = 6

Failure to mitigate the impact of an ambitious

effectiveness and efficiency programme on quality

of care

leading to

(a) Poor patient and family experience

(b) Regulatory action

(c) Impact on Trust's reputation

(d) Low staff morale

Q&E11 Medical Director /

Director of Nursing,

Midwifery and

Allied Health

Professionals

L3x I4 =12 12 12

(i) Not yet identified EEPs

(ii) QPIA on all schemes that come

through or which change

(i) QPIA process 2017/18 (ongoing)

L1 x I4 = 4

(i) Medical Director and Director of Nursing involved in Quality Impact

Assessment process

(ii) DNS, COO and MD involved in Efficiency and Effectiveness Committee

(iii) DNS, COO and MD in agreeing the effectiveness and efficiency measures

through ET

(iv) Friends and Family Test

(v) PLACE assessments

(vi) CQC inspections and mock-inspections

(vii) Regular meetings with NHS Improvement

(viii) Ward visits programme

(ix) Patient Experience Committee

(i) Reports to Clinical Governance Committee and Quality and Effectiveness

Committee

(ii) Recent quality accounts continuing to show good performance

(iii) Trust has track record of delivering effectiveness and efficiency

measures

(iv) No wards 'red' for quality in previous month

(v) QPIA process and outcomes reported to QEC and CGC.

(vi) Positive PLACE assessments.

(i) Live complaints tracker developed

(ii) Weekly PET/CG meetings to monitor progress/review agreed timescales

and manage the complainants expectations.

(iii) Weekly meetings with the Head of Patient Safety & Experience, Deputy

Director of Quality & Governance and DoN which includes escalation.

(iv) Quality dashboard includes CG performance presented at Clinical

Governance Committee on a monthly basis.

(v) Monitored through Patient Experience & Engagement Committee.

(i) Patient Experience Strategy approved

(ii) Positive Q3 and Q4 results presented to Board in January 2017/18 and

Q1 2018/19

(iii) Positive performance reported to Board throughout Summer 2018

(i) Histroical baseline assessment

(ii) Monitor impact for first three months

(iii) Information Governance Committee monitoring

(iv) Finance and Performance Committee report in initial months

(v) Suitably qualified Data Protection Officer appointed

(vi) Suitably trained staff

(vii) Communications campaign and processes in place

(i) DPO appointment made

(ii) Report to Finance and Performance Committee, April and May 2018

(iii) Report to Board of Directors, May 2018

(iv) Active action plan in place

(v) Notices to members, staff and patients regarding GDPR

(i) Support from Regional Procurement Team

(ii) Arrangement of substitute drugs and medicines

(iii) Databse of supply issues managed by RPT

(iv) Daily updates on shortages

(v) Holding to account of wholesalers for non-delivery of their contractual

obligations and monitoring the performance of wholesalers in the region

(vi) Local holding to account through account business managers

(vii) Escalation measures to Deputy Chief Pharmacist for persistent and acute

issues

(viii) Logistics team communicating shortages to the ward and pharmacy team

if stock not available for supply

(i) Temporary improvements to the supply chain

(ii) Updates from CMU (Commercial Medicines Unit of NHSE)

(iii) Risk interrogation to QEC (April 2018)

(iv) Government technical notes

(v) Letter and guidance on 'No Deal' Brexit, August 2018


DIRECTION OF

TRAVEL Q1 Q2 Q3 Q4 GAPS IN ASSURANCE ACTION TO ADDRESS GAPS TARGET RR

Failure to achieve compliance with financial performance and achieve financial

plan and subsequent cash implications

leading to

(i) Adverse impact on Trust's financial position

(ii) Adverse impact on operational performance


(iv) Regulatory action

F&P1 Director of Finance

L4 x I4= 16 16 16

(i) Achievement of strategic projects

(ii) Review of equipment and

maintenance

(iii) Review of private patient options

(iv) Unidentified CIP

(v) Workforce Plans

(vi) Maternity issues - CCG

(i) Project groups established and cases being

brought to Board

(ii) Review of equipment and maintenance

(March 2019)

(iii) Understand options for private-patient

(December 2019)

(iv) Plan to address the unidentified CIP and

workforce (ongoing)

L2 x I4 = 8

Failure to deliver Cost Improvement Plans in this financial year

leading to

(i) Negative impact on Turnaround

(ii) Negative impact on Trust's financial positon

(iii) Loss of PSF funding


L4 x I4 = 16 16 16

(i) Outstanding recurrent CIP target

to be found

(ii) Consistent reporting of on track

CIP schemes

(iii) See F&P1

(iv) Director of Efficiency cover

(i) Work with Executive Team on high risk and

unidentified schemes (Autumn 2018)

(ii) Schemes to be reported to F&P each month

(ongoing)

(iii) See Risk F&P1

(iv) VCF process for new Director of Efficiency

(September 2018)

L1 x I4 = 4

Failure to achieve income targets arising from issues with activity

leading to

(i) the Trust not being paid for the work it is doing and subsequent impact on the

financial plan

(ii) reputational impact arising from a financial shortfall

(iii) potential regulatory action arising from a financial shortfall


L2 x I5 = 10 15 10

(i) Capacity and demand plan

(ii) Activity modelling

(i) Capacity and demand plan and actvity

modelling (Autumn 2018)

L1 x I4 = 4

Failure to ensure that estates infrastructure is adequately maintained and

upgraded in line with current legislation, standards and guidance.

Note: A number of different distinct risks are contained within this overarching

entry. For further details please consult the E&F risk register.

leading to

(i) Breaches of regulatory compliance and enforcement




(v) Reduced levels of business resilience

(vi) Inefficient energy use (increased cost)

(vii) Increased breakdowns leading to operational disruption

(viii) Restriction to site development

F&P4 Director of Estates

and Facilities

L4 x I5 = 20 20 20

(ii) EFM transformation project (i) Transformation project awaiting strategic

development business case (Autumn 2018)

L2 x I5 = 10

Risk of critical lift failure

leading to

(a) Reduction in vertical transportation capacity in the affected area

(b) Impact on clinical care delivery

(c) General access and egress in the affected area

F&P19 / Q&E12 Director of Estates

and Facilities

L4 x I5 = 20 20 20

(i) Lift refurbishment - 4, 5 and 6 (i) Work on lift refurbishment to be completed

December 2018

L2 x I5 = 10

Strategic Aim 2 - We will ensure our services are high performing, developing and enhancing elective care facilities at Bassetlaw Hospital and Montagu Hospital and ensuring the appropriate capacity for increasing specialist and emergency care at Doncaster Royal Infirmary.

CONTROLS ASSURANCE

(i) Business and budget planning processes.

(ii) Financial governance policies and procedures.

(iii) Monthly monitoring of financial performance.

(iv) Data analysis of trends and action to address deterioration.

(v) Continued liaison with budget holders to identify risks to delivery.

(vi) Demand and capacity planning proccesses.

(vii) Detailed monitoring by Finance and Performance Committee.

(viii) Budgets set on recurrent outturn resulting in a more robust financial plan.

(ix) Budgets signed off by care groups and corporate departments.

(x) Monthly monitoring at Board and directorate level.

(xi) Uncommitted general contingency reserve.

(xii) Regular finance meetings with budget holders.

(xiii) Performance review meetings with NHSI.

(xiv) All directorates signed up to control total.

(xv) Appointment of suitably quaified Efficiency Director.

(i) Exceeded control total in 2016/17

(ii) Production of 2017/18 budget

(iii) Unqualified opinion on 2016/17 accounts

(vi) Accounts submitted to NHSI by deadline

(v) Financial plans submitted to NHSI

(vi) Board approval of budgets

(vii) Budget setting approved by Finance and Performance Committee

(viii) Minutes of accountability and NHSI meetings

(ix) External Audit review of financial performance (within Annual Accounts

work)

(x) First round of accountability meetings taken place

(xi) BDO governance review

(xii) Regular finance reports to F&P

(xiii) Strong performance in month 10

(xiv) Significant assurance audit with limited number of improvements on core

financial systems

(xv) External audit 2017/18

(i) Reporting to Estates Committee and Clinical Governance Committee

(ii) PLACE assessments

(iii) Contract monitoring arrangements

(iv) Issues raised through Governor Forum and Patient Experience Committee

(v) Issues and complaints statistics

(vi) Service contract with Lift service provider which includes X 2 resident lift

engineers on site permanently

(i) Report to Part 2 Board, 26 June 2018

(ii) Confirmation of ability to use STF funding

(iii) Catering updates to F&P, Board and Council of Governors

(iv) Communication through ET and to Governors

(v) Lifts down now back in commission

(i) Full Quality Risk Assessment and operational deliverability assessment of

plans.

(ii) Regular consideration of schemes by Management Board and Executive

Team.

(iii) Collaboration with other providers, to identify joint opportunities.

(iv) CIP tracker developed to provide visibility of progress agianst plan.

(v) Engagement in working together programme.

(vi) PMO led by new Effeiciecy Director, with associated management processes,

key deliverables, risk logs and reporting to Finance and Performance Committee.

(vii) Implementation of innovation from external reviews.

(viii) Regular meetings with NHSI to track progress.

(ix) Regenerated E&E Committee.

(x) CIP recovery meetings (fortnightly) with each group.

(i) Performance against CIP for 16/17 of £11.9m.

(ii) Monthly CIP reports to Finance and Performance and Board.

(iii) Assurance provided to NHSI at quarterly meetings.

(iv) New PMO governance processes agreed and implemented.

(v) BDO governance review.

(vi) Delivery of CIP in 2017/18 of £10.3m.

(vii) Schemes in place for 2017/18.

(viii) Director of Efficiency appointed.

(i) PTL meetings.

(ii) Accountability meetings.

(iii) Meetings with CCGs.

(iv) Holding to account through Finance and Performance Committee.

(v) Regular monitoring of activity plans.

(vi) Care groups signed up to deliver activity.

(i) Accountability meetings taking place.

(ii) Audit of maternity income.

(iii) Delivery of income from M1 - 4.

(i) Annual business plan supports identification of issues by Care Groups /

Directorates

(ii) Risk-based capital investment plans

(iii) Maintenance and support service contracts

(iv) Independent Authorising Engineers appointed for key services, providing

annual audits and technical guidance

(v) Revised business planning process for all capital investments

(vi) Estate condition and backlog maintenance assessment undertaken via 6-7

facet survey

(vi) Progress and monitoring of actions undertaken through compliance

committees e.g. health and safety committee

(vii) Board level health and safety training undertaken, October 2017

(viii) Completion of in-depth high voltage scheme (June 2017)

(i) Presentations to Finance and Performance and Governors Briefings

(ii) Catering contract agreed May 2017

(iii) New service assistants in post April 2017

(iv) Completed 6/7 facet survey

(v) Asbetos and window surveys complete

(vi) Asbestos management plan up to date

(vii) Window risk assessments complete

(viii) Water management protocols complete and progress commenced

(ix) Electrical infrastructure surveys complete

(xii) Waste contract completed and delivered

(xiii) New catering contract signed

(xiv) New gas main

(xv) Continuously premise assurance model

(xvi) Estates Strategy approved by Board and capital plan

(xvii) Estates strategy audited (significant assurance)

(xviii) Capital programme 18/19 agreed

(xix) PAM agreed April 2018 - good requires minimal improvement

(xx) 6/7 facet survey work agreed

(xxi) Seven year investment plan in place

(xxii) Regular EFM KPI Reports to BoD and six monthly H&S KPI reports t ANCR

(xxiii) PAM and ERIC completed

Failing to address the effects of the medical agency cap

leading to

(i) Negative patient and public reaction towards the Trust


F&P5 Director of People

and OD/ Chief

Operating

Officer/Medical

Director

L4 x I4 = 16 16 16

(i) Develop new service model to

mitigate medical staff shortage,

working across the Trust.

(ii) Develop and progress workforce

from using alternative workforce for

service delivery.

(iii) Agree with Trusts in WTP to

minimise cap breaches.

(iv) Decrease local agency spend.

(v) Flexible use of staff across ICS

system.

(vi) Results from collaborative bank

pilot to review.

(vi) NHSP Collaborative Bank worked

up for implemented.

(i) Hospital@ work (Autumn 2018)

(ii) In discussion with recruitment agencies to fill

gaps (Autumn 2018).

(iii) Medical collaborative bank taking place

(Autumn 2018).

(iv) Review of existing NHSP collaborative

contract (Autumn 2018).

(v) Local Workforce Action Board work taking

place.

L3 x I2 = 6

Failure to achieve compliance with performance and delivery aspects of the Single

Oversight Framework, CQC and other regulatory standards

leading to



F&P6 Chief Operating

Officer

L4 x I4 = 16 16 16

(i) Action plan towards outstanding.

(ii) Elective recovery plan.

(i) Action plan for outstanding due Autumn 2018.

(ii) Elective recovery plan (Autumn 2018)

L3 x I3 = 9

Failure to ensure that estates infrastructure is adequately maintained and

upgraded in accordance with the Regulatory Reform (Fire Safety) Order 2005 and

other current legislation standards and guidance.

Note: a number of different distinct risks are conatained within this overarching

entry. For further details please consult the EF risk register.

leading to

(i) Breaches of regulatory compliance could result in Enforcement or Prohibition

notices issued by the Fire and Rescue Services




F&P12 Director of Estates

and Facilities

L4 x I5 = 20 20 20

(i) Full compliance with

requirements of Fire Service

(ii) Actions to address Deficiency

Notice at Bassetlaw - partially

complete

(i) Training to be rolled out across 2018/19

(Rolling programme).

L2 x I5 = 10

Inability to meet Trust's needs for capital investment

leading to

(i) Inability to sustain improveemnts in Trust's estate.

(ii) Negative impact on patient safety.

(iii) Negative impact on reputation.


L4 x I4 = 16 16 16

(i) Development of ICS schemes.

(ii) Approval of CT scheme by DOH.

(i) Board to approve ICS business case.

(ii) Wait for CT decision - 6-8 weeks (October

2018)

L1 x I4 = 4

Lack of adequate CT scanning capacity at DRI

leading to

(i) Negative impact on patient safety.

(ii) Inability to safely manage the emergency and inpatient activity.


Officer

L3 x I3 = 9 9 9

(i) Approval from DOH. (i) Awaiting approval from DOH (October 2018)

L2 x I2 = 4

Uncertainty over ICS financial regime including single financial control total

leading to

(i) Impact on Trust's finances and control total



L2 x I4 = 8 12 8

(i) Uncertainty over ICS governance

structure.

(i) Further governance work taking place

(November 2018)

L2 x I2 = 4

Risk of fraud

leading to

(i) Impact on Trust's finance


ANCR1 Director of Finance

L2 x I4 = 8 8 8

N/A N/A

L1 x I4 = 4

(i) Local Counter Fraud Specialist work plan and investigations

(ii) Fraud awareness training.

(iii) DH Counter-Fraud regime and oversight

(iv) Liaison with DOF and Chair of ANCR

(v) Staff fraud questionnaire.

(i) Quarterly and annual LCFS reports

(ii) Achievement of satisfactory NHS Protect Quality Assessment outcome

(iii) Full completion of 2016/17 operational fraud plan and 2017/18 plan in

place

(iv) Completion of fraud staff survey

(vii) 79% completed fraud awareness training in 2017/18

(viii) NHS Protect assurance report to Board, October and November 2017

(i) Finance reports to Board and Finance and Performance Committee.

(ii) Capital governance governance structure - Corporate Investment Group and

Capital Monitoring Group.

(iii) Guidance and templates for investment and disinvestment.

(iv) Proactive prioritiation of schemes.

(v) Range of capital groups established and led by directors.

(i) DBTH part of bidding process for ICS funds and ET to agree priorities.

(ii) Five year review of capital requirements which have been prioritised.

(i) Allocation within 2017/18 capital programme.

(ii) Engagement with care group directors.

(iii) Mobile CT.

(i) Business case cleared at CIG.

(ii) Initial dicsussions at F&P and ICS level.

(iii) Case approved at Board, February 2018.

(iv) CT donation.

(v) Positive feedback from NHSI.

(i) Chair and exec attendance at ICS meetings.

(ii) Leadership at ICS level.

(iii) Developing governance structure.

(i) Ongoing discussions with ICS and at national level.

(ii) Framework approved June 2018.

(iii) Paper to board explaining options (Summer 2018).

(iv) Decision by Board to agree option 2.

(v) Initial governance workshop taken place, September 2018.

(i) Teaching hospital status communicated through recruitment.

(ii) Care Group to escalate recruitment difficulties to MD/COO.

(iii) Use of Trust staff in first instance to address gaps wherever possible.

(iv) Signed memo of understanding between all Trusts in the WTP to abide by a

standard set of principles.

(v) P&OD / Workforce reports to BoD.

(vi) Workforce and Education Committee.

(vii) Agency spend and breaches going to Exec Team and Finance and

Performance.

(viii) Better system around rate-to-fill and fill rates.

(ix) Use of social media to attract new candidates.

(x) Relationships with universities.

(xi) GMC Survey.

(xii) Medical agency locum panel.

(xiii) Grip & Control work including scrutiny of qualified nurses.

(xiv) Use of alternative workforce.

(i) Recruitment report to Board May 2017.

(ii) Workforce and Education Committee assurance reports to QEC & F&P.

(iii) Agency spend and breaches going to Exec Team and F&P.

(iv) Improved rate-to-fill and fill rates.

(v) Latest GMC Survey, in upper quartiles for a number of specialties.

(vi) F&P monitoring agency spend and reporting to Board.

(vii) Agency spend to F&P.

(viii) Weekly flash reports and meetings.

(ix) Bassetlaw@ work.

(x) QiMET process.

(xi) Nursing workforce within 3% cap.

(xii) Report to Board July 2018.

(i) Performance Management and Accountability Framework.

(ii) Business planning processes

(iii) Relevant policies and procedures.

(iv) Daily, weekly & monthly monitoring of targets.

(v) Regular monitoring of compliance.

(vi) Data analysis of trends and action to address shortfalls.

(vii) Continued liaison with leads to identify risks to delivery.

(viii) CQC Compliance Governance and Assurance Process.

(ix) External reviews policy.

(x) Monitoring at monthly Care Group accountability meetings.

(xi) A&E QAT process.

(xii) Demand and capacity planning proccesses.

(xiii) Weekly review of A&E Action plan in accountability meeting chaired by

COO.

(xiv) Licence to Operate linked to SOF.

(i) Full and unconditional registration with CQC.

(ii) Business Intelligence and Performance Reports .

(iii) Annual Report & Quality Account.

(iv) CE quarterly objectives report (BoD - quarterly).

(v) Internal audit of CQC readiness.

(vi) CQC Intelligent Monitoring reports & risk ratings.

(vii) In Group 2 on four hour waits.

(viii) A&E Improvement Progarmme North - showcasing best practice.

(ix) System Perfect.

(x) Removal of breach fo licence.

(xi) Estates performance reported to Board (April 2018).

(xii) CQC inspection report and action plan.

(xiii) Winter Plan considered by Board, September 2018.

(i) Regular external inspections from SYRS and Notts Fire Service

(ii) Improved fire safety risk assessments and evacuation strategies

(iii) Improved Fire Safety Training

(iv) Programme upgrade of fire detection systems

(v) Programme upgrade of structural fire precautions (compartments)

(vi) External Audit Fire Authorised Engineer

(vii) Fire safety training Trust Board and Exec Team

(viii) Further Development of Fire Safety Response Team structure

(ix) Risk based Capital Investment plans identified by estate condition and

backlog maintenance assessments via 6 - 7 facet surveys

(x) Progress and monitoring of actions undertaken through compliance

committees eg health and safety committee

(i) Physical works to DRI and MMH

(ii) Fire safety action plan

(iii) Report to Board in June 2017

(iv) Fire safety training scheduled July 2017

(v) Staff trained in fire safety - June 2017

(vi) Compartmentalisation, fire stopping, fire doors, fire dampers to the East

Ward Block (DRI) basement, ground floor and level seven and other areas

across the site

(vii) Upgrade of existing, and provision of additional, fire alarm and detection

systems at DRI and Montagu Hospital.

(viii) Approval of evacuation strategies for W&Cs and East Block.

(ix) HSE inspections of Women's Block

(x) Montagu evactuation strategy approved, December 2017

(xi) Priority list for fire strategies presented to Board

(xii) Training on evacuation strategies


DIRECTION OF TRAVEL

Q1 Q2 Q3 Q4 GAPS IN ASSURANCE ACTION TO ADDRESS GAPS TARGET RR

Breakdown of relationship with key partners and

stakeholders

leading to

(i) Negative impact on strategic objectives


F&P9 Director of

Strategy and

Improvement

L3 xI4 = 12 12 12

(i) ACS events planned with MPs and

councillors.

(ii) Joint meetings with SCH and

RDaSH.

(i) Engagement at PLACE level under consideration

(Autumn 2018)

(ii) Engagement meetings with SCH and RDaSH

(Autumn 2018)

L2 x I4 = 8

Failure to deliver strategic direction

leading to

(i) Negative impact on patients

(ii) Inability to configure services in the best

interests of patients

(iii) Negative perception of partners and staff

F&P18/QEC10 Director of

Strategy and

Improvement

L2 x I5 = 10 10 10

(i) Firmer arrangements for

committee review of milestones and

KPIs to be agreed.

(ii) Achivement of strategic

milestones.

(iii) Capital to achieve long term aims.

(iv) Realisation of Improvement

Practice work.

(i) Process for milestones and KPIs in development.

(ii) Monitoring and achivement of action plans

agreed at Board (2018-19)

(iii) ICS capital bids (Autumn 2018).

(iv) Improvement Practice Programme 2018-19.

L1 x I5 = 5

Failure to ensure business continuity / respond

appropriately to major incidents

leading to

(i) Negative impact on reputation

(ii) Regulatory enforcement

(iii) Negative impact on performance

F&P10 Chief Operating

Officer

L2 x I4 = 8 8 8

(i) Testing by internal audit.

(ii) Brexit plan.

(i) Internal audits (end of 2018/19)

(ii) Brexit planning ongoing.

L2 x I3 = 6

Strategic Aim 3 - We will increase partnership working to benefit people and communities.

CONTROLS ASSURANCE

(i) Partnership working processes - Working Together, STP, Accountable Care

Systems, HWB.

(ii) Engagement with commissioners & other local trusts.

(iii) Attendance at CCG governing body meetings.

(iv) CE meetings with NHS England.

(v) Regular briefings to Members of Parliament.

(vi) Partner Governor seats on the Council of Governors.

(vii) Regular item on Exec Team for feeding back.

(i) CE Reports to Board.

(ii) Updates on HWB activity.

(iii) Updates regarding Working Together and STP programme via CE report

(BoD).

(iv) Committees in common and STP MoUs.

(v) Support from commissioners.

(vi) Bassetlaw and Doncaster Place Plans endorsed.

(vii) Well Led Governance Review reinforces the Trust's partnership

arrangements.

(viii) ACS Conference for Governors taken place, October 2017 and with NEDs,

May 2018.

(ix) CiC meetings underway.

(x) Collaborative Partnership Agreements with Doncaster and Bassetlaw

signed, April and May 2018.

(xi) Outcome of legal challenges known and not, as yet, affecting ICS.

(xii) ICS MoU considered by Board, September 2018.

(xiii) CEO commenced formal secondment with ICS.

(i) Business continuity plans

(ii) Business Continuity Policy

(iii) Statement of Compliance against National Core Standards for EPRR

(iv) BRSG which monitors BC planning progress

(v) Business Continuity Group linked to operational structures

(vi) Major Incident Plan

(vii) Training of A&E staff on CBRN incidents

(viii) Emergency response plans in place (annually reviewed)

- Evacuation of a hospital site

- Mass Casualty Plan

- Pandemic Influenza Plan

- Severe Eeather Plan

- Prison Plan

- CBRNE plan

(ix) Incident Control Rooms in line with EPRR Command and Control guidelines

(x) Communications exercises undertaken twice yearly as required by statute

(xi) Command & control training for BoD & senior managers on-call

(xii) Revision of plans following test exercises.

(xiii) On-call senior mangement trained - Leading in a crisis and public enquiry

simulation

(i) Power outage testing Summer 2017

(ii) Annual confirmation of compliance against National Core Standards for

Emergency Preparedness, Resilience and Response (BoD, Nov 2016)

(iii) Test exercises: Sickness, fuel (2016)

(iv) Internal Audit follow-up review of business continuity arrangements

(v) Risk assessment of major incident and business continuity plans with NHS

England (2015)

(vi)Y&H peer review of major incident plans 2016.

(vii) External review of HAZMAT - compliant (September 2015)

(viii) Hazardous Substances policy agreed by Board 29.11.2016

(ix) Tabletop exercises undertaken, SY risk assessment completed and two

power cuts

(x) Working with Care Groups to develop relevant desktop exercises.

(xi) Trust unaffected by system-wide cyber attack, May 2017

(xii) Winter planning agreed by Board in July 2017

(xiii) Compliance with Annual Statement of Compliance against the NHS Core

Standards for Emergency Preparedness, Resilience and Response (2017/18)

(xiv) Presentation to Board on Emergency Planning, November 2017

(xv) Business continuity exercise (mostly completed), December 2017

(xiv) Further review of processes following power outage (Winter 2018)

(xv) Cold weather plan tested

(xvi) Esclation Policy for management of major incident - Trust/Council

(xvii) June 2018 testing complete

(xviii) Polciies agreed by MB

(i) Process for strategy review based on quarterly exception reporting and

annual report to Board.

(ii) Quarterly discussion at Executive Team on strategy.

(iii) LEAN Programme work.

(iv) Capital steering groups set up to consider approach to clinical site

development work.

(v) Operational groups taking forward individual enabling strategies (IT Steering

Group, Estates Group, etc).

(vi) Board committees with certain enabling strategies under their remit.

(vii) Dedicated resource within Strategy and Transformation.

(i) Overall strategic direction agreed, Summer 2017.

(ii) Enabling strategies approved by Board, 2017/18.

(iii) Board process for reviewing strategies agreed, April 2018.

(iv) Strategy review within board committee terms of reference.

(v) Key milestones agreed by ET, April 2018.

(vi) Strategy communicated to staff through Buzz and Foundations for Health.

(vii) Deep dives and exception reporting mechanism established (June 2018)


DIRECTION OF


Inability to sustain the Paediatrics service at

Bassetlaw

leading to

(i) Withdrawal of overnight service

(ii) Negative impact on local community

Q&E3 Chief

Operating

Officer

L2 x I2 = 4 4 4

(i) Recruitment of medical and

nursing staff

(i) Regular recruitment exercises

L1x I2 = 2

Reduction in hospital activity and subsequent

income due to increase in community provision

leading to

(i) Increased pressure on acute services

(ii) Negative impact on financial plan

F&P14 Director of

Finance

L4 x I3 = 12 12 12

(i) Understanding of impact of Place

Plan and ICS

(i) Meetings taking place with Council and

other partners to assess impact (ongoing)

L4 x I2 = 8

Commissioner plans do not come to fruition and do

not achieve the required levels of acute service

reduction

leading to

(i) Increased pressure on acute services

(ii) Negative impact on strategic direction

(iii) Negative impact on financial plan

F&P15 Chief

Operating

Offcer

L3 x I3 = 9 9 9

(i) Alignment of expectations

between Trust and CCG

(i) Ongoing negotiations (Autumn 2018)

L2 x I3 = 6

Strategic Aim 4 - We will support the development of enhanced community based services, prevention and self-care.

(i) Potential to dual run services

(ii) Contractual negotiations

(iii) External advice on contractual changes

(iv) Consideration of changes through ACPs

(v) Gooroo work

(vi) Meetings between DOFs of Trust and CCGs

(i) Active monitoring of position

(ii) Place Plans in place

(iii) Clinical services strategy in place

(iv) Both sides committed to outputs from Gooroo work.

CONTROLS ASSURANCE

(i) Consultant led paediatric assessment unit in place.

(ii) Arrangements for transferring overnight stays to DRI.

(iii) Communication with CCG and HOSC.

(iv) Arrangements with Sheffield Children's Hospital.

(v) Ongoing paediatric nurse recruitment.

(i) Reports on transferrals

(ii) Positive response to recruitment

(iii) Discussions with Notts Health O&S Committee in July 2017

(iv) Report to Board, August 2017 regarding future of overnight paediatric

service

(v) CEO's presentation to Governors, September 2017

(vi) Decision taken by Bassetlaw CCG, October 2017

(i) Measures to ensure ward base matches with cost base

(ii) Contract negotiation

(III) Nursing workforce report

(iv) Agency bank report

(v) Corporate Investment Group processes

(vi) Business change processes for associated service changes

(vii) Contract changes to go to F&P

(i) DBTH input into Place Plan

(ii) Assessment received for MoU


DIRECTION OF


Inability to recruit right staff and have staff with

right skills

leading to

(i) Increase in temporary expenditure

(ii) Inability to meet FYFV and Trust strategy

(iii) Inability to provide viable services

F&P8 Director of

People & OD

L4 x I4 = 16 16 16

(i) Leadership Strategy.

(ii) Radiographers work ongoing.

(iii) Actions identified in startegic milestones.

(i) P&OD structure - review being finalised

(Autumn 2018).

(ii) Recruitment for radiographers in place

(Autumn 2018).

(iii) Q4 2018/19

L2 x I4 = 8

Failure to engage and communicate with staff and

representatives in relation to immediate challenges

and strategic development

leading to

(i) Deterioration in management-staff relationships

(ii) Negative impact on performance

(iii) Negative impact on reputation

Q&E1 Director of

People & OD

L4 x I4 = 16 16 16

(i) Staff survey action plans fully signed up to.

(ii) Relationship with new chair of Partnership

Forum.

(iii)Actions identified in startegic milestones.

(iv) Actions identified in deep dive risk

interrogation, QEC (August 2018)

(i) Divisional action plans to be implemented

and monitored through accountability

meetings.

(ii) Development of staff side relationships

(Autumn 2018).

(iii) Q4 2018-19

(iv) See report to QEC.L2 x I4 = 8

Failure to improve staff morale

leading to

(i) Recruitment and retention issues


(iii) Increased staff sickness levels

Q&E6 Director of

People and

OD

L3 x I4 = 12 12 12

(i) Consistent positive scores for staff Friends

and Family Test.

(ii) Consistent positive scores for staff survey.

(iii) Actions identified in strategic milestones.

(iv) Active monitoring against departmental

action plans.

(i) Additional listening exercises.

(ii) P&OD action plans (Various).

(iii) Q4 2018-19

(iv) BPs to update on progress against each of

action plans.

L2 x I4 = 8

Strategic Aim 5 - As a Teaching Hospital we are committed to continuously developing the skills, innovation and leadership of our staff to provide high quality, efficient and effective care.

CONTROLS ASSURANCE

(i) HR policies and procedures.

(ii) Monitoring of use of agency staff through robust processes to stay within

cap.

(iii) Medical staff recruitment action plans.

(iv) Care Group Business Plans – workforce plans.

(v) E-Rostering processes.

(vi) VCF processes - bolstered.

(vii) Consultant appointment approval processes.

(viii) NHS Professionals processes & management information.

(ix) Pilot of Assistant Practitioner role.

(x) Links with universities, increasing local placements.

(xi) Developing bands 1-4 nursing roles.

(xii) Nurse associate roles - exploration.

(xiii) Increasing the attractiveness of the website, social media and open days.

(i) Monitoring by staff experience group.

(ii) Revised appraisal process.

(iii) Chief Executive's listening exercises and 'you said, we did'.

(iv) Staff involved in strategy engagement.

(v) Management passport qualification developed.

(vi) Localised action plans.

(vii) Staff survey action plan monitored by Board and QEC.

(viii) Revamped staff brief.

(xi) 'Bugbears and bright ideas' approach.

(x) Agreed approach to staffside - management meetings.

(xi) Achievment of teaching hospital status.

(i) Feedback from Friends and Family Q2.

(ii) Feedback from CEO's listening events and lunchtime meetings with

consultants.

(iii) Bugbears and bright ideas outcomes.

(iv) Report to QEC and Board, June 2017, on staff survey action plan.

(v) People and OD Strategy approved by Board in October 2017.

(vi) Improvements in staff survey results.

(vii) Action plans approved by Board (April 2018).

(i) Increased fill-rate, above national averages in most areas.

(ii) Recruitment report to Board, May 2017.

(iii) Regular NHSI reporting which is reported to Exec Team, increased to bank

as well as agency.

(iv) Benchmarking work.

(v) WTP work.

(vi) New style agency report reported monthly to Exec Team.

(vii) Work with ICS Local Workforce Action Board.

(viii) Accountability arrangements embedded.

(ix) Regular reports to F&P.

(x) Review of cohort recruitment.

(xi) Work on apprenticeships.

(x) We care for junior doctors work.

(xi) People & OD Strategy.

(xii) QiMET work.

(i) Process to engage with LNC.

(ii) Process to engage with Partnership Forum.

(iii) HR policies and procedures.

(iv) Staff engagement project strands.

(v) Staff experience group.

(vi) Listening events by CEO.

(vi) E&E Committee communications plan.

(vii) One-page strategy summaries.

(i) Suspensions/exclusions reports to ANCR.

(ii) P&OD reports to Board.

(iii) Briefings regarding staff engagement during restructures.

(iv) Records of ongoing engagement via Partnership Forum.

(v) Staff Survey results.

(vi) Grievance and employment tribunal rates.

(vii) Outcomes of negotiation & work with staff side.

(x) Delivery of engagement plan KPIs.

(xi) Listening events.

(xii) Buzz and social media interaction.

(xi) Meetings with staff regarding Hospital Services Review.

(xii) Staff survey action plans to Board, May 2018.

(xiii) Regular meetings with executive directors.

Title Chair’s and NEDs’ Report


Author Suzy Brain England, Chair


Decision

Assurance

Information x


The report covers the Chair and NEDs’ work in September and October 2018 and includes updates on a number of activities.


N/A


The report relates to all of the strategic objectives.


N/A


That the report be noted.

Chair’s and NEDs’ Report – October 2018

Butterfly Garden opening "Sometimes the smallest things take up the most room in your heart." - A.A Milne This is the quote from the wall in the new Butterfly Garden situated at DRI which it was my honour to open on 11th October. The garden is a special place dedicated to children who sadly left us too soon and was made possible thanks to kind donations from patients, staff and the wider public via the DBTH Charity. The project was the brainchild of DBTH’s Neonatal team, who first came up with the idea back in 1997, originally conceived as a memorial space that would be dedicated to those who have experienced a miscarriage, still birth or neonatal death. The intention was for this to be somewhere that families could reflect and find solace. Over time however, the garden evolved into a more general site, one that is suitable for use by all visitors and local residents. Headway on the project remained dormant for a period of time, until progress was dramatically reignited four years ago, spurred on by encouraging patient feedback and overwhelming staff enthusiasm. In response, staff at the Trust, in partnership with the Grace Project, organised several fundraising events and activities, with the help of bereaved families, in order to pull together money for the garden’s construction and eventual maintenance. Costing £15,000 much of it was raised by local well-wishers, with additional funding provided by DBTH. Governor update It was my pleasure to welcome Linda Espey, Steven Marsh and Sheila Walsh as new governors to the Trust on 2 October. Thank you also to Simon Marsh and the team from Nervecentre for a fascinating presentation on the development of a new Electronic Patient Record system at the Governor Brief. The potential for this to transform patient care and how the Trust does business is significant and we look forward to seeing how it progresses. Finally, congratulations to Peter Abell who, having recently joined the NHS Providers’ Governor Advisory Committee, has been recently confirmed as its chair.

Other meetings in the month On 26 September, I was involved in interviews for the Trust Board Secretary role and am delighted to welcome Gareth Jones who will be starting with us soon. I was also involved in recruitment for consultant dentists and anesthetists at the beginning of October. Richard and I attended the NHS Providers Conference and a summary of key issues is given in his report. I also attended the Trust’s AHP day and Women’s and Children’s Management team meeting and presented this month’s STAR award.

Feedback from the Annual Members’ Meeting Board will be aware that we changed the format of the Annual Members’ Meeting this year which, we hoped, would result in a more inclusive and accessible event for our governors, partners and members. Here are just three reflections I received in my inbox commenting on the event. We have agreed to go back to the Keepmoat Stadium next year. The date for the diary is Wednesday 18 September 2019, 4-7pm. “All I can say is change works. An outstanding meeting. Due in the main to the new format. A brilliant idea of seating everyone around tables and formatting questions together. I always felt these meetings were a bit like us and them. This evening’s arrangement gave everyone the opportunity to have their say but in a well-structured way. I thanked Moira Hardy, she set the ball rolling on our table. It was inclusion at its best and not just with the two ladies signing but by giving everyone the opportunity to speak it was sheer genius. All those who contributed to the organisation of the event as well as those who were in the spotlight need recognising for their enthusiasm, knowledge, awareness and vision. This is part of being outstanding as a Trust, I'm sure your own enthusiasm is contagious. I'm confident you will thank those whose efforts resulted in a very positive evening but I would like to thank you for your positive, determined manner in which you get things done, yet remain thoughtful and appreciative of everyone's commitment.” – A Trust governor “I just want to say that I was at the meeting last night and it was by far the best of the several I have attended. I have been rather overawed at the previous meetings as everyone seemed to know each other and I felt like a spare part but I persisted because I am interested in what the Trust is doing. The venue and the arrangement of the tables together with the fact that we were included in a small discussion was far less intimidating. It resulted in a much wider variety of good questions rather than, as I have felt in the past, a few people raising their particular concerns.” – A Trust member “I thought this year’s AMM was excellent. Well done for spearheading a very smoothly organised and cohesive event… Some great news about the Trust’s performance was shared – with key challenges ahead signaled. Placing executive, NED and governor representatives at each table with other Trust members created a cooperative atmosphere (along with other benefits). Resulting questions were diligently addressed by Richard and Jon. Venue, display stands, and event catering were good. Hazel and Phil did well articulating governors’ duties, work over the past year, and Trust links with partner organisations. Congratulations to all involved in delivery of the AMM this year.” – A Trust governor

Changing Places In late September, it was my pleasure to open our first ‘Changing Places’ facility at Bassetlaw Hospital. Located in the Outpatient Department, ‘Changing Places’ is a facility for anyone with a complex health issue who cannot use a standard disabled toilet as they require extra equipment and space. The room features a height adjustable adult changing bed, an electronic ceiling hoist, height adjustable sink, peninsular toilet, shower, non-slip floor and privacy screen. This facility has been championed by local mum Alison Beevers, whose son, Mylor, now 12, was born prematurely and is quadriplegic and has cerebral palsy. The facility, which will meet the needs of people with profound and multiple learning disabilities, motor neurone disease, multiple sclerosis, cerebral palsy, as well as older people who may need assistance, allowing them to use the toilet facilities safely and comfortably. Over 250,000 people in the UK need Changing Places toilets to enable them to get out and about.

NED reports Alan Chan Alan visited Trust AM studios to meet with the radio members to discuss the challenges of the radio station and to consider if there were ways to improve its reach and exposure to staff and patients at all DBHT hospitals. Alan has also discussed the current hospital open WiFi capability with Simon Marsh and other IT areas which could assist Trust AM. Alan had one-to-one meetings with Suzy Brain-England and Marie Purdue and also attended the Governor's Briefing. Pat Drake Pat attended the AHP Open day and presentations to see for herself the excellent work they are doing. She also accepted a national award on behalf of Dr Subedi. Dr Subedi has been instrumental in starting the Certificate of Eligibility for Specialist Registration (CESR) training in the Emergency Department at DRI. This has attracted good doctors to join the training at all levels, as well as experienced consultants who help run the department across sites. He has further enhanced the profile of the Trust by grabbing the attention of the Royal College of Emergency Medicine. The training programme is already bringing improvements to the Emergency Department and the department, which itself continues to be one of the best performing in the country. Pat also attended a Senior Management meeting in Women and Children’s Division and also the Clinical Governance session led by Mr Singh on moving the organisation to CQC outstanding. Sheena McDonnell Sheena attended the opening of the Butterfly garden. She prepared for the clinical excellence awards, undertook a buddy meeting with Karen, attended the NHS expo that was last month and the dinner for NHS and NE region. Kath Smart Kath has spent some more time with the Clinical Therapies team, visiting with staff and patients in both the Orthotics Service and the Children's Physiotherapy Services. She found it useful to see the hands on care which is provided and understand better the role of AHPs in DBTH. She also visited the Doncaster ED whilst following up on an audit recommendation in relation to safe and secure storage of medicines. Kath also had chance to participate alongside the Director of Finance, Governors, the Chair and CEO in the assessment and interview process for the new Board secretary.

As part of her buddying arrangements Kath was invited to take part in #systemperfect week for Urgent and Emergency Care in Doncaster. This afforded the chance to work with staff from DBTH, the CCG and RDaSH in gaining public views of the urgent and emergency care services, and also observing the in-reach service into ED, CDU and Gresley Suite which had been set up to assess the impact on discharges. Finally Kath attended the ICS Audit Chairs meeting for a discussion and feedback of views into the emerging Governance structure of the ICS.

1

Chief Executive’s Report

23 October 2018

Enhancing Exec Presence at Bassetlaw Since becoming Chief Executive it has been my ambition to emphasise our commitment to our staff and patients at Bassetlaw Hospital. They are a key part of our Trust but I have always felt we could do more to show that ‘we care’. Following discussions with colleagues and the Chair I have agreed that two executive directors should be based at Bassetlaw Hospital from Christmas. As a trust we expect our clinicians to work Trust-wide and it is important that we, as leaders, set the example. I am pleased to advise that the two colleagues that will be based there are Karen Barnard, Director of People and Organisational Development, and Moira Hardy, Director of Nursing, Midwifery and Allied Health Professionals. Work is currently being carried out to enable the necessary support infrastructure such as office space, IT and PA support to be put into place with a view to the new arrangements starting from Christmas. Their new offices will be based on the ground floor near the main entrance reception. The move is not just something that concerns Karen and Moira but will necessitate a different way of working including some more management-level meetings based at Bassetlaw and greater use of Skype for Business technology to allow digital working. One third of NHS trust CEOs have clinical background A recent study led by NHS Providers and the NHS Leadership Academy has found the perhaps surprising statistic that only one third of NHS trust chief executives have a clinical qualification. The report, Clinician to chief executive: Supporting leaders of the future, suggested that attracting more clinical expertise into leadership roles would benefit the NHS as this group has a "deep understanding of what matters most to patients, their loved ones and staff". The report also showed that of the 81 survey respondents, 79% of chief executives with a clinical background were no longer practising because of a lack of time, while 48% retain their registration to practice. Board will be aware that we are fairly unique in having four clinically qualified members in our exec team. We are also keen to demonstrate our commitment to enhance the Board-level experience of our clinicians and have already done so with deputies attending in place of the Medical Director and the exploration of the ‘shadow board’ concept.

2

Pathology gets accredited Earlier in the month, I received notification that Pathology Services at DBTH have now been granted full Accreditation for ISO 15189:2012 – Medical Laboratories from the United Kingdom Accreditation Service (UKAS) This has been a massive undertaking for all Pathology staff to enable us to achieve this. It is important to note that we are one of a few pathology services that decided to transition from CPA accreditation straight to UKAS ISO 15189:2012 as a whole Pathology Service and not as individual departments. This shows the good team ethos we have within our service. I would personally like to thank everyone for their hard work in attaining this accreditation. Brexit Follow-up Following on from my report last month, I received another letter from Secretary of State, Matt Hancock MP, along with a pack of materials, setting out what the Trust needed to do to step up preparations to ensure continuity of supply of goods and services in the event of a ‘no deal’ exit from the EU. The letter requests that individual trusts complete a self-assessment methodology for NHS trusts to use to identify contracts that may be impacted by the EU exit. We have been requested that this work be overseen by a senior officer with direct line of sight to the Board. New process for maternity investigations The Healthcare Safety Investigation Branch (HSIB) began operating on 1 April 2017 and is a team of experienced safety investigators, led by the chief investigator Keith Conradi. They conduct investigations into incidents and accidents that take place within NHS funded care in England. In November 2017 the Secretary of State for Health announced a new maternity safety strategy and directed HSIB to conduct 1000 independent safety investigations. As part of the roll out plan for Maternity Investigations HSIB will be going live with DBTH on the 3rd December 2018.

3

ICS launches The 1st October was an important day in South Yorkshire and Bassetlaw as the Integrated Care System went live. Alongside this change, local NHS leaders have emphasised their commitment to wanting to work more closely with local councils and the voluntary sector to improve the health and wellbeing of residents across the region and build on the work that is already taking place at a local level. This will be done on the basis of integrated care partnerships, under an umbrella of an ‘Integrated Care System’ (ICS) – one of only a handful across the country. Most of the partnership work between the NHS, councils and the voluntary sector will take place at a local level in each of the five Places covered by the arrangements: Barnsley, Bassetlaw, Doncaster, Rotherham and Sheffield. The ICS has been allocated around £25m of new funding in 2018/19 to invest in improving key services and is already establishing two new forums to work across South Yorkshire and Bassetlaw – a ‘Health and Care Institute’ linked with universities, colleges and schools to develop and support the workforce and an ‘Innovation Hub’ for researching new developments and technologies. The latest ICS first wave performance statistics (see appendix at end of report) show SYB to be performing well. DBTH goes ‘System Perfect’ During October, DBTH went ‘System Perfect’. This is a week-long exercise which looks at how health and social care pathways function when all hands are on deck and everything is working exactly as it should. A project which happens several times a year, the focus this time was emergency and urgent care and looking at how we can get patients home as safely and soon as possible. Throughout the summer months, DBTH saw a significant rise in Emergency Department attendances, due to a range of factors, however this was particularly prevalent amongst people aged 18 to 35, often termed as ‘millennials’. Throughout next week the System Perfect team will be seeking to better understand the usage of the service, as well as where care and treatment can be improved for patients.

4

Procurement Team is simply the best I was pleased to receive news this month that DBTH’s Procurement Team are the best in the South Yorkshire and Bassetlaw Integrated Care System as shown in the most recent ‘procurement league table’. Well done to Richard Somerset and the Team. Secretary of State announces crackdown on agency I, along with the Chair, attended the NHS Providers Conference in early October. It was a good opportunity to network with chief executive colleagues and also to hear from the Secretary of State, Matt Hancock MP. Continuing his interest in the benefits of digital technology, the Secretary of State appeared to Conference by video link. The key message was that continued use of agency staff was not cost effective and contributed to the reduction in the satisfaction of substantive staff. He urged the provider sector to do much more to reduce the reliance on temporary staff. New partnership with Hall Cross Academy the first of its kind Doncaster and Bassetlaw Teaching Hospitals (DBTH) has entered into a formal partnership with Hall Cross Academy in October 2018, making the latter a ‘Foundation School in Health’. The first agreement of its kind in the country, the partnership will see the local NHS provider and school working closely together, further developing opportunities for pupils wishing to pursue a career in health. With increasingly complex patient-need and an ever-expanding population, it is anticipated that the NHS will face further workforce demands in the near future. In order to address this challenge locally, DBTH and Hall Cross Academy are looking at innovative ways in which to support students as they look towards job prospects past the age of 16. By becoming a Foundation School in Health, it means the central Doncaster school will benefit from increased involvement from health professionals. This will include work experience and internships, further advice and information from experienced medics and clinicians, as well as the appointment of ‘Careers Champions’ within the local hospitals.

Minutes of the meeting of the Charitable Funds Committee

Held on Tuesday 31 July 2018

In the Boardroom, Doncaster Royal Infirmary

Present: Kath Smart

Suzy Brain England OBE Non-executive Director (Chair) Chair of the Board

Alan Chan Pat Drake Moira Hardy Richard Parker Linn Phipps Neil Rhodes Jon Sargeant

Non-executive Director Non-executive Director Director of Nursing, Quality and Allied Health Professionals Chief Executive Non-executive Director Non-executive Director Director of Finance

In attendance: Matthew Kane

Peter Brindley Phil Beavers Adam Tingle Michael Green Charlie Forshaw Matthew Bancroft Andy Thomas

Trust Board Secretary Executor of Fred and Ann Green Estate Public Governor Acting Head of Communications and Engagement EY (part) EY (part) Head of Financial Accounts Project Officer

ACTION Welcome and apologies for absence

18/7/1 The Chair welcomed EY to the meeting. Apologies for absence were presented on behalf of Sheena McDonnell and Sewa Singh.

Minutes of the meeting held on 22 May 2018

18/7/2 The minutes of the meeting of the Committee held on 22 May 2018 were APPROVED as a correct record, subject to the inclusion of an additional sentence at the end of 18/5/7: “Linn Phipps requested that within the new investment plan a key performance indicator be developed which set an objective for how fast the fund was to be spent which aligned with the Trust’s strategic objectives.” Action notes

18/7/3 The action notes were updated.

18/7/4 18/5/15 – The Trust’s Director of Finance and Director of Nursing, Quality and Allied Health Professionals were due to meet on 3 September to discuss the terms of reference for a new group for considering bids for smaller items of medical equipment and ensuring there was a clear and

MK

documented process in place for staff applying funds to follow. Those would come back to this Committee for approval. Annual Report & Accounts 2016/17

18/7/5 The Committee considered an update from the Director of Finance which presented the 2016/17 charitable funds annual report and accounts for approval, together with the ISA 260 and letter of representation.

18/7/6 The Committee were advised that the accounts were being presented late, due to a combination of factors including staff turnover, loss of corporate memory and utilisation of an outdated ledger system. The audit had been a challenging one for both the auditors and the Trust.

18/7/7 A draft version of the accounts had been to the Committee in May which showed that income was £0.58m in 2016/17, down £0.2m. Expenditure was approximately £2.39m but investment gains had increased by £1.4m. The Fund now stood at £9.324m, down £0.67m in the year.

18/7/8 In addition, there were two prior period adjustments which had been corrected. The audit uncovered a number of control weaknesses relating to receipting and income but EY acknowledged the work that had happened since January 2017 and the implementation of a new financial ledger. An unqualified opinion had been given on the statements.

18/7/9 The Chair acknowledged the work put in place to establish a better system of controls including delegated limits, additional staffing resource and the new financial system. The 2017/18 accounts would come to the Committee in September.

JS

18/7/10 The 2016/17 charitable funds annual report and accounts were APPROVED for submission. EY representatives left the meeting at this point.

Tendering of Investment Advisor

18/7/11 The Committee considered a report of the Director of Finance which gave an update on the tender process for the Charity’s investment advisor.

18/7/12 It was explained that while the current fund manager, INVESTEC, remained under contract and there was no identified risk with their continuing engagement it was accepted that this service had not been tendered for several years. Therefore, trust management had commenced a procurement process to retender the service.

18/7/13 Details of the proposed process and evaluation panel was set out in the report. The Trust was also seeking some external support for the process. The tender had closed on 27 July and yielded seven bidders.

18/7/14 Neil Rhodes expressed a wish for clear expectations to be set in respect of

reporting to the Committee. It was important the investment advisors understood that the Committee was responsible for the fund but were non-financial managers and therefore it was necessary to achieve a balance between reporting financial information and giving a suitable commentary. This information should also be sent out with the papers rather than tabled at Committee.

JS/MK

18/7/15 The update was NOTED. Fund Balances

18/7/16 The Committee considered a report of the Director of Finance which presented an update on the Charity’s fund balances.

18/7/17 The current fund balance was £8,954,766. The Committee was advised that given the number of individual funds within Charitable Funds, as well as the size and activity within them, a review was performed to ensure that the donated funds were able to be utilised fully, as well as being managed in an efficient way. In line with Charity Commission guidance and previous discussions, funds which were small and not deemed to be active (no activity since March 2017) were closed. The remaining monies in those funds had been transferred into a General Fund. In total, 62 funds with available funds of £166k had been closed as a result of this process.

18/7/18 All fund-holders had been advised that if the fund had not had either a donation or expenditure within the last six months, and they still wished to keep the fund, they would need to forward a plan to the Charitable Funds team, outlining how the fund would be utilised going forward, by 24 August. Any funds which had not had either a donation or expenditure in the last 6 months, and did not have a plan may be transferred into the General Fund.

18/7/19 Within the fund balances at 31 March 2018, there were a number of funds which were either overdrawn, or lacked the necessary detail to be appropriately used to improve the patient experience. As such, it was proposed that these funds would also be merged into a General Fund. In total, there were such 11 funds. The Committee noted that it was against Charity Commission guidance to have overdrawn funds and given the rationalisation of funds as detailed previously, it was felt to be an opportune time to further rationalise. It was also discussed that when expenditure was authorised within the delegated limits and reported via this report that a short narrative should be included to enable the Committee oversight of the purpose and impact of the expenditure, and to decide whether the Committee wished to use as a case study for a future meeting.

JS

18/7/20 The Committee APPROVED that:

(1) A letter to be sent to all remaining fund holders asking them to

provide plans if their fund was not active.

(2) Transfer funds which were overdrawn or lacked sufficient detail into a General Fund.

(3) The Charitable Funds Committee be the only body to authorise new funds to be set up, going forward.

Fundraising Update

18/7/21 The Committee considered a report of the Acting Head of Communications which set out progress against the Trust’s fundraising strategy.

18/7/22 Efforts had already raised £11k against a target of £75k. This included the sale of 400 copies of the Good Health books and an additional £2k raised through the national citizenship service.

18/7/23 There was a brief discussion around the need for ideas for large capital projects and the need to be clear with staff what activities contributed to the DBTH Charity.

18/7/24 It was agreed for the action plan to come back to the September meeting.

AT

18/7/25 The update was NOTED. Any other business

18/7/26 There was no other business to consider at this meeting.

Date and time of next meeting

18/7/27 The next meeting of the Committee would take place on 25 September 2018 at Doncaster Royal Infirmary at 4pm and this would include an update on progress with the Maternity Garden.

MK

Kath Smart Date Chair of the Committee

1

Minutes of the Meeting of the Management Board

of Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust

on Monday 17 September 2018 at 2:00pm

in the Boardroom, DRI

Present: David Purdue (Chair) Deputy Chief Executive & Chief Operating Officer Karen Barnard Director of People & Organisational Development Antonia Durham Hall Divisional Director – Surgery & Cancer Moira Hardy Director of Nursing, Midwifery and Allied Health Professionals Nick Mallaband Divisional Director – Medicine Sewa Singh Medical Director Jon Sargeant Director of Finance In attendance: Matthew Kane Trust Board Secretary Tim Noble Deputy Medical Director Ken Anderson Head of IT Programmes and Development (for Simon Marsh) Lauren Ackroyd General Manager Children and Families (for Eki Emovon) Kirsty Edmondson-Jones Director of Estates & Facilities Apologies: Richard Parker Chief Executive Eki Emovon Divisional Director - Children and Families Jochen Seidel Divisional Director – Clinical Specialities Simon Marsh Chief Information Officer Marie Purdue Director of Strategy & Improvement Action

Apologies

MB/18/9/1 Apologies as recorded above were noted.

Minutes of last meeting

MB/18/9/2 The minutes of Management Board meeting held on 13 August 2018 were approved as an accurate record subject to the correction of the job titles for the Divisional Directors.

Matters arising and action notes

MB/18/9/3 The action log was reviewed and updated.

2

MB/2/18/28 – Vacancy Control Process – Since the last meeting Internal Audit (IS) had undertaken a review of vacancy control and Grip & Control (G&C) processes; vacancy control processes had been found to be robust. The Director of Finance provided details of the report; it was noted that there had been some recommendations and these had been incorporated in to action plans. Nick Mallaband had met with colleagues to discuss a process for tracking all VCFs for his Division as this had proved difficult in the past; A system was needed so Divisions could find out whether VCFs were in place and track when VCFs were due to expire and this was discussed. The Director of Finance would look in to what information was currently held and whether this could be addressed. MB/18/4/36 - Study Leave allowance for Advanced Clinical Practitioners (ACPs) – There had been discussions at the Workforce & Education Committee (WEC) about funding for ACPs. Further work was needed to understand the position. During the meeting the Director of P&OD received confirmation that a pot of money had been identified and secured for ACP Continued Personal Development (CPD); it was noted that this would be managed by the ACP group.

JS

Enabling Strategy Update Presentation on the Finance & Commercial

Strategy

MB/18/9/4 Management Board received a presentation from the Director of Finance in relation to the Finance & Commercial Strategy.

MB/18/9/5 A key element of the Strategy related to the proposed creation of a Wholly Owned Subsidiary (WOS) and work relating to this area. A detailed timeline of progress to date was provided; work was progressing on the business case and was close to completion but there was still work to do.

MB/18/9/6 The Director of Finance provided background information and the reasons for considering creating a WOS. He explained which services may be included in the WOS along with details of what a governance structure may look like alongside of responsibilities a WOS usually assumes. The corporate structure and membership of the WOS Board had been discussed. It would likely comprise of a Managing Director, Director of Operations, Finance/Commercial Director, Chair (NED Role) and additional NED. One of the Trust’s NEDs would usually also serve as a NED for the WOS. It was noted that the Trust would, as the 100% shareholder, retain some key powers by way of a “retention of powers” agreement. A list of retention of powers had been developed and were summarised.

3

MB/18/9/7 In terms of the HR work stream it had been suggested that the appropriate model for a WOS would be dynamic TUPE arrangements whereby staff transferring into the WOS would retain Agenda for Change (A4C) terms and conditions (T&Cs) for as long as they worked for the WOS, including if they changed roles within the WOS. There was more work to do to look at pension arrangements and on a consultation process.

MB/18/9/8 Details of the set up costs and expected running costs for the WOS were discussed; these would include staff for a WOS Board, insurance costs, financial ledger and HR support and audit costs.

MB/18/9/9 Management Board considered the presentation in detail and there was a wide ranging discussion about the impact on staff, plans for clinical engagement, how Divisional Directors (DDs) would come to know about decisions, how a WOS Board would be appointed and paid; DDs felt it was important to ensure that any appointment process for a WOS Board was transparent. It was also important to ensure pay transparency for any Board members who sat on both the Trust and WOS Boards.

MB/18/9/10 Whilst recognising that a WOS arrangement had worked well at other Trusts, Antonia Durham-Hall raised concern about the impact on clinical engagement with some aspects of the WOS services in particular in terms of procurement arrangements and this was discussed.

MB/18/9/11 DDs welcomed assurance that the Board would want to ensure that any decision would be based upon staff maintaining their A4C T&Cs for as long as they worked for the WOS. There was discussion about how staff felt about the proposals; it was noted that communications with staff were increasing and CEO listening events were due to commence shortly.

MB/18/9/12 Broadly there was support from DDs for exploring the benefits of a WOS but concern was expressed about the potential future impact on existing staff in respect of matters not yet resolved, for example staff pensions arrangements.

MB/18/9/13 The Finance & Commercial Strategy update was DISCUSSED and NOTED.

MB/18/9/14 Post meeting note - Later in September 2018 it was announced that NHSI had asked Trusts to pause work on the creation of new subsidiaries. The Trust therefore suspended further engagement on the matter until further information was known.

Enabling Strategy Update Presentation on the People & OD Strategy

MB/18/9/15 Management Board received a presentation from the Director of People and

4

Organisational Development in relation to People & OD Strategy.

MB/18/9/16 The meeting was provided with an overview of the strategy which was to, amongst other things, foster and encourage better staff engagement with a Qi approach, deliver great management and leadership, support personal development and training, promote a healthy and safe work environment and enhanced workforce planning focusing upon efficiency and effectiveness. It was noted that an audit review of the strategy had provided significant assurance in terms of alignment with the Strategic Direction.

MB/18/9/17 Details of key milestones, challenges, interdependencies and opportunities were provided. Key challenges included engagement of key leaders in the provision of workforce plans and information, workforce planning/spread of Calderdale framework usage, education commissioning and apprenticeship opportunities and engaging with managers in terms of challenges in spending the levy.

The update was NOTED.

Finance Report

MB/18/9/18 Management Board considered a report of the Director of Finance that set out the Trust’s financial position at month 4 (July 2018), which was a deficit of £1.24m, adverse to plan in month by £94k. The cumulative position to the end of month 4 was a £7.4m deficit, which was £64k adverse to plan.

MB/18/9/19 The Director of Finance provided an update on the Month 5 (August 2018) position which was in the process of being finalised; there was more work to do on this, including the impact of the recent national agenda for change pay award.

MB/18/9/20 Key risks against delivery of the financial plan were set out in the report. It was noted that the Trust needed to achieve a £6.6m deficit to deliver the year-end control total and therefore needed to achieve a better than break even position for the rest of the year. There was significant work to do not least in terms of Delivery of CIP which had been back loaded in the plan and significant savings were still required to be identified and delivered. Whilst work continued the gap in the plan was not being closed quickly enough and Divisional Directors may be asked to find further savings. Also the CCGs were struggling to meet financial plans which could make achieving some of the CIPs more difficult (e.g. block contracts) and the Director of Finance gave details of this.

MB/18/9/21 A key risk to the delivery of the Trust’s financial control total was the significant variance on income growth assumptions of £3.5m between the Trust’s financial plan and commissioner assumptions and contract values.

5

Levels of over performance and the further modelling of RTT suggested that with the main commissioners the budget assumptions were fairly robust. Also the financial plan assumed £2m of Commissioner QIPP plans were not delivered. It was too early in the year to determine the impact of this, however the continued under performance was of concern. The Director of Finance provided further details of block contract issues and work on capacity and demand plans. It was key that the Trust only did work it was going to be paid for. The Chief Operating Officer and Deputy Chief Executive provided details of the CCGs position in terms of waiting list sizes, RTT and increased referrals.

The Finance Report was NOTED.

Corporate Risk Register

MB/18/9/22 Management Board considered a report of the Trust Board Secretary which set out the latest corporate risk register for consideration.

MB/18/9/23 There had been no risks escalated through Datix in the previous month. Updates were given on two risks previously escalated to Management Board. Following executive review, the risk relating to ‘Failure to achieve income targets arising from issues with activity’ had been de-escalated from 15 to 10. In addition, four BAF risks had seen changes to their ratings in the quarter; these were set out on page one of the covering report.

MB/18/9/24 Further to discussion at the Quality and Effectiveness Committee, the BAF had been revised to include a ‘direction of travel’ column which related to the likely direction of each risk in the following quarter, based on information held at the time. An upward arrow denoted a likely increase in risk rating. Two ratings are upward rated and details were set out in the report.

MB/18/9/25 In response to a query from the Director of Finance it was clarified that timeframes for review were included in the risk registers; the frequency of review depended on the level of risk.

The Corporate Risk Register was NOTED.

DBTH Winter Plan 2018/19 and Escalation Plan & Emergency Care Standards

MB/18/9/26 Management Board received the updated Emergency Department Escalation Plan which incorporated the Emergency Department (ED) escalation status setting, ED trigger points for both sites and associated action plan. The plan had been considered by Management Board previously and comments had now been incorporated.

6

MB/18/9/27 The Chief Operating Officer and Deputy Chief provided an update on the

outcome of a North of England meeting to consider 4hr Access, share learning from the previous winter and set out national expectations for winter 2018/19. The expectation was that all Trusts would achieve 95% by Q4 2018/19. Essentially the winter plan for the Trust would be similar to the previous year. The report covered the following key areas:

Learning from 2017/18 – National Perspective

Workforce

Bed Management

Flow

#System Perfect

Escalation – Including the new ED Escalation Policy

Challenges

MB/18/9/28 In terms of implementing the ED Escalation Policy it was important to agree on ‘rules of engagement’ in terms of how Divisions and directorates interacted with one another; historically there had sometimes been differences of opinion between the ED and other departments, and between departments, about patient referrals from ED due to, amongst other things, different opinions about what was best for the patient. In order to improve patient flow out of ED, and in the spirit of ‘Getting it Right First Time’, it was important that the most commonly disputed referrals were resolved and this was discussed. Management Board considered how best to ensure consistency in terms of referrals; it was suggested that the general surgical referrals pathways were laminated and placed in plain sight on the walls above/near telephones. These would be shared for electronic publication/printing.

DP/NM

MB/18/9/29 There was a brief discussion about flu point of care testing, this had worked well last winter but there had been some issues in terms of where and how to re-order the consumables; this was discussed and it was clarified that these needed to be ordered via pharmacy. It was noted that insufficient vaccine had been ordered to achieve vaccination of 100% of frontline staff as it had not previously been planned to achieve this; this was discussed and it was agreed that a further order would be placed.

MB/18/9/30 The DBTH Winter Plan 2018/19 and Escalation Plan & Emergency Care Standards were DISCUSSED and NOTED.

Information Items to note

MB/18/9/31 The Chief Executive’s Report, Business Intelligence Report and minutes from Corporate Investment Group on 30 July 2018 and the Business Resilience Steering Group (BRSG) on 19 July 2018 were all NOTED.

7

Any Other Business

MB/18/9/32 There was a brief discussion about issues with remote access to the Trust’s information systems from outreach clinics in the community. Antonia Durham-Hall reported that this had been ongoing for almost 2 years, some consultants had now said that if the issues couldn’t be resolved by the end of the year they would be unable to continue to run their clinics. Details of the concerns raised would be forwarded to Ken Anderson and the matter would be picked up outside of the meeting.

ADH/KA

MB/18/9/33 It was clarified that the new divisional structures were now reflected on Oracle.

MB/18/9/34 It was noted that the Trust was required to develop a Brexit Plan which was to cover nine work-streams. The Chair provided an overview of work to be undertaken.

Items for escalation from sub-committees

MB/18/9/35 None.


MB/18/9/36 The next meeting of Management Board would take place 15 October 2018 at 2pm in the Boardroom.

1

As at 17 October 2018

Board of Directors Agenda Calendar

STANDING ITEMS OTHER / AD HOC ITEMS

MONTHLY QUARTERLY BIANNUAL / ANNUAL

OCTOBER 2018

CE Report ANCR minutes Charitable Funds minutes

Performance Report Executive Team’s Objectives

MB Minutes

Finance & Performance Minutes

Finance Report

Chairs’ Assurance Logs

NOVEMBER 2018

CE Report QEC minutes

Performance Report Board Assurance Framework & corporate risk register Q2

MB Minutes Estates Quarterly Performance


Finance Report


DECEMBER 2018

CE Report Report from the Chair of the ANCR committee (Verbal)

Performance Report

MB Minutes


Finance Report


2


FEBRUARY 2019

CE Report QEC Minutes Budget Setting / Business Planning / Annual Plan

Finance Strategy

Performance Report Board Assurance Framework & corporate risk register Q3

MB Minutes

HWB Decision Summary


Finance Report


MARCH 2019

CE Report Budget Setting / Business Planning / Draft Annual Plan

Performance Report

MB Minutes

HWB Decision Summary


Finance Report


JANUARY 2019

CE Report ANCR minutes (16.12.16) Budget Setting / Business Planning / Annual Plan

Constitution

Performance Report Executive Team’s Objectives SOs, SFI, Scheme of Delegation CT/HASU (part 2)

MB Minutes Complaints, Compliments, Concerns and Comments Report

Joint working


External reviews policy

Finance Report


3


APRIL 2019

CE Report ANCR minutes Draft Annual Report Mandatory training update

Performance Report Executive Team’s Objectives Draft Quality Account

MB Minutes Estates Annual Report Staff Survey

HWB Decision Summary Board Assurance Framework & corporate risk register Q4 (inc. annual assurance summary)


Finance Report


MAY 2019

CE Report QEC Minutes Annual Report

Performance Report Quality Account

MB Minutes Annual accounts

HWB Decision Summary ISA260 and quality account assurance


Charitable Funds minutes

Finance Report Mixed Sex Accommodation


JUNE 2019

CE Report

Performance Report

MB Minutes


Finance Report


4


JULY 2019

CE Report ANCR Minutes ANCR Annual Report

Performance Report Estates Quarterly Performance

MB Minutes Board Assurance Framework


Finance Report


AUGUST 2019

CE Report QEC minutes Health and Wellbeing

Performance Report ANCR Minutes Missed Appointments

MB Minutes Executive Team Objectives


Finance Report


SEPTEMBER 2019

CE Report Winter Plan

Performance Report EPPR

MB Minutes Annual Compliance against the National Core Standards for Emergency Preparedness, Resilience and Response (EPRR)


Finance Report


1

Minutes of the meeting of the Board of Directors

Held on Tuesday 25 September 2018

In the Boardroom, Doncaster Royal Infirmary

Present: Suzy Brain England OBE Chair of the Board Karen Barnard

Alan Chan Pat Drake

Director of People and Organisational Development Non-executive Director Non-executive Director

Moira Hardy Sheena McDonnell

Director of Nursing, Midwifery and Allied Health Professionals Non-executive Director

Richard Parker Chief Executive Linn Phipps Non-executive Director David Purdue Chief Operating Officer Jon Sargeant Director of Finance Kath Smart Non-executive Director In attendance: Dr Tim Noble

Adam Tingle Deputy Medical Director (for Sewa Singh) Acting Head of Communications and Engagement

Matthew Kane Trust Board Secretary George Webb

Peter Abell Mike Addenbrooke Lynne Logan David Cuckson Cindy Storer Vicky Barradell Michelle Thorpe Esther Lockwood Beth Cotton Jane Curtis & Darcie the Cat

Governor Governor Governor Governor Governor Deputy Director of Quality and Governance (part) Consultant Geriatrician and Trust Falls Lead (part) Matron (part) Advanced Nurse Practitioner, Care of the Elderly (part) Advanced Nurse Practitioner, Care of the Elderly (part) Pets as Therapy (part)

ACTION

Welcome and apologies for absence

18/9/1 Apologies for absence were presented on behalf of Neil Rhodes and Sewa Singh. Marie Purdue, Director of Strategy and Transformation, had also given apologies due to being on other Trust business.

Declarations of Interest

18/9/2 No interests were declared in the business of the public session of the meeting.

Actions from the previous minutes

18/9/3 The list of actions from previous meetings was noted and updated:

2

18/08/27 – The Freedom to Speak Up email address was in place and had been publicised.

The board development work with Karl George, of The Governance Forum, was to be considered at a future Board meeting.

KB/MK

Presentation slot – Person Centred Care

18/9/4 The Board considered a presentation from Cindy Storer, Deputy Director of Quality and Governance, and colleagues on the work the Trust was doing around person centred care.

18/9/5 The presentation focussed around the issue that hospitals focussed on treating a person’s medical condition rather than seeing them in a holistic way. Patient centred care attempted to tackle this and generally led to better patient outcomes.

18/9/6 Person centred care comprised a range of different initiatives including My name is …, PJ Paralysis, Achieving Reliable Care and John’s Campaign. The team had also recognised that hospital was a difficult environment and patients needed stimulation to reduce delirium, loss of cognitive ability and likelihood of depression. The use of home comforts such as social dining and pets as therapy helped.

18/9/7 Next steps included the following:

Expert care of complexity

Recognition of frailty

Change of culture and expectations

Collaboration across health and social care

Promoting skills in early discharge planning

Enhanced Care implementation

Making mealtimes matter

Review of visiting times

Advance Care Planning

Patient Centred Care days

18/9/8 In response to a question regarding the hygiene implications of having a cat on a ward, Board was assured that Darcie only appeared on some wards such as Care of the Elderly and then only stayed for an hour at a time. Patients had an opportunity to make it clear if they had pet related allergies.

18/9/9 In response to a question from Pat Drake, the Board were advised that the Team did see some older people with learning disabilities although the numbers were not significant. In response to a question from Linn Phipps, Board were advised that outcomes were measured through decreases in falls, waits and costs. Further work would take place on more person centred outcomes.

3

18/9/10 The Chief Executive commended the work and cited the establishment of the Falls Team as an example of how the Trust prioritised person centred care. This had been possible through the use of Fred and Ann Green Legacy funding and had contributed to a number of benefits.

18/9/11 The Chair referred to a recent meeting she had held with the Chair of DN Colleges which had highlighted some areas of joint working around the Hospital Radio which could be expanded to include interviews with some of the patients. The Deputy Director of Quality and Governance would make contact with the College through the Trust’s partner governor.

18/9/12 The Board NOTED the update.

Research and Development Strategy

18/9/13 The Board considered a report of the Director of Nursing, Midwifery and Allied Health Professionals that sought approval of the revised Research and Development Strategy for the Trust.

18/9/14 In response to a question from the Director of Finance, Board was advised that an income target would be set out in the action plan. Furthermore, the Board were advised that there was the potential for Research and Development to do more work with a neighbouring trust around establishing a joint facility that would also fit with the Council’s aim of making Doncaster a university town.

18/9/15 In response to a question from Kath Smart around the Trust’s development of an electronic patient record (EPR) system, the Board was advised that capital remained a challenge in view of the Trust’s other challenges such as backlog maintenance. One option for progressing the EPR would be through charitable funds. Funding required would be likely to be around £1.5m but the benefits would be substantial in terms of escalation, handling sepsis and electronic notes.

18/9/16 The Board APPROVED the Research and Development Strategy.

Annual Statement of Compliance against the NHS Core Standards for Emergency Preparedness, Resilience and Response (2018-19)

18/9/17 The Board considered a report of the Accountable Emergency Officer that provided assurance in respect of the Trust’s performance against the NHS Core Standards for Emergency Preparedness, Resilience and Response.

18/9/18 The Trust was a Category One Responder under the Civil Contingencies Act 2004 (CCA), which meant it has a key role in preparing for and responding to a range of emergency situations and significant service disruptions. Each year the Accountable Emergency Officer was required to declare, on

4

behalf of the Trust, the overall level of compliance against NHS England’s Evaluation and Testing Conclusion.

18/9/19 For 2018-19, the Trust declared substantial compliance against the Core Standards, being fully compliant in 59 of the 64 standards and partially compliant in the other four.

18/9/20 The Board:

(1) NOTED the self-assessment process undertaken for 2018-19.

(2) APPROVED the statement of compliance at Appendix A of he report for submission to NHS England (Yorkshire and the Humber).

(3) APPROVED the Improvement Plan at Appendix B for submission to

NHS England (Yorkshire and the Humber).

Freedom to Speak Up Self-assessment and Action Plan

18/9/21 The Board considered a report of the Director of People and Organisational Development that sought approval of the Trust’s self-assessment against the Freedom to Speak Up Guardian process.

18/9/22 The report reported the Trust’s current level of compliance against the Freedom to Speak Up requirements and identified several actions:

The development of a refreshed strategy for Freedom to Speak Up to include the introduction of divisional FTSU champions to support the Guardians

The extension of Freedom to Speak Up to the role of the Trust’s Diversity & Inclusion group to ensure that any barriers were removed for those in more vulnerable groups

A refreshed communications plan to ensure staff were familiar with how to raise concerns on an ongoing basis

Refresh of the leadership development programme to ensure that all managers and leaders across the Trust were aware

18/9/23 Noting the requirement to develop a Freedom to Speak Up Guardian Strategy, the Board felt that this would be best developed through a Board workshop.

KB/MK

18/9/24 Commenting on the self-assessment, Linn Phipps felt more information around the benefits to patient care needed to be included. Capacity and resource was also discussed.

18/9/25 In response to a question from Sheena McDonnell around how assured

5

the Board were that the actions identified would be delivered, the Board were advised that there was an ongoing plan to deliver actions. Likewise, Kath Smart emphasised the need to evidence and evaluate positive work.

18/9/26 In response to questions from the Chair, the Board was advised that requests for anonymity made it more difficult to feedback on cases so was not directly encouraged.

18/9/27 Although the Trust had also used governors as Freedom to Speak Up Guardians, they would not be involved in investigating cases and for the most part acted as ambassadors for the role.

18/9/28 Board ENDORSED the self-assessment and action plan. Winter Planning

18/9/29 The Board considered a report of the Deputy Chief Executive and Chief Operating Officer which identified the key areas which needed to be put in place to improve patient outcomes and experience during Winter.

18/9/30 Despite much public and media attention on last year, Winter 2017 was in fact the best performing winter for the Trust in four years mainly due to issues around patient flow and the absence of Norovirus. Bed provisions for this year were outlined to the Board along with details of the electronic bed management system being put in place.

18/9/31 An update was given on the proposals to improve stranded and super stranded patients in order to improve bed provision over Winter. The Trust was currently the fifth best performing trust in the country in this particular area of work.

18/9/32 Workforce remained an issue although the improved support from Rapid Response would be provided from Notts Healthcare. New requirements meant 100% of frontline staff would be required to be vaccinated against the flu and would be required to account for not having it if they refused.

18/9/33 In response to a question from the Chair around staffing, the Board were advised that in the first instance the Trust could pull on staff from Outpatients, Education and Theatres prior to use of bank and agency.

18/9/34 Issues continued in relation to appropriate financial support. It was anticipated that there may be funding for Winter pressures but this would most likely have targets attached. Last year the Trust secured £1.4m through achieving four hour target.

18/9/35 Linn Phipps was keen to ensure the Trust captured its learning from the previous Winter and what the key success measures would be for this Winter including whether or not staff and patient experience was captured.

6

18/9/36 Board was reminded that the vaccination campaign would commence in

the following week with key messages being put out through staff communication channels.

18/9/37 The Board was ASSURED by the actions identified to improve patient outcomes and NOTED the report.

Chairs Assurance Logs for Board Committees held 20 September 2018

18/9/38 The Board considered a report of the chairs of Finance and Performance Committee and Audit and Non-Clinical Risk Committee following their meetings on 22 September 2018. In Neil Rhodes’ absence, Pat Drake presented the report from Finance and Performance Committee.

18/9/39 The Finance and Performance Committee had considered medical agency and current financial challenges. Audit and Non-clinical Risk Committee explored recent internal audits including one concerning current Grip and Control processes, progress against the recommendation tracker and health and safety assurance.

18/9/40 In response to a question from the Chair, Kath Smart and Sheena McDonnell gave assurance that recommendation owners were owning audit actions and setting more measurable targets although there remained challenges around obtaining evidence of completion.

18/9/41 Board NOTED the updates.

Finance Report – August 2018

18/9/42 The Board considered a report of the Director of Finance that set out the Trust’s financial position at month 5, which was a £3.4m deficit, an adverse variance against plan in month of £1,008k.

18/9/43 The cumulative position to the end of month 5 is a £10.9m deficit, which was £1.1m adverse to plan. However the Trust needed to achieve a £6.6m deficit to deliver the year-end control total, and therefore needed to essentially achieve a better than break-even position for the rest of the year.

18/9/44 The Board was advised that August was traditionally a challenging month with this year also having pay implications with the full extent of the pay award being implemented. Agency spend dipped by £30k but still posed a number of challenges.

18/9/45 Cost improvement was £418k behind in the month, there was still an unidentified gap of £2m and delivery of some of the Trust’s big schemes were not within the Trust’s control. Cash finished at £1.4m.

7

18/9/46 In response to a question from Linn Phipps, the Director of Finance reported that achievement of the control total would be a significant challenge although there were issues that could turn that round in a positive way.

18/9/47 Following the resignation of the Director of Efficiency, the Board were

apprised as to the monthly cost improvement programme process. There was also an open discussion about medical grip and control and some of the reasons for the recent underperformance which was to do with the transition to four care groups.

18/9/48 The Board NOTED:

(1) The Trust’s deficit for month 5 (August 2018) was £3.4m, which was an adverse variance against plan in month of £1,008k. The cumulative position to the end of month 5 was a £10.9m deficit, which was £1.1m adverse to plan.

(2) The progress in closing the gap on the Cost Improvement Programme.

(3) The risks set out in the paper.

Performance Report as at 30 August 2018

18/9/49 The Board considered a report of the Chief Operating Officer, Medical Director, Director of Nursing, Midwifery and Allied Health Professionals and Director of People and Organisational Development that set out operational and workforce performance in month 5, 2017/18.

18/9/50 Performance against key metrics included:

Four hour access – the Trust achieved 92.6% against the national

standard of 95%

RTT – The Trust performed slightly below contract target, reaching

88.5%

Cancer targets – The 62 day performance achieved the 85%

standard, coming in at 86%.

HSMR – The Trust's rolling 12 month HSMR remained better than

expected at 90.5.

C.Diff – One case was recorded in month and below (better than)

year trajectory

8

Nursing workforce - The Trust’s overall planned hours versus actual

hours worked was 98%

Appraisal rate – The Trust’s appraisal completion rate remained

static at 78.85%

SET training – Once again, there was an increase in compliance with

Statutory and Essential Training (SET) and at the end of August the

rate was 82.49%.

Sickness absence – Year-to-date figure at 4.1%

18/9/51 The month had seen an increase in the number of cancelled operations, mainly due to scheduling and sickness. It was agreed to deep dive this area at a future Quality and Effectiveness Committee.

DP

18/9/52 There was an explanation given around a debate on the counting of emergency pathways with further guidance awaited from NHS England. Further to a question from Sheena McDonnell, an explanation was given around the dip in Friends and Family response rates.

18/9/53 The Board NOTED the Performance Report.

Reports for Information

18/9/54 The following items were NOTED:

Chair and NEDS’ report

Chief Executive’s report

Minutes of Finance and Performance Committee, 20 August 2018

Minutes of Management Board, 13 August 2018

Board of Directors Agenda Calendar

Items escalated from Sub-Committees

18/9/55 None.

Minutes

18/9/56 The minutes of the meeting of the Board of Directors on 21 August 2018 were APPROVED as a correct record. Any other business

9

18/9/57 There were no items of other business raised.

Governors questions regarding business of the meeting

18/9/58 Further to a question from Peter Abell, the Board was advised that four Freedom to Speak Up cases had been heard in the previous quarter and all had been closed.

18/9/59 Following a question from Mike Addenbrooke on the same issue, it was confirmed that volunteers also had access to the Freedom to Speak Up Guardians.

18/9/60 Following a further question from Mike Addenbrooke, the Board was advised as to some of the changes happening in the Patient Experience Team which included a new head of service, Liam Wilson, and a relocation back to the front entrance near Gate 4.

18/9/61 Following a question from David Cuckson, the Board was assured that the Trust’s creditors were being paid in a timely way.


18/9/62 10.00am on Tuesday 23 October 2018 in the Boardroom, Doncaster Royal Infirmary. Exclusion of Press and Public

18/9/63 It was AGREED that representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

Suzy Brain England Date Chair of the Board