trust board part 1 - sheffield children's hospital · trust board part 1 schedule tuesday 26...

TRUST BOARD PART 1Schedule Tuesday 26 March 2019, 8:30 AM — 10:30 AM GMTVenue BOARDROOMOrganiser Claire Coles

Agenda

1. AGENDA 1

03~19 Part 1.doc 2

2. 59/19 WELCOME FROM THE CHAIRMAN AND APOLOGIES FORABSENCE

4

3. 60/19 DECLARATION OF INTERESTS OR AMENDMENTS TO THEREGISTER OF INTERESTS

5

4. 61/19 MINUTES OF THE LAST MEETING 6

02 Draft Public Minutes 26 February 2019 V2.doc 7

5. 62/19 ACTIONS ARISING FROM THE MINUTES - ACTIONS LOG 15

02 Matters Arising Report for March Public Board V1.doc 16

6. 63/19 SPOTLIGHT PRESENTATION - BECTON SCHOOL 20

63~19_Becton School Presentation SCH.pptx 21

7. 64/19 CHIEF EXECUTIVE REPORT AND INTEGRATED PERFORMANCEREPORT INCLUDING MONTH 11 FINANCE REPORT

27

64~19_ - 2019 - Board.doc 28 64~19_CEO Report March 19.doc 30 64~19_IPR - February 2019 (V2 for Board).pdf 31 64~19_Finance Board Report Cover 15.3.19.doc 54 64~19_FINANCE REPORT FEB 2019 (M11)v2.ppt 55

8. 65/19 QUALITY COMMITTEE 69

65~19_QC cover sheet March 2019.doc 70

9. 67/19 APPOINTMENT OF DEPUTY CHAIR 72

67~19_Appt of Deputy Chair.doc 73

10. 68/19 QUARTERLY REPORT FROM THE GUARDIAN OF SAFE WORKINGHOURS

75

68~19_Paper to the Board of Directors Mar 2019.doc 76 68~19_Guardian report March 2019.docx 77

11. 69/19 DEVELOPING OUR QUALITY STRATEGY FURTHER 86

69~19_TB March Quality Strategy Cover Sheet.doc 87 69~19_Quality Strategy Board paper.docx 88

12. 70/19 STAFF SURVEY 2018 92

70~19_Board Report for Information_2019 - staff survey - March2019.doc

93

13. 71/19 BOARD ASSURANCE FRAMEWORK 96

71~19_BoD BAF Q4 2019 cover.doc 97 71~19_App A - BAF Updated March 2019.pdf 99 71~19_App B - BAF risk scoring 2018-19.docx 140

14. 72/19 EXECUTIVE DECISION MAKING 142

72~19_BoD report - executive decision-making.docx 143 72~19_B1 Executive Team TORs.doc 149 72~19_B2 MB TORs.doc 154 72~19_B3 TLF TORs.doc 158

15. 73/19 ICS FINANCE AND PERFORMANCE REPORT AND ACP REPORT 162

73~19_March Board ICS Month 10 cover sheet.doc 163 73~19_Appendix A_ ICS CEO report_March 2019 FINAL and

appendices.pdf166

73~19_Appendix B_Financial reporting Month 10 draft v2 (AP).docx 181 73~19_Appendix C_SCH Board- ACP Programme Directors Report

March.doc188

16. 74/19 USE OF THE TRUST SEAL 192

74~19_Use of Trust Seal.doc 193

17. 75/19 ANY OTHER BUSINESS 195

18. 76/19 DATE OF NEXT PUBLIC MEETING: Tuesday 30 April 2019, 08:30hours in the Boardroom

196

19. Matters arising from previous meeting 197

1. AGENDA

Meeting of the Board of Directors held on Tuesday 26 March 2019 at 08:30hrs – 13:00hrs

The Boardroom

PART ONE

1.1 BOARD BUSINESS

59/19 WELCOME FROM THE CHAIRMAN AND APOLOGIES FOR ABSENCE

60/19 DECLARATION OF INTERESTS OR AMENDMENTS TO THE REGISTER OF INTERESTS

61/19 MINUTES OF THE LAST MEETING The Board is asked to approve the minutes of the Board meeting held on 26 February 2019

To approve

62/19 ACTIONS ARISING FROM THE MINUTES - ACTIONS LOG To note

1.6 PATIENT FOCUS (TO BE TAKEN AT 08:35)

63/19 SPOTLIGHT PRESENTATION – BECTON SCHOOL, Mr James Gibson, Head Becton School The Board is asked to receive the presentation from the Head of Becton School.

To note

1.2 QUALITY, PERFORMANCE & RESOURCES (TO BE TAKEN AT 08:55)

64/19 CHIEF EXECUTIVE REPORT AND INTEGRATED PERFORMANCE REPORT INCLUDING MONTH 11 FINANCE REPORT, Mr J Somers, Chief Executive The Board is asked to note the report which provides context and updates the Board on key activities during the last month and presents an overview of performance within the Trust, and note the Month 11 Finance Report.

To note

1.3 GOVERNANCE (TO BE TAKEN AT 09:15)

65/19 QUALITY COMMITTEE, Ms P Mitchell, NED, Chair of the Quality Committee The Board is asked to note any key issues arising from the Quality Committee held 11 March 2019.

To note

67/19 APPOINTMENT OF DEPUTY CHAIR, Mr M Kane, Associate Director of Corporate Affairs The Board is asked to approve the proposal for Deputy Chair.

To Approve

1.4 REPORTS FOR BOARD CONSIDERATION (TO BE TAKEN AT 09:25)

68/19 QUARTERLY REPORT FROM THE GUARDIAN OF SAFE WORKING HOURS, Dr N West, Safe Working Hours Guardian The Board is asked to note the content of the report from the Safe Working Hours Guardian and agree any actions required.

To note & gain assurance

69/19 DEVELOPING OUR QUALITY STRATEGY FURTHER, Mrs S Shearer, Director of Nursing and Quality The Board is asked to approve the Strategy, which outlines quality improvement over the next 3 years.

To note

70/19 STAFF SURVEY 2018, Mr S Ned, Director of Human Resources and OD The Board is asked to note the areas where the Trust has improved staff experience compared with the 2017 staff survey, together with an update against the 2017 action plan, and discuss action to improve staff experience over the coming year.

To note

71/19 BOARD ASSURANCE FRAMEWORK, Mr M Kane, Associate Director of Corporate Affairs The Board is asked to review the Board Assurance Framework following discussion at the March Risk and Audit Committee.

To note & gain assurance

72/19 EXECUTIVE DECISION MAKING AND GOVERNANCE, Mr J Somers, Chief Executive The Board is asked to approve the proposed changes to improve executive decision making.

To Approve

1.5 STRATEGIC ISSUES (TO BE TAKEN 10:10)

73/19 ICS FINANCE AND PERFORMANCE REPORT, Mr J Somers, Chief Executive, and Mr M Smith, Chief Finance Officer The Board is asked to note the ICS Chief Executive Report, performance scorecard, and Month 10 finance report, and report from the ACP Director, to ensure the Trust continues to be updated, and agree any actions required.

To note & discuss

AGENDA

TRUST BOARD PART 1 1. AGENDA Page 2 of 197

1.7 CLOSING MATTERS (TO BE TAKEN AT 10:20)

74/19 USE OF THE TRUST SEAL, Mr M Kane, Associate Director of Corporate Affairs

The Board is asked to note the use of the Trust Seal. To note

75/19 ANY OTHER BUSINESS Action as appropriate

76/19 DATE OF NEXT PUBLIC MEETING: Tuesday 30 April 2019, 08:30hrs in the Boardroom. Action as appropriate

TRUST BOARD PART 1 1. AGENDA Page 3 of 197

2. 59/19 WELCOME FROM THECHAIRMAN AND APOLOGIES FORABSENCE

3. 60/19 DECLARATION OF INTERESTSOR AMENDMENTS TO THE REGISTEROF INTERESTS

4. 61/19 MINUTES OF THE LASTMEETING

1

29/19 – 46/19

Minutes of the Meeting of the Board of Directors - Part One

on Tuesday 26 February 2019 at 08.30hrs

The Boardroom

In the Chair: Ms S Jones Chair Present: Mr A Baker Non-executive Director Ms R Brown Director of Strategy and Operations Mr J Cowling Non-executive Director Mr S Green Non-executive Director Mr P Lauener Non-executive Director Mr S Ned Director of Human Resources and Organisational Development / Deputy CE Dr J Perring Medical Director Ms S Shearer Director of Nursing and Quality Mr M Smith Chief Finance Officer Mr J Somers Chief Executive

Apologies: Ms P Mitchell Non-executive Director In attendance: Mrs C Coles Corporate Affairs Officer (Minute Taker) Mr M Kane Associate Director of Corporate Affairs Ms R Sobieraj Senior Communications Officer Dr N Jay (item 34/19) Paediatric Consultant Mrs J Mathers (item 35/19) PALS Manager One Parent (item 35/19) Mrs J Griffin (item 44/19) Freedom To Speak Up Guardian Mrs L Redfern Improvement Manager Three members of the public

TRUST BOARD PART 1 4. 61/19 MINUTES OF THE LAST ... Page 7 of 197

2

Action 29/19 WELCOME FROM THE CHAIRMAN AND APOLOGIES FOR ABSENCE Ms Jones, Chair, welcomed Board Members and noted the apologies as above.

30/19 DECLARATION OF INTERESTS OR AMENDMENTS TO THE REGISTER OF INTERESTS No declarations were noted.

31/19 MINUTES OF THE LAST MEETING The draft minutes of the meeting held on 29 January 2019 were approved as an accurate record of the meeting.

32/19 MATTERS ARISING The Board noted the updates on the actions arising report. 146/18 Aseptic Suite Business Case The Chief Finance Officer confirmed that the business case for the aseptic suite had been approved, therefore the action would be closed. The report and additional update was noted.

Action closed

33/19 CHIEF EXECUTIVE REPORT AND INTEGRATED PERFORMANCE REPORT INCLUDING MONTH 10 FINANCE REPORT The Chief Executive provided an overview of key issues, highlighting key points from supporting papers appended for information and invited Executive Directors to outline key successes or issues currently affecting the Trust.

The Trust had met all its NHS Improvement targets and key performance indicators for January.

A comprehensive positional update on the number of outstanding policies and clinical guidelines was provided to the Board in its assurance of progress to review these as a priority. The Trust had 182 policies listed, and of these prior to January 2019 there had been 35 that required review, in January this rose to 43 and then February saw a further increase to 47. Of the 47, 12 related to HR, the review dates for these HR policies were being extended via the committee approval process. Of the remaining 35 policies two policies had been ratified with minor amendments, nine were at the ratification stage, eight were ready for approval and 16 were in development. The Board noted that 18 policies had been approved or ratified during February. Looking forward five policies required review in March, three in April, eight in May and four in June. The process had already commenced to ensure authors were reviewing these policies now. The Board was informed that management responsibility for the policy approval process had been tightened, and an improvement was expected going forward.

Whilst overall monitoring of performance sat with the Director of Nursing and Quality, the responsibility for reviewing out of date policies and guidelines lay within divisions and authors. Further assurance was provided in that the Director of Nursing and Quality received daily position reports in oversight of the issue. A report to understand the frequency that policies were accessed on the intranet had been undertaken.

It was confirmed to the Board that the backlog for out of date policies was being prioritised, a review of the number of policies would be undertaken, mechanism for managing the review process would be reviewed and a report would be brought to the June Board following embedding of the new process and responsibilities.

Planner


3

The Trust held 857 clinical guidelines. These were discussed on a monthly basis as part of divisional performance meetings, this had shown a month on month improvement in reviewing out of date guidelines.

The Board was assured that the system for reviewing clinical guidelines was robust through the Clinical Audit and Effectiveness Committee, noting the issue related to the ownership of guidelines.

The Board was further assured that both of these areas of concern were reviewed on a monthly basis through divisional level integrated performance reports within divisional performance meetings. Key Updates

The Board noted preparations for the Care Quality Commission Well Led inspection. A briefing pack for interviewees would be available at the end of February.

The recent publication of the Kark Review was highlighted to the Board in relation to the Fit and Proper Person Test following the regulator’s concerns that some checks were not being discharged correctly within trusts and that it was too easy for inappropriately skilled and qualified directors to move between trusts. A number of recommendations had been proposed however further clarity was being sought from NHS Improvement on how some of these could be implemented. The Board noted concern on the public accessibility of a central database. It was unclear how a central database would be made available but was likely to be similar to the register for disqualified directors. The Board noted that foundation trusts had the power to appoint their own board members.

The Board was encouraged to attend the staff Star Awards ceremony which was taking place on 9 March.

The Trust had been successful in being allocated the care of the acutely ill child hosted network. There were five hosted networks which had been allocated across the system. There was a cost for each network, with contributions to these networks shared across the system. The Trust recognised that appropriate resource would be required to ensure the network worked. Whilst technically governance arrangements of the networks sat with the ICS this was being clarified through the hospital services review forum.

The Board noted the income benefit of hosting a network and consideration for the future was required in relation to contact methods and right clinical pathways supported.

Performance for complaints responses within the timeframe was being investigated to understand the position. The Director of Nursing and Quality would also explore whether the deadline for responding was appropriate.

The Board was assured that migration of the Trust’s email system on to NHS mail was being managed on a phased migration and testing was already underway.

The Board noted the Trust had achieved its quarter three target and received its PSF funding. However at month 10 the finance position had slipped away from plan.

The Board scrutinised the financial position as this was not done at the Finance and Resources Committee due to timing of the meeting was before the reporting timeframe. Whilst the Trust had achieved its month 9 control total all flexibilities had been used to achieve this position. The Trust was reported £1.2m away from plan, this was further than expected. Further discussion on the forecast outturn position would be held in Board Part 2 and was expected to be £1.5m away from plan at year end. The clinical divisions were offsetting each other’s position, the two other divisions were now also reporting away from plan which additionally impacted on the

DNQ


4

overall position. A number of actions were in place but there was a risk to delivery of activity position by year-end. The Finance and Resources Committee would scrutinise the position further at their next meeting.

Whilst increased utilisation within divisions had been made, challenges in recruiting to key posts was impacting on activity within some areas. A positive impact of the Was Not Brought campaign was showing in comparison to performance of previous years.

The Board noted the report and key additional verbal updates.

34/19 SPOTLIGHT PRESENTATION – WHAT CAN PHYSICIAN ASSOCIATES DO? The Consultant Paediatrician gave a presentation on findings following a visit to the USA to investigate physician associates as a workforce. The following was highlighted to the Board: i) A business case for physician associates had been considered previously by the

Trust Executive Group to understand the role and opportunities.

ii) Regulation would be introduced in the UK within the next 12 months and good robust training schools were already in place including within Sheffield universities. Board commented that this presented an opportunity for the Trust.

iii) Copies of the reports from the visit would be circulated to the Board.

iv) The Chair and Chief Executive would raise the issue at the Children’s Alliance and encourage system wide consideration of the role including within the ACP. There was also potential for funded places within Health Education England.

The report presentation was noted and Dr Jay thanked for her presentation.

Corp. Affairs

Chair / CEO

35/19 PATIENT STORY The Chair welcomed the parent to the meeting. The following points were noted / action agreed: i) The parent provided background on her experiences at the Trust. This was a

powerful account which highlighted areas for improvement. ii) The Medical Director noted that outpatients department could be better designed for

patients with autism and would explore options for ensuring patients and their families did not feel isolated or anxious when waiting for their appointment in a quiet room, and ensure relevant protocols were in place.

iii) The child’s ‘All about me cheat sheet’ and ‘Frightometer’ ideas were positively received by the Board. These were simple ideas but could be used by other parents of complex needs children. It was suggested these could be showcased at the clinical summit. The Director of Nursing and Quality would discuss these ideas with Ward Managers.

iv) The parent offered assistance to the Trust where she could provide any input. v) The parent would be approached to become a governor and the Chair would write

to thank the parent for her input and ideas to take forward. The report was noted.

MD DNQ AD-CA Chair

36/19 QUALITY COMMITTEE Mr Lauener, Non-executive member of the Quality Committee, highlighted the key issues arising from the Quality Committee meeting on 18 February 2019 as outlined in the supporting summary assurance report. The following points were made / emphasised: i) The good progress of safeguarding and transition was reported to the Committee


5

with new processes put in place over the past two years. The Committee had requested this progress was captured in a single page summary for a managers’ briefing pack. The Board was further assured of progress following feedback from a back to the floor visit to the safeguarding team by two non-executives.

ii) The Committee had been encouraged to see progress over the past year in its apprenticeship programme but recognised there was more to do to achieve the government target of 2.3 per cent of work force to be apprentices, as the Trust was currently reporting 1.3 per cent.

iii) There was more to do to link the long-term plan future workforce challenges to future workforce. The Trust was linked in to this work looking at making the NHS a better place to work. A visit to the trust by a former special advisor to the government had taken place. He was impressed with work on apprenticeships.

The report and additional verbal update was noted.

37/19 FINANCE AND RESOURCES COMMITTEE Mr Baker, Chair of the Finance and Resources Committee, presented key issues arising from the meeting on 13 February 2019 as outlined in the supporting summary assurance report. The following was noted: i) The Board was signposted to the month 10 position which had been verbally

reported to the Committee. The Committee had noted the risk around financial team resourcing and collectively supported the Chief Finance Officer to recruit to posts as a priority due to challenge to year-end position.

ii) The Committee had received the narrative to the financial plan which had been submitted prior to the meeting.

iii) The Procurement Director had attended the meeting to present the procurement transformation plan for 2019/20. The Committee recommended to Board nomination to the NED procurement role.

Board: (i) Noted the report and additional verbal update. (ii) Approved the appointment of John Cowling as NED lead for Procurement.

38/19 PEOPLE STRATEGY The Director of HR and OD presented the report for information. The following was noted: i) The Board noted the paper which set out the key performance indicators and

milestones for three of the five chapters of the strategy. The remaining two chapters would be taken to the March Finance and Resources Committee. These themes had been scrutinised by the Finance and Resources Committee at their February meeting. Work had now shifted to focus on delivering the strategy. Monitoring the impact would be the next challenge.

ii) The update was provided to Board for its assurance of progress, and following Board approval of the style reporting of progress would be taken through the Finance and Resources Committee.

The report was noted.

39/19 CULTURE AND BEHAVIOUR STRATEGY

The Director of HR and OD presented the report for information. The following was noted: i) Both the culture and behaviors and people strategies would be summarised into a


6

user friendly document. ii) A key focus of this strategy was in relation to leadership and there had been a

focused effort to engage the Trust Executive Group in this work. The strategy will widen leadership development out and collective leadership, areas of concern and best impact. It would also explore values based leadership in how managers conduct themselves.

iii) The Board supported the dashboard which was a clear measure of impact on the staff survey results.

iv) Work was also being undertaken with learning and development around the pathway to excellence for nursing as a key staffing group within the organisation, and a quality strategy was being developed and would be brought to the March Board, the crossover was recognised and the strategies would align.

v) The Finance and Resources Committee considered this critical to bring together in the next stage and link back to the marketing conversations. The Board noted the strategy was live and dynamic.

The Board noted the report.

40/19 SEVEN DAY SERVICES ASSURANCE FRAMEWORK The Medical Director presented the report for information. The following was noted: i) The Board noted the report following self-assessment against the priority standards

following introduction of standards of care across the week to support providers to deliver high quality care across seven days.

ii) The Trust’s performance would be monitored through the board assurance framework and the Trust was expected to meet standards by March 2020.

iii) A small amendment would be made to the date within the draft submission. iv) The Board approved the draft template for submission and delegated responsibility

for future approval to the Quality Committee with exception reporting to the Board. v) The Board was assured that the framework related to general paediatrics, and that

the emergency department had already done a lot of work to ensure services were in place across seven days, this aligned with the major trauma centre.

The Board noted the report.

41/19 REVIEW OF THE CONSTITUTION The Associate Director of Corporate Affairs presented the changes to the Constitution. The following key points were noted: i) The changes to the Constitution had been reviewed and scrutinised by a working

group and Risk and Audit Committee and recommended for approval by the Council of Governors.

ii) Whilst Governors had been content with the direction of travel they were keen to preserve the youth voice on the Council of Governors. Actions would be taken to target and encourage recommended youth forums, particularly the Trust’s Youth Forum, with appropriate support in place.

iii) The Board were supportive of the changes and composition of the Council and recommended monitoring the impact of changes on geographic changes, and review and offer support to governors within other areas.

iv) The Trust had a statutory duty to reflect patient and geographic areas. The Board approved the changes to the Trust’s Constitution.


7

42/19 BOARD STANDING ORDERS, STANDING FINANCIAL INSTRUCTIONS AND SCHEME OF DELEGATION The Associate Director of Corporate Affairs presented the changes to the Board standing orders, standing financial instructions and scheme of delegation. The following key points were noted: i) The changes had been summarised within Appendix A. The main change

highlighted was the change to financial limits, this had been supported by the Risk and Audit Committee and aligned consistently with the wider system.

ii) Changes to the delegations had been discussed at Trust Executive Group. The Board approved the changes to the Board standing orders, standing financial instructions and scheme of delegation.

43/19 ICS FINANCE AND PERFORMANCE REPORT The Chief Executive and Chief Finance Officer presented the report for information. The following was highlighted to the Board: i) The Board noted that as an ICS it should be leading on self-regulation to avoid dual

regulation. ii) The Board noted performance of the ICS had slipped slightly due to RTT within one

trust being below target, this was an area of focus, in addition to A&E performance and cancer waits which were already key focus.

iii) A discussion took place on how the management structure of the ICS might work going forward.

iv) The Board noted that the ICS had secured its PSF funding and there was a £2m risk in quarter 4. Arrangements were complicated following declaration within the system around over performance, this gave less flexibility to offset positions within the system.

v) The Board noted the Trust was the biggest risk within the system to achieve its control total.

The report was noted.

44/19 FREEDOM TO SPEAK UP – BOARD SELF-EVALUATION TOOL The Freedom To Speak Up Guardian presented the reports for information. The following points were noted: i) The Board approved the self-evaluation with contribution provided by Board, and in

particular Ms Mitchell was thanked for her contribution, to give Board direction. ii) The Board recognised it was within the top 50 trusts in the country for freedom to

speak up with good support within the organisation, noting there had been challenge to the National Guardian’s Office to focus on trusts which were non-compliant.

iii) The self-evaluation would be submitted to NHS Improvement and National Guardian’s Office.

iv) The Board approved the proposed vision and strategy for submission to NHS Improvement and National Guardian’s Office. Two metrics would be developed for reporting within the integrated performance report to provide direction.

v) The Board noted nervousness around the challenge to acknowledge concerns raised within 10 days.

vi) The Board recognised the journey taken to reach this point, and was assured there was good awareness of raising concerns within the organisation, and this was actively promoted by non-executives through back to the floor visits. The Freedom


8

To Speak Up Guardian would be happy to join non-executives on back to the floor visits.

The reports were noted.

45/19 ANY OTHER BUSINESS CQC unannounced inspection The Board noted the Care Quality Commission unannounced core service inspection of the emergency department, outpatients, transition and surgery taking place over the next 3 days.

46/19 DATE OF THE NEXT PUBLIC MEETING Tuesday 26 March 2019, 08:30hrs in the Boardroom.


5. 62/19 ACTIONS ARISING FROM THEMINUTES - ACTIONS LOG

Actions Arising Report – updated following 26 February 2019 Board Meeting held in Public

Action ref:

Date Action raised

Action Action with

Target date to

complete Progress / evidence that

completed

33/19 Chief Executive Report and Integrated Performance Report

26/02/19

Performance for complaints responses within the timeframe was being investigated to understand the position. DNQ would also explore whether the deadline for responding was appropriate.

DNQ March 2019

DoN has discussed this with HoL&G. The issue arose when the previous incumbent left and a series of agency complaints managers did not effectively manage the situation and a backlog arose. HoL&G will provide a report (to QC) of reasons for delays. This has been delayed due to the management of two CQC document requests. Added to cross working report. Action closed.

34/19 iii) Spotlight Presentation – What can physician associates do?

26/02/19 Copies of the reports from the visit would be circulated to the Board.

Corp. Affairs

March 2019

Completed, information circulated. Action closed.

34/19 iii) Spotlight Presentation – What can physician associates do?

26/02/19

Chair and CEO to raise the issue at the Children’s Alliance and encourage system wide consideration of the role including within the ACP.

CEO March 2019

Update provided 23/3/19: New models of care are a key issue in the NHS 10 year plan and it was agreed with alliance members that STP’s / ICS’s were at different stages of maturity in terms of planning. A national transformation board is being developed and new models of care are likely to be a key work-stream. The SCH CEO has indicated that he would be willing to take on a national role given the advanced work being undertaken at SYB level. The physician associate role is being looked at within the programme of new models of care and future sustainability. Action closed.

35/19 iii) Patient Story 26/02/19

The child’s ‘All about me cheat sheet’ and ‘Frightometer’ ideas could be used by other parents of complex needs children. These could be showcased at the clinical summit. DNQ to discuss

DNQ March 2019

Documents shared with HoNs for onward circulation and discussion. Action closed.

TRUST BOARD PART 1 5. 62/19 ACTIONS ARISING FRO... Page 16 of 197

these ideas with Ward Managers.

35/19 v) Patient Story 26/02/19

The parent offered assistance to the Trust where she could provide any input, and would be approached to become a governor.

AD-CA Feb 2019

Action completed. Action closed.

35/19 v) Patient Story 26/02/19

Chair would write to thank the parent for her input and ideas to take forward.

Chair Feb 2019

Letter sent. Action closed.

Completed Actions updated following 26 February 2019 Board Meeting held in Public

Action ref:

Date Action raised

Action Action with

Target date to


completed

214/18 Freedom To Speak Up – Board Self-Evaluation Tool

31/07/18 The Board to undertake a self-evaluation at the October meeting.

Chair Oct Feb 2019

Self-assessment complete. Vision and strategy now being developed for Boards consideration. Action closed. Minute Ref: 44/19.

290/18 v) Presentation of the People Strategy

06/11/18

A front facing staff focused version around the key themes to be developed. Reference to the gender pay gap would be referenced within the chapters. Consideration to be given to a potential role for the shadow board in the next phase of work to develop a cohesive plan and identify timelines for the final strategy.

DHROD Feb 2019

Action closed. Minute Ref: 38/19.

290/18 vi) Presentation of the People Strategy

06/11/18

Strategy to be developed through Committee support, and prioritisation of chapters considered. Completed strategy to be taken to February FRC and February Board.

DHROD Feb 2019


291/18 v) Presentation of the Culture and Behaviour Strategy

06/11/18

The timelines for the final strategy to be identified, and final chapters and programme of activity to help achieve this culture within all aspects of the organisation to be developed and taken to the December FRC, and February Board.

DHROD Feb 2019



29/01/19

Additional extraordinary Committee meetings would be arranged as appropriate to ensure policies were approved in a timely manner.

Corp. Affairs

Feb 2019

EO Quality Committee arranged for 21/02/19. Action closed.



29/01/19 WNB campaign video would be shared with Governors.

DSO Feb 2019

The “Take my place” film was shown at the joint COG and Board strategy session on 12.02.19. Action closed.


29/01/19

A small number of suggested formatting changes would be made to future reports, with additional information for some areas to give clarity on what actions have been taken to address areas of improvements.

DSO Feb 2019


06/19 ii) Quality Committee 29/01/19

A review of evidence would be brought back to a future meeting to articulate progress of transition, and provide an updated position for the Board.

DNQ Feb 2019

A summary of progress would be provided within the CQC: Managers information pack due to be circulated on 01.03.19. Action closed.

07/19 i) Finance and Resources Committee

29/01/19 DSO to circulate the SWOT analysis to the Board following the recent R&TP workshop.

DSO Feb 2019

SWOT analysis circulated 25.02.19. Action closed.

146/18 Aseptic Suite Business Case

23/05/18

A proposal would be brought back to a future meeting to consider further, in protecting the Trust from extra costs. An application to the Integrated Care System for any additional capital could be considered.

CFO Feb 2019

Completed. Included within prioritised ICS submission. Action closed. Minute Ref: 32/19.

Actions Scheduled updated following 26 February 2019 Board Meeting held in Public

Action ref:

Date Action raised

Action Action with

Target date to


completed

355/18 iv) Estates Review 18/12/18

Decisions could not be made by the estates team in isolation, and would require clinical input and Board steer to answer a number of challenges and questions on Ryegate accommodation.

CFO/HoE April 2019

Presentation and discussion on key issues and themes for April Board. Headline key strategic issues / decisions / constraints to be pulled together.

355/18 v) Estates Review 18/12/18

Head of Estates and CFO to investigate options within the city, and would flesh out options, issues and questions of key elements to support a robust discussion at Board. A slot would be allocated within the Part 3 section to get a collective view and steer on estates, clinical and charity competing priorities.


11/19 iv) Delivering “Caring Together”: Q3 Performance against Corporate Objectives 2018/19

29/01/19

Rating of progress of the objectives would be changed to ‘BRAG’ rating, and future quarterly reports would be scrutinised at Executive Briefing to ensure consistency of rating and ensure realistic assessment of the position before bringing the report to Board.

DSO April 2019


26/02/19

The backlog for out of date policies was being prioritised, the mechanism for managing the review process would be reviewed and a report would be brought to the June Board following embedding of the new process and responsibilities.

DNQ June 2019

35/19 ii) Patient Story 26/02/19

MD would explore options for ensuring patients and their families did not feel isolated or anxious when waiting for their appointment in a quiet room, and ensure relevant protocols were in place.

MD April 2019


6. 63/19 SPOTLIGHT PRESENTATION -BECTON SCHOOL

4 S C H O O L S I N O N E

Becton School

TRUST BOARD PART 1 6. 63/19 SPOTLIGHT PRESENTATION - B... Page 21 of 197

The Four Sites

Becton Centre Moncrieffe

Kenwood Sheffield Childrens’ Hospital


Becton Centre

Referral Process All referrals come from Tier 3 CAMHS

(generally sections 2, 3 and 7)

CohortAmber Lodge (8) - Age 5-11, SEMH/Diagnosis, Day patients (12 Weeks)

Emerald Lodge (12) - Age 8-13, Complex Mental Health Issues, ResidentialSapphire Lodge (14) - Age 13-18, Complex Mental Health Issues, Residential

Ruby Lodge (7) - Age 7-18, Dual Diagnosis, Residential (12 Weeks)

Curriculum Emerald and Sapphire as broad and Balanced as possible, Ruby and Amber are more around accurate assessment of pupils current learning levels and needs.


Sheffield Childrens’ Hospital

Referral ProcessThrough Medical Professionals Decision to Admit to

SCH. We currently offer 4th day teaching.

Cohort(300-500 Annually) Age 5-16 Physically Ill pupils with a variety of health issues including Cancer, Cystic fibrosis,

ABI, Burns and Others.

CurriculumShort term stop gap to reduce impact of illness on

education.


Moncrieffe

Referral Process

All Referrals have to come from a medical consultant. If physical usually from SCH or Tier 3 CAMHs for Mental

Health Issues

Cohort

(70) Age 5-16 with a variety of physical and mental health difficulties

Curriculum

Mainstream core subjects


Kenwood

Referral Process

EHCP Through LA

Cohort

(38) Autism with high anxiety/mental health issues (Must have worked with CAMHS)

Curriculum

Bespoke and Varied – Some pupils doing A Level Math, Chemistry and Physics, some pupils having a vocational

curriculum.


7. 64/19 CHIEF EXECUTIVE REPORTAND INTEGRATED PERFORMANCEREPORT INCLUDING MONTH 11FINANCE REPORT

EXECUTIVE SUMMARY

Title

Integrated Performance Report and Chief Executive’s Report

Report to

Trust Board

Date

26 March 2019

Executive Sponsor

Ms R Brown, Director of Strategy and Operations

Author

Mr C Radford, Deputy Director of Strategy and Operations

Purpose of Report

To present to the Trust Board an overview of performance within the Trust. This provides a summarised description of the Trust’s most recent performance against key national and local performance indicators at the end of February 2019.

Please tick as appropriate

Approval

Assurance Information

Executive summary – the key messages and issues

The Integrated Performance Report (including quality, activity, workforce and performance) including a high level dashboard is structured around the organisation’s five strategic aims. All data relates to February 2019 unless otherwise specified (e.g. sickness absence which is reported one month in arrears). Key Achievements The Trust continued to achieve all Cancer standards throughout February. The Trust has continued to achieve the ED Waiting Time standard, with 97% of patients being

seen within four hours. The Trust achieved the 92% target for patients on an incomplete pathway within 18-weeks. The results of the 2018 Staff Survey have been published. 1,717 staff responded, equating to

a response rate of 53.5% - the highest ever response rate for the Trust and above the national average of 41%.

Areas for Improvement There were two serious incidents during February, one of which was classified as a ‘never

event’. One incident related to ENT and the second incident was an Information Governance breach. Investigations have been undertaken and accordingly reported to external bodies.

There was one patient reported as waiting over 52 weeks for treatment. This was due to a pathway error and a definitive treatment is scheduled to take place during March. The cause of the breach has been investigated and where possible steps put in place to minimise potential for future recurrence.

TRUST BOARD PART 1 7. 64/19 CHIEF EXECUTIVE REPO... Page 28 of 197

There were two patients who were unable to be accommodated for their operation within the

28-day target from point of on-the-day cancellation. Both of these patients have subsequently been accommodated.

The diagnostic target was not achieved during February with 98.19% of patients waiting less than six weeks for their test against the national target of 99%. The main reason for non-achievement of the standard was as a consequence of a recording error which has since been addressed.

How this report impacts on current risks or highlights new risks Failure to effectively deliver healthcare impacts on the safety and quality of patient

experience, regulatory compliance and loss of confidence of the wider community. Risk that we do not maintain financial stability due to failure to deliver the financial plan

resulting in requirements for additional CIPs or reduction in level and standard of services. Failure to ensure that the Trust has a motivated, suitably trained and engaged workforce

impacts on operational performance, transformational change and achievement of strategic objectives.

Failure to ensure that the Trust recruits staff in the right numbers and with the appropriate breadth of skills and competencies to deliver high quality services now and in the future.

Risk that insufficient leadership capacity and capability prevents necessary transformational change.

Risk to clinical service viability due to failure to meet nationally defined standards or unfavourable changes to the commissioning of services.

Failure to engage effectively with partner organisations and the local community threatens the ability of the Trust to deliver its strategic ambition.

Failure to engage with our clinicians prevents the development / implementation of an effective clinical strategy that responds to the needs of patients and other health and social care partners.

Failure to ensure that the required IT infrastructure and strategy is in place to deliver clinical services and support clinical strategy and transformation impacts on the Trust's ability to deliver services, improve quality and transform services.

Capacity constraints impact on our ability to deliver planned activity and manage demand impacting on operational efficiency, service quality and financial performance.

Recommendations and next steps

The Trust Board is asked to note the report and provide comment.


Chief Executive’s Report – March 2019 1. Integrated Performance Report

The Integrated Performance Report for February is attached. This includes an Executive Summary of Trust wide performance against the five strategic aims. 2. Care Quality Commission (CQC) Update

The CQC undertook its unannounced inspection of four core services between 26 – 28 February, these included Transition, ED, Outpatients and Surgery. Key themes were collated during and after the visit and initial feedback received that all staff were caring, compassionate and engaged with their patients and families. They returned for a second visit between 12 – 14 March to inspect CAMHS and covered both community and inpatient areas. As with the core services visit, key themes were collated and initial feedback received from the CQC was that all staff were caring and compassionate. The Trust is now preparing for the Well Led Inspection which will take place between 2 - 4 April 2019. The final report is expected mid June. 3. Star Awards 2019 The annual Star awards took place on 8th March 2019 at the University of Sheffield Octagon Centre. Over 700 nominations were received for this year’s awards (the highest ever). Compere Amy Garcia from BBC Look North was joined by Rahul Mandal winner of this years ‘Great British Bake Off’ to announce the winners and runners up in each category. A full list of the 2018 winners and runners-up can been seen at http://nww.sch.nhs.uk/news/472-photos-and-list-of-winners-from-the-2019-star-awards together with photos from the evening. 4. Staff survey results are in Staff survey results are in and the Trust had the highest response rate so far with 53.5% (1717 members of staff) completing the survey. This is well above the national average response rate of 41% and enables us to use the feedback to develop work further. Detailed reports are available and an action plan is now being developed to ensure continued improvements are made. 5. Was Not Brought (WNB) Launch On 26 February, the Trust launched its campaign ‘ Take My Place’, which encourages families to pass on their appointments at least four days in advance. The launch saw 406 colourful paper aeroplanes dropped from the roof of the hospital’s main entrance, representing the number of appointments missed in a week. The launch got wider news and social media coverage. 6. Annual Caring Together Summit A reminder to save the date for the annual Caring Together summit on Thursday 26th September 2019.


http://nww.sch.nhs.uk/news/472-photos-and-list-of-winners-from-the-2019-star-awards

http://nww.sch.nhs.uk/news/472-photos-and-list-of-winners-from-the-2019-star-awards

Integrated Performance Report

Reporting Period: February 2019

TRUST BOARD PART 1 7. 64/19 CHIEF EXECUTIVE REPORT AND IN... Page 31 of 197

Contents 2

Section Title Page Number

1.1 Executive Summary 3

1.2 Executive Summary – Continued 4

2.0 High Level Dashboard 5

3.0 Legal & Governance KPIs 6

4.0 Friends & Family KPIs 7

5.0 Safety & Patient Experience Indicators 8

6.0 Discharge Summaries 9

7.0 Workforce - Sickness Absence & Training KPIs 10

8.0 Accident & Emergency and Ambulance Handovers 11

9.0 Referral to Treatment (18 Weeks) 12

10.0 Diagnostics (DM01) & Long Stay Inpatients 13

11.0 CAMHS Waiting Times 14

12.0 Cancer Waits 15

17.0 eReferrals Appointment Slot Issues 16

18.0 Outpatient Clinic WNB (Was Not Brought – Previously DNA) 17

19.0 Outpatient Review List 18

20.0 Outpatient Clinic & Theatre Utilisation 19

21.0 Activity v Plan: Outpatients and Inpatients 20

22.1 Finance – Agency Spend & Cash Balance 21

22.2 Finance – Income and Expenditure & CIP 22

23.0 CQUIN 23


1.1 Executive Summary 3

Provide high quality patient experience and outcomes:

• There were two serious incidents reported in February, one of which was classified as a ‘never event’. One incident related to ENT and the second incident was an Information Governance breach. Investigations have been undertaken and accordingly reported to external bodies.

• The number of incidents pending investigation which are overdue increased during February. Work is being undertaken within the clinical divisions to address the backlog and significant progress has been made over recent months.

• The number of policies and clinical guidelines which are out of date have reduced over recent months. This is being routinely discussed at the monthly Divisional Performance Review Meetings to drive a sustained improvement.

• The response rate in the Friends and Family test continued to remain above the Trust target. Work is being undertaken to implement a new data collection method from April following the discovery of patients’ ability to submit multiple returns.

• Of the four internal targets relating to discharge summaries, none of these were achieved, however, work continues within Divisions and a pilot is being developed on two wards to implement a policy of only allowing a patient discharge once a discharge summary has been completed.

Empower motivated and compassionate staff:

• Sickness absence in terms of time lost during January was 4.45% (target reported one month in arrears) and is higher than the Trust target level of 4%. This is however, a slight reduction on the same period last year.

• Both PDR and Mandatory Training compliance remained below the 90% Trust target at 74% and 86% respectively. • The Annual Star Awards Ceremony was held on 8th March to recognise both individuals and teams throughout the organisation who have contributed to improving

the services they deliver and improve patient experience. • The results of the 2018 Staff Survey have been published. 1,717 staff responded, equating to a response rate of 53.5% - the highest ever response rate for the Trust

and above the national average of 41%.

Lead improvements in paediatric care:

• Roll-out of laptops commenced during February in order to extend mobile working and enable electronic patient record keeping for Speech and Language Therapy teams. This will continue through throughout March alongside provision of new smart-phones for all clinical staff. A similar roll-out is progressing in parallel with CAMHS teams, ahead of their migration onto SystmOne from the end of March.


1.2 Executive Summary – Continued 4

Build clinical and financial sustainability:

• The four-hour ED standard continued to be achieved at 96.8% throughout February against the 95% national target. • The percentage of ambulance handovers within thirty minutes continued to be achieved at 100%. • The percentage of patients on an 18-week RTT incomplete pathway was achieved at Trust-level at 92.05% against the national standard of 92%. • There was one patient reported as waiting over 52 weeks for treatment. This was due to a pathway error and a definitive treatment is scheduled to take place

during March. The cause of the breach has been investigated and where possible steps put in place to minimise potential for future recurrence of the same issue. • 14 patients had their operation cancelled on the day for non-clinical reasons. This is a reduction of 7 from the previous month. There were two patients who were

unable to be accommodated within the 28-day target from point of cancellation. Both of these patients have subsequently been accommodated. • The diagnostic target was not achieved during February with 98.19% of patients waiting less than six weeks for their test against the national target of 99%. Non-

achievement of the standard was as a consequence of a recording error which has since been addressed. • All national cancer standards continued to be achieved at 100% during February. • Was Not Brought rates for first appointments deteriorated slightly during February in comparison to the previous month to 9.65% against the 9% target. This does

however, continue to be an improving position on the same period last year. • Was Not Brought rates for follow-up appointments during February improved on the previous month and continues to be an improvement on the previous year. • A review of all surgical patients waiting in peripheral clinics has been undertaken and waiting lists clinically validated by the relevant consultant. The first aim is to

reduce all patients waiting over 100 weeks – Rotherham DGH clinics have 11 patients over 100 weeks, this will be cleared by 28/3/19; Doncaster RI has 36 patients over 100 weeks, this will be cleared by 7/5/19; Chesterfield Royal has 1 patient waiting over 100 weeks and this will be cleared by 1/4/19.

• Freedom of Information backlog clearance started in September, but is progressing slower than initially anticipated and will not be complete until Q4. The main areas that account for the bulk of the outstanding requests are Finance, Procurement and HR. New requests are being acknowledged within three days of receipt and the majority are being processed within the twenty-day deadline. An FOI reporting system has been built by the Information Department which now provides a suite of monitoring reports to identify trends and to support swifter escalation of process bottlenecks.

Discover new ways of improving child health:

• A campaign to encourage parents and carers to pass on their appointments when they are unable to attend was launched in March by releasing a cascade of 406 paper planes through our main entrance ceiling to provide a visual representation of the number of missed appointments each week. The campaign has been covered in the local media and the Trust’s social media sites.

• There are currently 12 active Microsystem Improvement Projects ongoing within the Trust and 18 Service Evaluations / Audits initiated during the month of February.


2.0 High Level Dashboard 5

Organisational Aim Indicator Target Target Aim Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

Number of Incidents Reported N/A N/A 527 586 490 515 537 393 321 439 507 357 424 431

Number of Serious Incidents Reported 0 Below 1 0 2 1 0 4 1 1 0 1 0 2

Number of Never Events Reported 0 Below 0 0 0 1 0 1 0 0 0 0 0 1

Number of Incidents Pending Investigation that are Overdue 0 Below 527 382 223 146 129 174

Number of Actions Outstanding from Serious Incident/Never Event Action Plans N/A N/A 13 7 10 23 22 3 9 22

Number of Complaints Received N/A N/A 16 20 12 25 17 19 29 20 11 17 13 9

Complaints Responded Within Deadline N/A N/A 9 7 6 13 4 2 4 7 10 8 5 6

Percentage of Complaints Responded Within Deadline 100.00% Above 35.00% 35.29% 81.25% 14.29% 15.38% 30.77% 36.84% 50.00% 47.06% 19.23% 30.00%

Number of Claims/Inquests Registered N/A N/A 4 0 0 6 0 0 1 0

Number of Freedom to Speak Up Concerns Raised N/A N/A 1 3 15 6 9 2 6 5 8 5 5 5

Response Rate in the Friends and Family Test 7.57% Above 3.09% 4.02% 2.81% 4.87% 6.00% 6.62% 8.11% 9.27% 9.46% 10.36% 7.99% 8.11%

Percentage of Recommendations in the Friends and Family Test 92.10% Above 85.14% 85.36% 85.15% 83.07% 79.06% 82.27% 83.84% 83.38% 81.07% 81.79% 76.97% 80.12%

Percentage of staff who recommend this organisation to friends / family if they needed care or treatment N/A N/A 89.08% - - 89.00% - - 89.93% - - - - -

Number of C.Diff Cases 2 Below 0 0 0 0 0 0 0 0 0 0 0

Number of MRSA Cases 0 Below 0 0 0 0 0 0 0 0 0 0 0

Number of MSSA Bacteraemia Cases N/A N/A 1 0 1 0 1 1 2 0 0 2 0

Number of Clinical Guidelines Out of Date 0 Below 35 45 44 43 45 52 45 50 53 65 51 47

Number of Policies Out of Date 0 Below 82 81 63 67 58 53

Number of patients with an inpatient length of stay over 30 days (Acute & Tier 4 CAMHS) N/A N/A 36 36 42 33 34 35 28 36 37 32 29 34

Percentage of Discharge Summaries Complete (inc CAMHS Brief) 100.00% Above 80.10% 76.78% 77.87% 75.00% 78.04% 81.42% 74.41% 71.98% 70.75% 79.17% 77.10% 77.90%

Percentage of Discharge Summaries Completed Within 24 Hours of Discharge Date (inc CAMHS Brief) 100.00% Above 75.37% 70.37% 72.28% 70.05% 70.19% 75.17% 69.38% 67.76% 66.88% 70.67% 71.84% 71.07%

Percentage of Full Discharge Summaries Complete (CAMHS only) 100.00% Above 62.50% 87.50% 100.00% 100.00% 100.00% 100.00% 100.00% 66.67% 100.00% 100.00% 100.00% 83.33%

Percentage of Full Discharge Summaries Complete Within 2 weeks (CAMHS only) 100.00% Above 25.00% 50.00% 100.00% 33.33% 66.67% 27.27% 66.67% 33.33% 100.00% 75.00% 50.00% 33.33%

Outpatient Appointment Letters Sent Within 10 Days N/A N/A

Outpatient Letter Typing Turnaround N/A N/A

Sickness Absence (percentage of time lost) 4.00% Below 3.97% 3.74% 3.16% 3.38% 3.93% 3.99% 4.12% 3.89% 3.71% 3.92% 4.45%

PDR Compliance 90.00% Above 82.00% 80.00% 79.00% 75.00% 76.00% 76.00% 76.00% 75.00% 73.00% 74.00% 75.00% 74.00%

Mandatory Training Compliance 90.00% Above 88.00% 88.00% 87.00% 85.00% 85.00% 86.00% 85.00% 85.00% 85.00% 85.00% 86.00% 86.00%

Retention of Staff N/A N/A - - - 88.50% 88.39% 88.05% 88.73% 88.75% 87.95% 88.24% 88.57% 88.55%

Number of Excellence Reports Submitted N/A N/A - - - - 27 28 25 24 25 13 26 34

Staff engagement as measured by the Staff Survey (Organisation Average) N/A N/A 3.82 - - - - - - - - - - -

Percentage Increase in staff feeling valued as measured by the Staff Survey N/A N/A - - - - - - - - - - -

Percentage of staff who recommend this organisation to friends / family as a place to work N/A N/A 60.82% - - 63.00% - - 62.70% - - - - -

A&E 4+ Hour Waits 95.00% Above 97.31% 97.70% 98.47% 98.35% 98.56% 98.60% 96.63% 96.54% 97.04% 97.37% 96.52% 96.80%

Percentage of Ambulance Handovers Within 30 Minutes 100.00% Above 99.25% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

18 Weeks RTT (Referral to Treatment) Time - Incomplete 92.00% Above 93.01% 93.81% 93.86% 93.37% 93.07% 92.67% 92.03% 93.39% 93.24% 92.19% 92.76% 92.05%

18 Weeks RTT (Referral to Treatment) Number of Patients Waiting 52+ Weeks - Incomplete 0 Below 0 0 0 0 0 0 0 0 0 0 0 1

Diagnostic Waits (DM01) Within 6 Weeks 99.00% Above 99.52% 99.75% 99.67% 99.42% 99.68% 99.58% 99.48% 99.50% 99.29% 99.09% 99.22% 98.19%

CAMHS Tier 3 Waiting Times (Wait to 1st Appt) - 18 Weeks 92.00% Above 96.31% 97.05% 97.36% 99.35% 97.85% 96.15% 99.39% 96.67% 95.00% 94.34% 96.15% 93.53%

CAMHS Tier 3 Waiting Times (Wait to 2nd Appt) - 18 Weeks 92.00% Above 59.64% 54.94% 55.94% 57.64% 62.12% 61.42% 65.69% 65.37% 62.88% 67.12% 74.95% 74.19%

Eating Disorder Routine Patients - 28 Days (Incomplete) 92.00% Above 80.00% 50.00% 100.00% 100.00% 100.00% 33.33% 100.00% 100.00% 75.00% 100.00% 100.00% 75.00%

Eating Disorder Urgent Patients - 7 Days (Incomplete) 92.00% Above N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

Early Intervention for Psychosis (EIP) - 14 Days (Incomplete) 92.00% Above N/A N/A N/A N/A N/A N/A 100.00% 100.00% 100.00% N/A 100.00% 100.00%

2 Week Wait from GP Referral to 1st Outpatient Appointment (All Cancers) 93.00% Above 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

31 Day Wait from Diagnosis to 1st Definitive Treatment (All Cancers) 96.00% Above 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

31 Day Wait for Subsequent Treatment where Treatment is Surgery 94.00% Above 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% N/A N/A N/A N/A N/A N/A

31 Day Wait for Subsequent Treatment where Treatment is an Anti-Cancer Drug Regime 98.00% Above 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Cancelled Elective Operations (on the day for non-clinical reasons by the hospital) - Patients Not Offered TCI Within 28 Days 0 Below 4 1 0 0 0 0 0 0 0 1 0 2

Number of Urgent Operations Cancelled for the 2nd or More Time 0 Below 0 0 0 0 0 0 1 0 0 1 0 0

Mixed Sex Accommodation Breaches (patients over 16 years) 0 Below 0 0 0 0 0 0 0 0 0 0 0 0

eReferral Utilisation (Percentage booked through eReferrals) N/A N/A 56.69% 71.30% 80.54% 96.04% 95.31% 95.40% 95.58% 100.00% 100.00% 100.00% 100.00% 99.92%

eReferral Appointment Slot Issues per eRS Booking (ASI Ratio) N/A N/A 0.20 0.06 0.12 0.15 0.18 0.13 0.24 0.17 0.13 0.12 0.07 0.16

WNB (Was Not Brought - previously DNA) Rate (New) 9.00% Below 9.45% 11.63% 10.96% 10.08% 12.46% 12.94% 11.67% 9.88% 9.36% 10.56% 8.33% 9.65%

WNB (Was Not Brought - previously DNA) Rate (Follow Up) 11.00% Below 12.43% 12.92% 13.41% 11.97% 13.14% 13.31% 12.46% 11.74% 12.76% 13.65% 11.84% 11.46%

Outpatient Clinic Utilisation - Acute 80.00% Above 74.45% 78.70% 78.03% 80.25% 77.03% 76.66% 78.55% 79.84% 79.33% 76.04% 79.68% 79.40%

Theatres Utilisation 85.00% Above 86.54% 83.55% 85.05% 85.03% 83.42% 87.09% 83.33% 84.29% 82.48% 80.16% 80.48% 82.19%

Contract - % Variance from Plan - A&E 0.00% Above -12.24% -5.82% 2.78% 4.47% 5.72% -5.94% 1.36% 2.71% 3.41% 8.41% 14.10% 7.49%

Contract - % Variance from Plan - Oupatient Attendances 0.00% Above -10.61% -3.22% 8.45% 3.06% 1.12% -15.61% 4.75% -0.66% 3.37% -11.24% 1.45% -3.40%

Contract - % Variance from Plan - Elective Inpatient Spells 0.00% Above -24.03% -7.72% 4.92% 0.36% -9.02% -8.96% -1.43% -17.23% -14.05% -20.75% -12.62% -11.62%

Contract - % Variance from Plan - Non-Elective Inpatient Spells 0.00% Above -9.72% -13.29% -18.47% -12.52% -18.19% -14.98% -6.71% -2.43% -7.91% -7.14% -10.74% -9.26%

Agency spend (£'000) N/A N/A 416 129 111 189 145 126 142 241 190 207 201 292

Income & Expenditure in month position (against control total) £'000 ((surplus)/deficit)) N/A N/A 1242 -210 -58 -204 -92 557 -90 520 131 -599 1237 58

Income & Expenditure cumulative position (against control total) £'000 ((surplus)/deficit)) N/A N/A 434 -210 -268 -472 -564 -7 -97 423 554 -45 1192 1250

£ Delivery of CIP (£'000) N/A N/A 680 0 92 129 300 640 358 414 489 1365 246 458

Percentage Delivery of CIP (against YTD profiled plan) 100.00% Above 56.60% 0.00% 40.26% 39.15% 80.12% 146.48% 81.98% 66.33% 63.84% 80.19% 71.00% 67.66%

Cash Balance (£'000) N/A N/A 20955 17765 16188 15402 17711 17419 16493 16501 15673 16272 14366 14759

Number of FOIs outstanding at the end of the month that are overdue 0 Below - 0 40 82 87 91 92 92 104 120 125 150

Percentage of FOIs outstanding at the end of the month that are overdue 0.00% Below - 0.00% 46.51% 70.09% 67.44% 74.59% 80.70% 82.14% 77.04% 87.59% 76.22% 73.17%

Number of Active Microsystem Projects N/A N/A 0 0 0 0 0 0 0 14 13 13 14 12

Increase in clinical research N/A N/A

Audits / Service Evaluations Inititated N/A N/A 23 28 32 33 22 13 19 22 28 23 25 18

Key:

Green Achievement - performance is in line with the identified target

Red Non-achievement - performance is below the required standard

Discover new ways of

improving child health

through research

Empower motivated

and compassionate

staff

Provide high quality

patient experience and

outcomes

Build clinical and

financial sustainability

Metrics highlighted in grey denote that data is intended for inclusion at a future date 0 Data has been provided, with zero actual, therefore performance is 0.

RAG Data Notes

Blank data Data is not available/has not been provided yet.

N/A Data has been provided, the denominator is zero, therefore percentage cannot be calculated.


Incidents

Note: Managers have 21 days following the incident being reported to complete investigations. The figures shown in the chart above are the amount of incidents pending investigation that are classed as overdue at the end of the reporting period.

Lead: Sally Shearer Timescale: Monthly

Key Issues: • There was a slight increase month on month in reported incidents and reporting levels

for February 2019 exceed that of February 2018. • Number of incidents pending investigation has increased slightly month on month. • Two Serious Incidents including one Never Event reported in the month. • Increase in outstanding SI action plans due to three reports sent to CCG in February.

Key Actions: • Ensure teams continue to complete outstanding SI action plans. • Outstanding incident investigations has slightly risen, Divisions need to ensure

investigations are conducted in a timely manner. • Ensure Divisions continue to provide timely responses to all Complaints received.

3.0 Legal & Governance KPIs

Complaints

Policies & Guidelines

6

Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19Number of Incidents Reported 586 490 515 537 393 321 439 507 357 424 431 Of which are… No of Serious Incidents 0 2 1 0 4 1 1 0 1 0 2 Of which are… Never Events 0 0 1 0 1 0 0 0 0 0 1

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

Trust Total 0 0 0 0 0 527 382 223 146 129 174 0

Target 0 0 0 0 0 0 0 0 0 0 0 0

Previous Year 0 0 0 0 0 0 0 0 0 0 0 0

0

100

200

300

400

500

600

Number of Incidents Pending Investigation that are Overdue - 2018/19

Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

Number of Clinical Guidelines Out of Date 45 44 43 45 52 45 50 53 65 51 47

Number of Policies Out of Date 82 81 63 67 58 53


Trust Total 35.0% 35.3% 81.3% 14.3% 15.4% 30.8% 36.8% 50.0% 47.1% 19.2% 30.0%

Target 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Previous Year

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Percentage of Complaints Responded Within Deadline - 2018/19


% of Clinical Guidelines Out of Date 8.8% 8.4% 8.2% 8.7% 9.8% 8.4% 9.3% 9.8% 12.0% 9.4% 8.6%

% of Policies Out of Date 44.3% 44.3% 34.4% 36.2% 31.9% 29.0%

Target 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

50.00%

Percentage of Clinical Guidelines and Policies Out of Date - 2018/19


Friends & Family Test – Response Rate

Note: the target line shown above is based on the national average for the previous financial year.


Key Issues: • The Trust continues to work on a set of actions to improve uptake across all areas. • The Friends and Family Netcall module continues to see an increased uptake in

response rates within ED.

Key Actions: • Work is being undertaken to implement a new data collection method from April

following the discovery of patients’ ability to submit multiple returns.

4.0 Friends & Family KPIs

Friends & Family Test – Percentage Recommended

Note: the target line shown above is based on the national average for the previous financial year.

Staff Friends & Family Test – Q2 2018/19

The table below shows the latest quarterly information for the staff friends & family return: Notes: 1. Staff FFT data is reported on a quarterly basis (however there is no submission for Q3). 2. Percentages for Recommended and Not Recommended may not equal 100%. This is due to neutral responses being selected (these include ‘Neither likely nor unlikely’ and ‘Don't know’).

7


Current Year 85.4% 85.2% 83.1% 79.1% 82.3% 83.8% 83.4% 81.1% 81.8% 77.0% 80.1%

Previous Year 94.1% 96.9% 94.7% 94.5% 88.2% 90.4% 87.9% 90.8% 86.3% 87.0% 87.9% 85.1%

Target 92.1% 92.1% 92.1% 92.1% 92.1% 92.1% 92.1% 92.1% 92.1% 92.1% 92.1% 92.1%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Percentage Recommended


Current Year 4.0% 2.8% 4.9% 6.0% 6.6% 8.1% 9.3% 9.5% 10.4% 8.0% 8.1%

Previous Year 2.2% 1.3% 2.0% 1.9% 2.1% 1.8% 2.0% 2.3% 2.1% 2.0% 3.6% 3.1%

Target 7.6% 7.6% 7.6% 7.6% 7.6% 7.6% 7.6% 7.6% 7.6% 7.6% 7.6% 7.6%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

Response Rate

RecommendNot

RecommendRecommend

Not

Recommend

How likely are you to recommend this organisation to friends and

family if they needed care or treatment991 25 90% 2%

How likely are you to recommend this organisation to friends and

family as a place to work691 175 63% 16%

Volume %


Patient Experience – Mixed Sex Accommodation


Key Issues: N/A

Key Actions: N/A

Patient Experience – Cancelled Operations

Lead: Ruth Brown Timescale: Monthly

Key Issues: • There were two patients who had their

operations cancelled on the day for non-clinical reasons who were subsequently not accommodated within the 28-day standard.

Key Actions:

• All on the day cancellations continue to

be managed closely and prioritised accordingly to accommodate as soon as possible after cancellation.

Patient Safety – Infection Control

Notes: 1. Data for number of cases is now reported monthly in arrears due to the processing time required for the samples. 2. Number of C.Diff Cases Per Month are trust attributable cases where there has been a lapse in care (i.e. avoidable) and the target of 2 is for the whole year. 3. The number of C.Diff Cases that have not been determined as avoidable or unavoidable are also highlighted in amber in the table above.


Key Issues: • There were no infection control issues experienced during January.

Key Actions: • Ongoing monitoring of standards.

5.0 Safety & Patient Experience Indicators 8

Target Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Total

Number of C.Diff Cases (Hospital Attributable) - 1 2 0 1 1 0 0 2 1 1 9

Of which are… No of Avoidable Cases 2 0 0 0 0 0 0 0 0 0 0 0

Of which are… No of Unavoidable Cases - 1 2 0 1 1 0 0 0 0 0 5

Of which are… No of TBC Cases - 0 0 0 0 0 0 0 2 1 1 4

Number of MRSA Cases (Hospital Attributable) 0 0 0 0 0 0 0 0 0 0 0 0

Number of MSSA Bacteraemia Cases (Hospital Attributable) N/A 0 1 0 1 1 2 0 0 2 0 0

High Risk Elective Patients - Percentage Screened 100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%


Cancelled Elective Operations (on the day for

non-clinical reasons by the hospital) - Patients

Not Offered TCI Within 28 Days

0 1 0 0 0 0 0 0 0 1 0 2 4

Number of Urgent Operations Cancelled for the

2nd or More Time0 0 0 0 0 0 1 0 0 1 0 0 2


Mixed Sex Accommodation Breaches (patients

over 16 years)0 0 0 0 0 0 0 0 0 0 0 0 0


Acute & Brief CWAMH Discharge Summaries (completed within 24 hours)


Key Issues: • The number of discharge summaries completed continues to remain below target.

Key Actions: • Work continues within Divisions and a pilot is being developed on two wards to

implement a policy of only allowing a patient discharge once a discharge summary has been completed.

CWAMH Discharge Summaries – Full (completed within 2 Weeks)

6.0 Discharge Summaries 9


Completed 76.8% 77.9% 75.0% 78.0% 81.4% 74.4% 72.0% 70.8% 79.2% 77.1% 77.9% 0.0%

Completed Within 24 Hrs 70.4% 72.3% 70.1% 70.2% 75.2% 69.4% 67.8% 66.9% 70.7% 71.8% 71.1% 0.0%

Prev Yr - Completed 80.3% 82.5% 76.9% 78.0% 80.5% 79.4% 77.6% 83.2% 83.1% 80.9% 81.6% 80.1%

Prev Yr - Completed Within 24 Hrs 70.5% 75.4% 73.3% 72.8% 76.7% 73.7% 72.3% 76.7% 74.0% 76.0% 74.1% 75.4%

Target 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Trust Total

Percentage of Discharge Summaries Completed (and within 24 Hours of Discharge Date) - 2018/19


Completed 87.5% 100.0% 100.0% 100.0% 100.0% 100.0% 66.7% 100.0% 100.0% 100.0% 83.3% 0.0%

Completed Within 2 Wks 50.0% 100.0% 33.3% 66.7% 27.3% 66.7% 33.3% 100.0% 75.0% 50.0% 33.3% 0.0%

Prev Yr - Completed 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 62.5%

Prev Yr - Completed Within 2 Wks 14.3% 0.0% 0.0% 11.1% 0.0% 12.5% 0.0% 50.0% 50.0% 33.3% 50.0% 25.0%

Target 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

CWAMH

Percentage of Full Discharge Summaries Completed (and within 2 weeks of Discharge Date) - 2018/19


Key Issues: • The number of discharge summaries completed continues to remain below target.

Key Actions: • Work continues within Divisions and a pilot is being developed on two wards to

implement a policy of only allowing a patient discharge once a discharge summary has been completed.


Sickness Absence Levels – All Staff (% of Time Lost)

Please note: Sickness reporting runs a month in arrears.

Lead: Steve Ned Timescale: Monthly

Key Issues: • Sickness absence during January in terms of time lost was 4.45%. This is an increase

on the previous month and attributable to the winter period. The figure continues to remain lower than last year and since the implementation of the revised sickness absence policy.

• PDR compliance reduced slightly in comparison to the previous month at 74% against the 90% target.

• Mandatory training compliance remained static on the previous month at 86% against the 90% target.

Key Actions: • Sickness absence, PDR and Mandatory Training compliance is routinely discussed at

Executive level with Divisional management teams as part of the Performance and Quality Review Meetings. This enables assurance to be provided that these areas are being managed appropriately.

7.0 Workforce - Sickness Absence & Training KPIs

PDR Compliance – All Staff

Mandatory Training Compliance – All Staff

10


Trust Total 3.74% 3.16% 3.38% 3.93% 3.99% 4.12% 3.89% 3.71% 3.92% 4.45%

Target 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00%

Previous Year 4.68% 4.92% 4.85% 4.80% 4.75% 4.59% 5.18% 4.65% 4.80% 4.73% 4.21% 3.97%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

Sickness Absence - 2018/19


Trust Total 80.00% 79.00% 75.00% 76.00% 76.00% 76.00% 75.00% 73.00% 74.00% 75.00% 74.00%

Target 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00%

Previous Year 71.00% 67.00% 67.00% 69.00% 71.00% 75.00% 79.00% 80.00% 80.00% 79.00% 77.00% 82.00%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

PDR Compliance - 2018/19


Trust Total 88.00% 87.00% 85.00% 85.00% 86.00% 85.00% 85.00% 85.00% 85.00% 86.00% 86.00%

Target 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00%

Previous Year 85.00% 85.00% 84.00% 85.00% 86.00% 86.00% 86.00% 87.00% 88.00% 88.00% 88.00% 88.00%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Mandatory Training Compliance - 2018/19


Activity Performance - A&E Attendances

A&E Quality Indicators & Ambulance Handovers

8.0 Accident & Emergency and Ambulance Handovers

A&E 4 Hour Waits (95% of Patients Seen & Discharged/Admitted Within 4 Hours)


Key Issues: • Performance within ED continues to exceed the national standard of 95% of

patients being seen and discharged or admitted within four hours. • ED Unplanned re-admission rates remain higher than the national target of 5%

(this is for both adults and children). However, audits indicate that this is not as a result of poor patient outcomes.

Key Actions: • The standard is routinely monitored on an ongoing basis with pressures within ED

and patient flow operationally managed as and when they occur.

11

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

A&E 4 Hour Waits Performance2018/19

% Waiting under 4 Hours Target Previous Year

Area Indicator Data Period Target Aim Actual YTD Last 6 Months Trend

A&E 4+ Hour Waits February 95% Above 96.80% 97.47%

A&E Time to Initial Assessment for Patients

Arriving by Ambulance (95th Percentile)February 00:15:00 Below 00:12:00 00:12:00

A&E Median Time to Treatment February 01:00:00 Below 00:47:00 00:35:00

A&E Unplanned Reattendance Rate February 5% Below 9.49% 8.84%

A&E Left Without Being Seen February 5% Below 1.41% 1.22%

Percentage of Ambulance Handovers Within 15

MinutesFebruary 100% Above 99.10% 96.38%

Percentage of Ambulance Handovers Within 30

MinutesFebruary 100% Above 100.00% 100.00%

Number of Ambulance Handover Times Between

30 & 60 MinutesFebruary 0 Below 0 0

Number of Ambulance Handover Times Over 60

MinutesFebruary 0 Below 0 0

Accident and

Emergency

Ambulatory

0

1000

2000

3000

4000

5000

6000

Ap

r-1

8

Ma

y-1

8

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

De

c-18

Jan

-19

Feb

-19

Ma

r-19

Act

ivit

y


Actual 4477 5095 4960 4927 3363 4567 5206 5408 5370 5227 4911

Plan 4754 4957 4748 4660 3575 4506 5069 5230 4954 4582 4569

Previous Year 4546 4983 4728 4790 3617 4610 5409 5333 4963 4533 4614

Variance From Plan -5.8% 2.8% 4.5% 5.7% -5.9% 1.4% 2.7% 3.4% 8.4% 14.1% 7.5%

A&E Attendances


9.0 Referral to Treatment (18 Weeks)

RTT Incomplete Performance (92% of Patients Waiting Under 18 Weeks For Treatment)


Key Issues: • Trust performance continued to remain above the 92% target during February. • The standard was achieved at Divisional level with the exception of Surgery and

Critical Care. • There was one patient waiting over 52 weeks for treatment. This was due to a

pathway error and a definitive treatment is scheduled to take place during March.

Key Actions: • The cause of the breach has been investigated and where possible steps put in

place to minimise potential for future recurrence. • Long-wait patients continue to be reviewed, discussed and actively managed at

weekly Divisional PTL Meetings.

RTT Incomplete Performance by Division

Number of Patients On Incomplete Pathways Over 52 Weeks

Underperforming Specialties Ranked by Margin (Volume)

12

Month Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

52+ Weeks 0 0 0 0 0 0 0 0 0 0 1

Month Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

MED 95.20% 94.82% 94.19% 93.68% 93.50% 92.58% 94.03% 94.09% 93.30% 94.30% 93.63%

S&CC 92.37% 92.76% 92.28% 92.17% 91.45% 90.83% 92.21% 92.44% 90.71% 91.02% 90.52%

PDG 94.49% 94.71% 94.99% 94.48% 94.35% 94.58% 95.44% 93.33% 93.88% 94.29% 92.25%

Trust Total 93.81% 93.86% 93.37% 93.07% 92.67% 92.03% 93.39% 93.24% 92.19% 92.76% 92.05%

86.00%

88.00%

90.00%

92.00%

94.00%

96.00%

98.00%

100.00%

Feb

-18

Mar

-18

Ap

r-18

May

-18

Jun

-18

Jul-

18

Au

g-18

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan-

19

Feb

-19

Trust Total Incomplete Performance February 2018 - February 2019

Trust Total MEDicine S&CC PDG Target

Division Local Specialty Performance %Excess Breaches (over

the 8% allowance)

MEDicine Neuro-Disability 78.47% 50

Surgery & Critical Care Paediatric Dentistry 61.19% 42

Surgery & Critical Care Trauma & Orthopaedics 88.79% 22

Surgery & Critical Care Exodontia 82.76% 11

Surgery & Critical Care Paediatric Surgery 90.40% 11

Surgery & Critical Care Pain Clinic 82.19% 8

Surgery & Critical Care Scoliosis 85.83% 8

Surgery & Critical Care Neurosurgery 85.44% 7

Surgery & Critical Care Ophthalmology 90.21% 7

MEDicine Paediatric Nephrology 84.81% 6

MEDicine Respiratory 90.53% 3

Surgery & Critical Care Eye Dept - Orthoptic 75.00% 2

Surgery & Critical Care Plastic Surgery 91.40% 2

MEDicine TB 83.33% 1


Long Stay Inpatients (Number of Acute and CAMHS Inpatients with Length of Stay of 30+ Days (as at the end of the month))

Lead: Jeff Perring Timescale: Monthly

Key Issues:

• Work is currently ongoing to further understand Length of Stay across the Trust. • This work has been brought into the work-stream focussing specifically on complex

patients and will continue into this year with the core work providing the basis for service development options.

Key Actions:

• Length of Stay information continues to be routinely circulated to bed-holding Divisions to ensure that a co-ordinating consultant is in place, along with a care plan and estimated date of discharge (where possible).

10.0 Diagnostics (DM01) & Long Stay Inpatients 13

Diagnostic (DM01) Waiters (99% of Patients Waiting Under 6 Weeks For Diagnostic Test)


Key Issues:

• The diagnostic standard was not achieved during February with 98.19% of patients waiting less than six weeks for their test against the national target of 99%.

• Non-achievement of the standard was as a consequence of two patients in Surgery and Critical Care. The remaining breaches encountered within Medicine were due to a recording error.

Key Actions:

• The Medical Division is currently undertaking work with the Performance Team to address any issues and gain consistency of understanding of terms used between clinical and non-clinical teams.


Current Year 36 42 33 34 35 28 36 37 32 29 34

Previous Year 36 39 39 33 30 26 27 23 22 32 38 36

0

5

10

15

20

25

30

35

40

45

Long Stay Inpatients (30+ Days)

80.00%

82.00%

84.00%

86.00%

88.00%

90.00%

92.00%

94.00%

96.00%

98.00%

100.00%

Feb

-18

Mar

-18

Ap

r-18

May

-18

Jun

-18

Jul-

18

Au

g-18

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan-

19

Feb

-19

Trust Total DM01 Performance

February 2018 - February 2019

Trust Total MEDicine S&CC PDG Target

Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19

MED 99.29% 99.50% 99.50% 99.27% 99.11% 99.33% 99.15% 98.82% 99.20% 98.41% 99.15% 99.24% 96.42%

S&CC 96.30% 94.74% 100.00% 100.00% 98.51% 100.00% 100.00% 100.00% 95.24% 100.00% 91.30% 92.16% 97.14%

PDG 100.00% 99.75% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Trust 99.48% 99.52% 99.75% 99.67% 99.42% 99.68% 99.58% 99.48% 99.50% 99.29% 99.09% 99.22% 98.19%


CAMHS ED (Eating Disorder) and EIP (Early Intervention for Psychosis) Incomplete Performance (92% of Patients Waiting Under 18 Weeks)

Data notes: due to the small number of patients on ED / EIP pathways, individual cases can have a large impact on the percentage performance.


Key Issues: • Incomplete performance for EIP

continued to be achieved at 100%. • Incomplete performance for ED routine

patients deteriorated in-month, though patient numbers remain low.

Key Actions: • Ongoing monitoring.

CAMHS Tier 3 Incomplete Performance (92% of Patients Waiting Under 18 Weeks)


Key Issues: • Referral to Assessment remains above the 92% agreed with Commissioners. • Performance in relation to Referral to Treatment continues to improve.

Key Actions: • The service is currently undertaking multiple work-streams to improve waiting times,

including: demand and capacity pathway reviews with Transformation teams; introduction and review of the new "Six Session" model. As previously noted, wait times may increase during this period due to the impacts of the introduction of EPR across the service, including both training and post go-live activity.

11.0 CAMHS Waiting Times 14

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%


Wait to 1st Appt 95.90% 96.31% 97.05% 97.36% 99.35% 97.85% 96.15% 99.39% 96.67% 95.00% 94.34% 96.15% 93.53%

Wait to 2nd Appt 61.15% 59.64% 54.94% 55.94% 57.64% 62.12% 61.42% 65.69% 65.37% 62.88% 67.12% 74.95% 74.19%

Target 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00%

CAMHS Tier 3 Incomplete Performance


0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

CAMHS ED & EIP Incomplete Performance


ED Routine

ED Urgent

EIP

Target


ED Routine (< 28 Days) 0 4 1 4 2 3 1 1 5 3 6 4 3

ED Routine (Total) 0 5 2 4 2 3 3 1 5 4 6 4 4

ED Routine N/A 80.00% 50.00% 100.00% 100.00% 100.00% 33.33% 100.00% 100.00% 75.00% 100.00% 100.00% 75.00%

ED Urgent (< 7 Days) 0 0 0 0 0 0 0 0 0 0 0 0 0

ED Urgent (Total) 0 0 0 0 0 0 0 0 0 0 0 0 0

ED Urgent N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

EIP (< 14 Days) 0 0 0 0 0 0 0 2 1 1 0 1 1

EIP (Total) 0 0 0 0 0 0 0 2 1 1 0 1 1

EIP N/A N/A N/A N/A N/A N/A N/A 100.00% 100.00% 100.00% N/A 100.00% 100.00%

Incomplete Pathways


12.0 Cancer Waits 15

Cancer Waits – 2 Week & 31 Day Waits


Key Issues and Actions: • All cancer waits continue to be achieved at 100%.


Previous year 100.00%100.00%100.00%100.00%100.00%100.00%100.00%100.00%100.00%100.00%100.00%100.00%

Current year 100.00%100.00%100.00%100.00%100.00%100.00%100.00%100.00%100.00%100.00%100.00%

Target 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00%

50.00%

55.00%

60.00%

65.00%

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

2 Week Wait from GP Referral to 1st Outpatient Appointment (All Cancers)


Previous year 100.00% 100.00%100.00% 100.00% 100.00%100.00% 100.00% 100.00%100.00% 100.00% 100.00%100.00%

Current year 100.00% 100.00%100.00% 100.00% 100.00%100.00% 100.00% 100.00%100.00% 100.00% 100.00%

Target 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00%

50.00%

55.00%

60.00%

65.00%

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

31 Day Wait from Diagnosis to 1st Definitive Treatment (All Cancers)


Previous year 100.00%100.00% 100.00%100.00% 100.00% 100.00%100.00%

Current year 100.00%100.00%100.00%100.00%100.00%

Target 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00%

50.00%

55.00%

60.00%

65.00%

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

31 Day Wait for Subsequent Treatment where Treatment is Surgery


Previous year 100.00% 100.00%100.00% 100.00% 100.00%100.00% 100.00% 100.00% 100.00% 100.00%100.00%

Current year 100.00% 100.00%100.00% 100.00% 100.00%100.00% 100.00% 100.00%100.00% 100.00% 100.00%

Target 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00%

50.00%

55.00%

60.00%

65.00%

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

31 Day Wait for Subsequent Treatment where Treatment is an Anti-Cancer Drug Regime


eRS Appointment Slot Issue (ASI) Ratio Comparison

The graph below shows the ASI ratio for the current financial year, previous financial year, with a comparison against the agreed trajectory target and to the national average for the current year. Notes: 1. The Appointment Slot Issue (ASI) Ratio is calculated as the Total ASIs/Total Bookings

for the stated time period 2. National ASI data for January & February 2019 was not yet published at the time of

reporting.


Key Issues: • The number of ASIs continued to remain below the national average.

Key Actions: • ASIs along with clinic capacity are routinely reviewed on a daily basis by the

Outpatient service.

eRS Appointment Slot Issues (ASIs)

The table below shows the Appointment Slot Issues encountered in the current reporting month by Division.

17.0 eReferrals Appointment Slot Issues 16


Current Year 0.06 0.12 0.15 0.18 0.13 0.24 0.17 0.13 0.12 0.07 0.16

Previous Year 0.50 0.63 0.57 0.35 0.30 0.24 0.39 0.24 0.25 0.11 0.15 0.20

Current Year National Average 0.20 0.22 0.23 0.22 0.20 0.19 0.20 0.20 0.20

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

eReferrals Appointment Slot Issue Ratio

Division Local SpecialtyAppointment

Slot Issues (ASIs)Total Bookings

Appointment

Slot Issues (ASI)

Ratio

MEDicine Allergy 41 136 0.30

Clinical Haematology 9 5 1.80

Continence Service 42 8 5.25

Dermatology 67 99 0.68

Endocrinology 39 0.00

Haemophilia 1 -

Hepatology 2 0.00

Immunology 11 0.00

Lipid 3 0.00

Metabolic Bone Disease 1 2 0.50

Oncology 1 -

Paediatric Nephrology 2 -

Paediatric Neurology 84 0.00

Paediatrics 4 314 0.01

Respiratory 47 0.00

Rheumatology 8 15 0.53

Sleep Clinic 2 7 0.29

UTI/Daytime Wetting 2 0.00

MEDicine Total 178 774 0.23

Surgery & Critical Care ENT 1 331 0.00

Fracture 2 0.00

Neurosurgery 1 1 1.00

Ophthalmology 4 166 0.02

Paediatric Surgery 86 191 0.45

Pain Clinic 2 2 1.00

Plastic Surgery 5 43 0.12

Scoliosis 2 9 0.22

Trauma and Orthopaedics 2 275 0.01

Surgery & Critical Care Total 103 1020 0.10

Grand Total 281 1794 0.16

Notes:

1. The Appointment Slot Issue (ASI) Ratio i s ca lculated as the Tota l ASIs/Tota l Bookings for the s tated time period

2. Where there are ASIs but zero bookings within a service, the ratio wi l l be displayed as - and highl ighted in red

No Appointment Slot Issues

Appointment Slots Issue Ratio > 0 and < 1

Appointment Slot Issue Ratio > 1 (meaning there are more ASIs than appointments booked)

RAG Rating Key:

eReferrals Appointment Slot Issue (ASI) Ratio - February 2019


Outpatient Clinic WNB – Follow-up Appointments

18.0 Outpatient Clinic WNB (Was Not Brought – Previously DNA) 17

Outpatient Clinic WNB – New Appointments


Key Issues: • Was Not Brought rates for first appointments increased slightly during February. • The level does however, remain at its one of the lowest during the current fiscal

year and is a 1% reduction on the same period last year.

Key Actions: • A campaign to encourage parents and carers to pass on their appointments when

they are unable to attend was launched in March. The impact of the campaign will be closely monitored as part of the Outpatient Programme Board and as part of the Modernising Outpatients Programme.


Key Issues: • Was Not Brought rates for follow-up appointments reduced during February. • The level continues to remain lower than last year.

Key Actions: • A campaign to encourage parents and carers to pass on their appointments when

they are unable to attend was launched in March. The impact of the campaign will be closely monitored as part of the Outpatient Programme Board and as part of the Modernising Outpatients Programme.


Current Year 11.6% 11.0% 10.1% 12.5% 12.9% 11.7% 9.9% 9.4% 10.6% 8.3% 9.6% 0.0%

Previous Year 10.9% 11.1% 10.9% 10.0% 11.0% 10.6% 9.0% 9.8% 11.0% 11.0% 10.6% 9.3%

Target 9.0% 9.0% 9.0% 9.0% 9.0% 9.0% 9.0% 9.0% 9.0% 9.0% 9.0% 9.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

Trust Total Outpatient WNB Rate (%) - New Appointments


Current Year 12.9% 13.4% 12.0% 13.1% 13.3% 12.5% 11.7% 12.8% 13.7% 11.8% 11.5% 0.0%

Previous Year 13.5% 13.9% 14.0% 13.3% 13.4% 13.6% 12.8% 11.3% 14.9% 13.2% 12.3% 12.3%

Target 11.0% 11.0% 11.0% 11.0% 11.0% 11.0% 11.0% 11.0% 11.0% 11.0% 11.0% 11.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

Trust Total Outpatient WNB Rate (%) - Follow-up Appointments


Specialties ranked by % of patients on the review list who are overdue (Latest Snapshot: 28/02/2019)

Outpatient Review List (Patients waiting past their review date)

Note: the figure shown in the grey box on the chart denotes the longest waiter in weeks at the point the snapshot was taken.


Key Issues: • The Trust continues to have significant overdue review lists in a number of areas.

Key Actions: • Work is continuing in a number of areas to both administratively and clinically

validate outpatient review lists. • A plan and trajectory is in place to accommodate all review list patients within

Surgery peripheral clinics. Work is being undertaken to bring the clinic management and appointment booking back in-house.

19.0 Outpatient Review List 18

148 153 157 159 164 1490

1000

2000

3000

4000

5000

6000

Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19

Outpatient Review List - Overdue Patients by Due DateSeptember 2018 – February 2019

0-3 Months 3-6 Months 6+ Months

Division Local Specialty % Overdue Total OverdueLongest Wait

(Weeks)

MEDicine TB 54.05% 20 12

Surgery & Critical Care PSU Peripheral Clinic 50.35% 430 149

MEDicine Neuro-Disability 39.43% 1305 82

MEDicine Neurofibromatosis 31.88% 22 13

MEDicine Sleep Clinic 26.70% 59 24

Surgery & Critical Care Refraction 24.75% 196 107

Surgery & Critical Care Ophthalmology 23.40% 299 80

MEDicine Gastroenterology 21.01% 352 13

MEDicine Immunology 20.05% 89 24

MEDicine Paediatric Neurology 19.52% 219 19

MEDicine Lipid 19.51% 16 29

MEDicine Paediatric Nephrology 18.16% 77 15

MEDicine Paediatric Dietetics 17.78% 16 4

MEDicine Metabolics 16.78% 24 19

MEDicine Allergy 15.58% 440 31

MEDicine Cystic Fibrosis 15.00% 6 8

Surgery & Critical Care ENT 14.46% 215 23

Surgery & Critical Care Paediatric Surgery 14.46% 170 47

MEDicine Rheumatology 14.24% 41 20

MEDicine Dermatology 11.90% 110 34

MEDicine Hearing Services - Audiology 11.42% 165 5

MEDicine Respiratory 11.33% 133 16

Surgery & Critical Care Scoliosis 10.87% 66 24

Surgery & Critical Care Pain Clinic 10.17% 30 9

Surgery & Critical Care Orthoptic 9.99% 73 50

MEDicine Endocrinology 9.44% 84 41

MEDicine Cardiology 8.68% 69 13

MEDicine Constipation 7.69% 7 0

MEDicine Epilepsy Nurse Clinic 7.53% 7 11

MEDicine Continence Service 6.99% 39 28

MEDicine Paediatrics 5.81% 37 4

MEDicine Metabolic Bone Disease 5.74% 14 12

Surgery & Critical Care Plastic Surgery 5.41% 12 7

Surgery & Critical Care Neurosurgery 4.82% 16 8

Surgery & Critical Care Trauma and Orthopaedics 3.78% 83 32

Surgery & Critical Care Limb Reconstruction 2.20% 4 1

MEDicine Home Oximetry Test 1.47% 1 0

MEDicine Community Paediatrics 0.83% 4 4


Theatre Utilisation

The data is calculated based on elective lists only and excludes Audit and Bank Holiday Lists, and any MRI lists or external theatre activity. Where a list is scheduled to run all day, these are counted as 2 sessions. Theatre Utilisation shows the percentage of time used in theatre (touch time) of the total planned theatre time. Touch Time has been calculated using the minutes between Enter Anaesthetic Room and Enter Recovery. This is in line with the national methodology used by NHSI and Four Eyes. Planned Theatre Time has been calculated by counting all day lists as 420 mins and AM/PM lists as 210 mins.


Key Issues: • Theatre utilisation increased throughout February and was higher than the same

period last year.

Key Actions: • Theatre utilisation is continued to be monitored routinely and work to maximise

utilisation and throughput undertaken on an ongoing basis.

20.0 Outpatient Clinic & Theatre Utilisation 19

Outpatient Clinic Utilisation

The data and graph below show the utilisation rates for outpatient clinics at trust level. Notes: Utilisation rate is calculated by the following method: Total Attends / Total Slots. Missing Attendance Indicator refers to where it has not yet been recorded on the system whether the patient attended or not.


Key Issues: • Clinic utilisation was marginally below the Trust target of 80% throughout February.

Utilisation continues to be an improving position on the previous year.

Key Actions: • Clinic utilisation is continuing to be reviewed on an on-going basis as part of the

Modernising Outpatients Programme. • Forward Look meetings have been introduced between the Outpatient service and

Clinical Divisions to review clinics and actively address any utilisation issues.

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

Position

Attends 78.70% 78.03% 80.25% 77.03% 76.66% 78.55% 79.84% 79.33% 76.04% 79.68% 79.40% 78.57%

Was Not Brought (WNB) 12.34% 12.57% 11.35% 12.50% 13.13% 12.27% 11.53% 12.09% 12.60% 11.03% 11.41% 12.05%

Patient Cancellations - On the Day 2.04% 1.65% 1.66% 2.01% 1.69% 1.86% 1.86% 1.83% 2.41% 2.00% 2.13% 1.91%

Patient Cancellations - 24 - 72 Hours Notice 0.96% 1.05% 0.86% 0.95% 0.79% 1.07% 0.95% 1.06% 1.23% 1.07% 0.85% 0.99%

Missing Attendance Indicator 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.02% 0.00%

Vacant (Patient Cancellations >72 Hours Notice)0.68% 0.86% 0.74% 0.98% 1.05% 0.87% 0.74% 0.48% 0.82% 0.58% 0.74% 0.77%

Vacant Slots 5.28% 5.85% 5.13% 6.53% 6.68% 5.38% 5.09% 5.21% 6.89% 5.63% 5.46% 5.71%

Current Year Utilisation (%) 78.70% 78.03% 80.25% 77.03% 76.66% 78.55% 79.84% 79.33% 76.04% 79.68% 79.40% 78.57%

Target Utilisation (%) 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%

Previous Year Utilisation (%) 76.6% 76.5% 77.6% 77.3% 76.2% 75.9% 75.8% 77.8% 73.6% 75.9% 75.1% 74.5% 76.1%

Trust Total

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Attends Was Not Brought (WNB) Patient Cancellations - On the Day

Patient Cancellations - 24 - 72 Hours Notice Missing Attendance Indicator Previous Year Utilisation (%)


Current Year 83.6% 85.0% 85.0% 83.4% 87.1% 83.3% 84.3% 82.5% 80.2% 80.5% 82.2%

Previous Year 86.2% 85.9% 83.1% 82.1% 83.2% 82.2% 88.2% 83.8% 78.6% 82.5% 80.0% 82.4%

Target 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Theatre Utilisation


Activity Performance – Outpatient Attendances (1st & FUp)


Key Issues: • Outpatient attendances are currently below plan by 524 episodes. • Elective inpatient and daycases are below plan by 200 episodes. • Non-elective inpatients are below plan by 49 episodes.

Key Actions: N/A

21.0 Activity v Plan: Outpatients and Inpatients

Activity Performance - Elective Inpatients (IP & DC)

Activity Performance – Non-Elective Inpatients

20

0

500

1000

1500

2000

2500

Ap

r-1

8

Ma

y-1

8

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

De

c-18

Jan

-19

Feb

-19

Ma

r-19

Act

ivit

y


Actual 1409 1682 1609 1528 1529 1505 1636 1624 1295 1652 1519

Plan 1527 1603 1603 1680 1680 1527 1977 1891 1633 1891 1719

Previous Year 1461 1580 1691 1419 1532 1487 1638 1611 1286 1613 1444

Variance From Plan -7.7% 4.9% 0.4% -9.0% -9.0% -1.4% -17.2% -14.1% -20.7% -12.6% -11.6%

Elective Inpatients (IP & DC)

0

100

200

300

400

500

600

700

Ap

r-1

8

Ma

y-1

8

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

De

c-18

Jan

-19

Feb

-19

Ma

r-19

Act

ivit

y


Actual 471 471 472 454 418 522 587 583 600 500 477

Plan 543 578 540 555 492 560 602 633 646 560 526

Previous Year 548 587 563 589 487 568 642 630 615 534 475

Variance From Plan -13.3% -18.5% -12.5% -18.2% -15.0% -6.7% -2.4% -7.9% -7.1% -10.7% -9.3%

Non-Elective Inpatients

0

5000

10000

15000

20000

Ap

r-1

8

Ma

y-1

8

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

De

c-18

Jan

-19

Feb

-19

Ma

r-19

Act

ivit

y


Actual 14192 16759 15836 16261 13395 15344 17559 17625 13121 17192 14916

Plan 14658 15453 15364 16081 15874 14642 17661 17029 14773 16931 15440

Previous Year 12697 15992 15475 15047 13097 15317 15866 17686 13323 16354 13999

Variance From Plan -3.2% 8.5% 3.1% 1.1% -15.6% 4.8% -0.6% 3.5% -11.2% 1.5% -3.4%

Outpatient Attendances (1st & FUp)


Cash Balance (£'000)

Please note: reporting may run a month in arrears.

Lead: Mark Smith Timescale: Monthly

Key Issues: • The Trust is currently c£3.73m behind the planned cash balance of £18.49m with

a balance of £14.759m.

Key Actions: • Refined Capital expenditure profile to be incorporated into Cash Flow projection

Agency Spend (£'000)



Key Issues: • The Trust has been issued with a agency expenditure ceiling by NHS Improvement

of £3,441k for 2018/19, pro-rated evenly throughout the year. This equates to circa 3% of the pay bill.

• The external agency spend is currently tracking below the control target year to date, with a spend of £1.432m against a target of £3.154m.

Key Actions: • Direct engagement of Agency Medical staffing with expected savings factored into

savings plan.

22.1 Finance – Agency Spend & Cash Balance 21


Trust Total 129 240 429 574 700 842 1083 1273 1480 1681 1973 0

Target 241 483 724 965 1207 1448 1689 1930 2172 2413 2654 2896

Previous Year 156 317 553 791 1079 1301 1542 1869 2138 2153 2414 2830

0

500

1000

1500

2000

2500

3000

3500

Agency Spend (£'000) - 2018/19

Cumulative Position


Trust Total 17,765 16,188 15,402 17,711 17,419 16,493 16,501 15,673 16,272 14,366 14,759

Target 21,771 20,280 18,386 18,568 16,778 15,144 16,038 16,804 17,501 18,126 18,490 18,863

Previous Year 30,770 28,447 29,357 29,715 27,903 24,396 21,870 19,721 19,557 21,691 21,870 20,955

0

5000

10000

15000

20000

25000

30000

35000

Cash Balance (£'000) - 2018/19


Cost Improvement Programme (£ Delivery (£’000) and Percentage Delivery (against YTD profiles plan))



Key Issues: • Current CIP performance is £2.151m behind plan for 11 months of the financial

year 2018-19. • Significant year to date Divisional variances against plan are: Medicine - £1.208m behind plan SCC – £966k behind plan

Key Actions: • The CIP programme alongside Income underperformance remain to be the Trusts

greatest risk to Control total achievement.

Income & Expenditure position (against control total) £'000 ((surplus)/deficit))



Key Issues: • Current performance against control total at period 11 (February 19) is £1.29m

behind(deficit) of the YTD control total. • Within this YTD Trust wide performance there are significant variances to

Divisional planned forecast positions at period 11. The expected profile of Divisional financial performance was not seen in the period which worsened the Trust position and is now unlikely to recover. This has resulted in the Trust FOT now moving to £2.0m away from control total (Previously £1.5m)

• Key actions for Divisions is for previously agreed FOT positions to be mitigated.

Key Actions: • Divisions to provide assurance. Mitigation on their FOT position.

22.2 Finance – Income and Expenditure & CIP 22


Trust Total (Cumulative) -210 -268 -472 -564 -7 -97 423 554 -45 1192 1250 0

Previous Year (Cumulative) -452 164 78 -410 -255 -58 -259 -515 -198 -949 -808 434

Plan/Control Total (Cumulative) 0 0 0 0 0 0 0 0 0 0 0 0

-1500

-1000

-500

0

500

1000

1500

Income & Expenditure (against control total) £'000 ((surplus)/deficit)) - 2018/19Cumulative Position


£ Delivery (£'000) 0 92 221 521 1161 1519 1933 2422 3787 4033 4490 0

Percentage Delivered 0.0% 20.1% 28.1% 44.8% 72.6% 74.6% 66.3% 63.8% 80.2% 71.0% 67.7% 0.0%

Target £ Delivery (£'000) 229 459 788 1161 1598 2035 2914 3793 4722 5679 6636 8600

Previous Year £ Delivery 203 421 699 1013 1313 1583 1849 2308 2683 2937 3281 3961

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

0100020003000400050006000700080009000

10000

Cost Improvement Programme - 2018/19

Cumulative Position


23.0 CQUIN 23

Action Required:CCG-1c - Staff Health & W: Flu Vaccinations

CCG-2a - Sepsis Screening

Q1 Q2 Q3 Q4CCG-5 - Transitions out of CAMHS

Claire Pearson This CQUIN is joint with SHSC. Target 3 around patients achieving their tranistion goals has been a challenge to achieve due to patient engagement, transfer of goal information and waitinglist for therapy in Adult services.

SCH is improving the information it hands over to mitigate for this where possible, however this element of transition is likely to be consummed by ongoing agendas and we are unclear as to whether the CCG will accept this.

- - - -90,175 -90,175

- - - -90,175 -90,175 CCG-6 - Advice and Guidance

Jude Stone In Q2 we only had 16 reuqests but failed to achieve the 2 day turn around.

In Q3 we had 31 requests and 97% were returned within 2 working days. In addition we now have 77% of the services we offer providing this service.

- -54,105 - - -54,105

- -54,105 - - -54,105

- - - - -

- - - - -

CCG-1a - Staff Health & W: Staff Survey

Jane Clawson This continues to an unknown outcome until the publication of the Staff Survey results.

Work has been undertaken to address some of the factors relating to this target.

- - - -120,233 -120,233

CCG-2d - Antibiotic Sarah Thompson Multi-faceted approach leading to behaviour change required.Ward rounds need to be more targeted and to be financially secured. No electronic system in Pharmacy. 1 target remains unattainable for SCH currently.

Strategy developed and now being implemented.Ward round funding being secured through the directorates and paper going to TEG. Targets for 2 indicators have been successfully re-negotiated with CCG. Revised target 2 has been submitted to CCG and is yet to be confirmed. CQUIN funding supporting additional clinical support and new pharmacy role, which has been funded going forward into the new financial year.

- - - -30,058 -30,058

- - -45,087 -150,291 -195,379 - -54,105 -45,087 -240,466 -339,659

- 18,035 - 18,035

Projected Finance Risk, £

CWAMHs

This quarter we failed to achieve 2/3 of the Sepsis targets. This had been a sustained improvement and the team are now evaluating how to ensure the paractises are fully embedded.

Only CQUIN Schemes RAG rated Amber or Red are shown below. Forecast financial loss shown by quarter.

Division CQUIN

SCC Total

Targetted work has been undertaken and we have now fully achieved the 75% target. This is a significant achievement.

TOTAL VALUE of CQUIN for 18/19: £3,297,779

MEDicine

MEDicine Total

RAG

Status

Risks Mitigating Actions

Trust Wide

Success Stories:

There are major issues for which there is currently no resolution. Full year financial forecast reduced to £0.

Trust Wide Total

PDG TotalCCG-1 - Staff Health & Wellbeing

CCG-2 - Reducing Impact of serious infections (Sepsis and Antimicrobial resistance)

Total for all CQUINs

The project is on track to being delivered on time and within budget. Full year financial forecast is 100%.

There are problems but they are under control. Each milestone within the project has been RAG rated. Amber milestones which are pass/fail are forecast 100% financial achievement. Those with partial payment are forecast 50% financial

achievement.

Total Projected

Finance Risk, £

CWAMHs Total

SRO


EXECUTIVE SUMMARY

Title M11 January 2019 Financial Report

Report to

Trust Board (Part 1) Date 26 March 2019

Executive Sponsor

Mark Smith - Chief Finance Officer

Author

Simon Alexander - Head of Financial Management

Purpose of report

To provide Board the Trust YTD financial position at Month 11 (February 2019)


Approval Assurance X Information X

Executive summary –the key messages and issues

The Trust reported a deficit of c£56k in period 11 resulting in a £1.29m deficit YTD from control total.

The key issues at Month 11 are:

* CWAMH and Non Clinical Support Divisions now forecasting to be c£0.2m away from FOT. * Period 9 and 10 DPR meetings for CWAMH agreed previous FOT values. Division to provide mitigation to return to original FOT.

How this report impacts on current risks or highlights new risks The Trust has revised the financial FOT performance following M11 performance to under-deliver against the control total by c£2m. This is a deterioration form the previously declared £1.5m under delivery against control total. There are still variables and uncertainties within the position and every possible effort is being made to minimise the gap

Recommendations and next steps Board is asked to:

NOTE the position and key actions around FOT performance of CWAMH, and Non clinical support divisions (Divisions away from “recovery plan” trajectory to mitigate returning to previous FOT).

AGREE the resolution recommended by the Finance and Resources Committee: o That NHS Improvement be notified that the Trust was, likely to miss its 2018/19 control total

by approximately £2.0m, this being subject to year-end position ,ongoing conversations with partners and a detailed review of 18/19 financial initiatives.


KEY MEASURES

Plan Actual Var Plan Actual Var

£m £m £m £m £m £m

I&E: Surplus/(Defict) Control total basis 0.06 0.00 (0.06) (3.07) (4.36) (1.29)

Agency expenditure (NHSI Ceiling= Plan) 0.29 0.29 (0.01) 3.15 2.25 0.90

CIP 0.96 0.46 (0.50) 6.64 4.49 (2.15)

Cash balance 18.49 14.76 (3.73)

Income (15.86) (16.42) 0.57 (175.93) (174.52) (1.41)


£m £m £m £m £m £m

Income: Contracted 14.09 13.72 (0.36) 155.07 151.85 (3.22)

Income: Other 1.77 2.70 0.93 20.86 22.67 1.81

Total income 15.86 16.42 0.57 175.93 174.52 (1.41)

Pay 10.69 11.54 (0.85) 123.12 124.71 (1.59)

Non Pay 3.61 3.70 (0.09) 41.29 43.49 (2.20)

Total Expenditure 14.30 15.24 (0.94) 164.40 168.20 (3.79)

EBITDA 1.56 1.19 (0.37) 11.53 6.32 (5.21)

Non operating expenditure 1.03 0.77 0.27 11.02 6.95 4.07

Surplus/(Defict) 0.53 0.42 (0.12) 0.51 (0.63) (1.14)

Less:items excluded form control total 0.47 0.42 0.05 3.59 3.73 (0.14)

Surplus/(Deficit) Control total basis 0.06 0.00 (0.06) (3.07) (4.35) (1.29)

KEY MEASURES

INCOME AND EXPENDITURE SUMMARY

M11 YTD (February 2019)

M10 YTD (January 2019)

FINANCE REPORT TO THE TRUST EXECUTIVE GROUP 20th March 201911 Months to 28th February 2019

1

Summary Activity Income Expenditure CIP Agency Cash Run Rate Divisional

Key issues:

•For the year to date, the Trust is in a £1.29m deficit position against the control total .

In month the Trusts recorded a £2k surplus against a planned control total surplus position of £58k resulting in a £56k deficit against plan.

The FOT position has moved from being previously c£1.5m deficit to control total to now £2.05m away from control total . In month performance has not recovered YTD performance as expected leading to a revised FOT position

The year to date Trust position of £1.29m deficit is made up of:

Key message:Adverse Divisional financial FOT positions.CWAMH and Non Clinical Divisions are c£.2m adrift from their stated FOT values. Key action for Divisions to confirm and mitigate back to their previously agreed FOT position .

£m

(1.413) Income deficit (£1.966m inc CIP)

Outpatients £1.15m behind plan

Accident and Emergency £367k ahead of plan

EL/Daycase £1.99m behind plan

R&D income £667k ahead of plan

2.080 Pay surplus (£1.59m deficit inc CIP)

Nursing vacancies/cap planning £2.519m surplus

Admin vacancies £721k surplus

Balancing Cap planning surplus

(2.204) Non Pay deficit

Lab equipment and materials £890k above plan

BMT £111k above plan

IT hardware/software £182k above plan

Bought in Services (NHS) £116k above plan

(2.150) CIP shorfall YTD

2.60 Contingency ( £4.06m exc CIP)

(0.141) Control total adj.

(1.29) Control total surplus/(deficit)



2


SLAM ACTIVITY (actual/£) SLAM ACTIVITY (actual/£) Narrative

Key issues:

• Medical activity is circa £3.750m below plan YTD (exc. Drugs and devices). Main areas of underperformance are :

Outpatients £1.15m behind plan - £106k deficit in February

Elective (inc. Day case) activity is £1.99m behind plan. Bone marrow transplant is £393k behind year to date plan

Accident and Emergency is £367k ahead of plan ytd resulting from an additional 1,907 children seen versus the plan based on last years performance.

Key actions:

•Medicine division tasked by the Director of Finance to scope three specialties OP capacity and the reported utilisation rate.

Owner:

Medicine division.

£0

£2,000,000

£4,000,000

£6,000,000

£8,000,000

£10,000,000

£12,000,000

£14,000,000

£16,000,000

Ap

r-17

Ma

y-17

Jun

-17

Jul-1

7

Au

g-17

Sep

-17

Oct-1

7

No

v-17

De

c-17

Jan

-18

Feb

-18

Ma

r-18

Ap

r-18

Ma

y-18

Jun

-18

Jul-1

8

Au

g-18

Sep

-18

Oct-1

8

No

v-18

De

c-18

Jan

-19

Feb

-19

Act

ivit

y £

SLAM Income - 2018-19 (excluding drugs and devices)

£ Price Plan £ Price Actual

Commissioner Price Plan Price Actual Variance

Collaborative 51,401,859 51,334,880 (66,979)

Devolved Admin 201,124 89,901 (111,223)

NHSE 93,438,907 92,729,403 (709,505)

Overseas Visitors 52,767 64,528 11,761

Other 15,632 7,443 (8,189)

Internal (Non Commissioned) 2,966,795 - (2,966,795)

Private Patient 80,301 39,027 (41,274)

Grand Total 149,147,587 145,396,596 (3,750,991)

Total Income performance by Commissioner YTD at M11:


SLAM ACTIVITY SLAM ACTIVITY Narrative


3


-

5,000

10,000

15,000

20,000

25,000

30,000

35,000

Aug-17 Oct-17 Dec-17 Feb-18 Apr-18 Jun-18 Aug-18 Oct-18 Dec-18 Feb-19

Aug-17

Sep-17 Oct-17Nov-

17Dec-17 Jan-18 Feb-18

Mar-18

Apr-18May-

18Jun-18 Jul-18

Aug-18

Sep-18 Oct-18Nov-

18Dec-18 Jan-19 Feb-19

AE 3,617 4,610 5,409 5,333 4,963 4,533 4,614 4,833 4,477 5,095 4,960 4,927 3,363 4,567 5,206 5,408 5,370 5,227 4,911

DC 1,162 1,077 1,230 1,171 941 1,204 1,081 1,052 1,030 1,217 1,171 1,129 1,119 1,092 1,179 1,201 975 1,220 1,124

EL 389 438 427 452 380 420 546 454 392 590 638 436 479 441 456 424 319 432 396

NEL 949 1,162 740 680 731 607 894 917 501 1,075 792 589 512 773 773 538 547 470 421

OP 13,69 16,48 16,87 18,65 14,23 17,31 14,95 15,88 15,43 18,10 17,09 17,59 14,75 16,04 18,60 17,82 13,53 17,80 15,32

Other 5,819 5,439 5,933 6,340 5,187 6,357 5,938 6,048 5,938 5,777 5,921 5,728 5,757 5,116 6,342 7,671 6,492 7,892 7,544

Grand Total 25,63 29,21 30,61 32,62 26,43 30,43 28,02 29,18 27,77 31,86 30,57 30,40 25,98 28,03 32,55 33,07 27,23 33,04 29,72

Activity by POD 2017/18/19 (excluding Drugs and devices) Key issues:

•Outpatients saw an decrease of 14% attendances in February compared to January. For the same period last year Jan-Feb the Trust saw a comparable decrease of 14%.

•Accident and Emergency attendances are currently tracking ahead of attendances for the same period in 2017/18 (2.66%).



4


Key issues:

•Pay costs are £1.59m unfavourable compared to the planned expenditure.

•Removing unmet CIP targets this is £2.07m favourable. The capacity funding set aside has not been fully utilised by divisions to deliver the activity as services explore alternative delivery models to improve efficiency.

•Key Divisional Pay variances:SCC £1.05m surplus (£1.88m removing CIP)£1.408m Nursing vacancies and Cap planning

•In addition, planned developments assumed to commence at the start of the year (i.e. investment in ward nursing establishment -as shown in the Nursing staff graph opposite) has been delayed due to recruitment resulting in the YTD surplus. This along with current vacancies accounts for a large proportion of the Nursing and Medical variance.

Key actions:

•Financial planning and cost pressure asks for 2019-20 are consistent with activity assumptions and FOT expenditure 2018-19.

Owner:•All Divisions to review.



£m £m £m £m £m £m

Drugs/Blood 0.91 0.82 0.09 11.55 11.19 0.35

IT Software/Hardware 0.17 0.17 (0.00) 1.91 2.09 (0.18)

Medical/Laboratory equipment 0.65 0.79 (0.14) 7.15 8.21 (1.06)

Services from NHS organisations 0.50 0.41 0.09 5.46 5.57 (0.11)

Services from Non NHS organisations 0.15 0.17 (0.03) 1.61 1.65 (0.04)

Other 1.24 1.3 (0.09) 13.6 14.8 (1.16)

Total (Surplus/(Deficit)) 3.61 3.70 (0.09) 41.29 43.49 (2.20)

EXPENDITURE (Non Pay)

M11 YTD (Feb 2019)

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19

Trust: Non Pay expenditure

Plan

Actual


5


Key issues:

Non pay expenditure is £2.204m above plan year to February 2019 as a result of:

•Lab equipment and materials £1.06m above plan, the majority of this is offset by additional income from activity over and above that planned at the beginning of the financial year.

•Services from other NHS organisations £116k – SLA values (Maintenance contracts, patient testing)

•Work services £215k, one off costs associated with the relocation of corporate departments to the Moorfoot building and repair/maintenance of CAMH properties

•Bone marrow transplant costs £111k due to activity levels which as previously reported experience a lag in funding based on the child discharge date.

Key actions:

• Continued grip and control procurement measures remain in place and Divisions to ensure no spike in March 2019 expenditure.

Owner:All Divisions/Simon Alexander (Head of Financial Management)



Division breakdown £'000 £'000 £'000 Workstream breakdown £'000 £'000 £'000

CLINICAL SUPPORT 92 94 2 7 Day Services 0 0 0

CWAMH 524 535 11 ACP 0 0 0

FINANCE 216 144 (72) Careful Money Management 2571 3,099 528

MEDICINE 1460 223 (1,236) Enablers 336 342 6

PDG 731 650 (81) ICS 0 0 0

RESEARCH 16 - (16) Improving Flow 67 57 (10)

SCC 1404 424 (980) Modernising Outpatients 0 0 0

NON CLINICAL SUPPORT 307 219 (88) Service Development 380 381 1

HR 37 - (37) Well prepared surgery 0 0 0

CENTRAL 1855 2,202 347 Workforce 1519 612 (907)

Other 1769 (1,769)

TOTAL 6,642 4,491 (2,151) TOTAL 6,642 4,491 (2,151)

-

CIP

YTD (Feb 2019) YTD (Feb 2019)

£-

£1,000

£2,000

£3,000

£4,000

£5,000

£6,000

£7,000

£8,000

£9,000

£10,000

Ap

r-1

8

Ma

y-1

8

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

De

c-18

Jan

-19

Feb

-19

Ma

r-19

2018-19 CIP Performance ('000) Cumulative target

Monthly actual

Monthly target

Cumulative actual


6


Key issues:

•Delivery of the £8.6m efficiency plans at month 10 is £4.49m compared to a profiled plan of £6.64m.The work stream that is significantly behind plan in terms of finance at this stage is Workforce – this has been well documented.

•Under YTD CIP delivery resulting in £2.151m deficit partially offset by pay vacancies and unspent capacity planning funding.

• This element of the Trust’s financial plan remains the most significant risk in terms of delivery.

•

Key actions:

All Divisions and work streams to ensure full transaction of schemes for 2018/19 in M11 and M12.

Owner: All Divisions and Finance leads



7


Key issues:

•The Recovery and transformation board oversee productivity and efficiency schemes which contribute to the CIP target of the Trust and improve financial performance but do not contribute to the CIP target.

Key actions:

• Under delivery of the CIP target is the Trust greatest financial risk alongside Income underperformance against plan. Recovery plans for the Trust current FOT value incorporate all recovery actions and schemes .

Owner:

• All Divisions

Divisional CIP FOT 2018-19

£ Divisional Target £ Divisional FOT

Medicine 1,677,000 181,140

SCC 1,613,000 491,070

CWAMH 602,000 617,480

PDG 840,000 721,600

Finance 248,000 147,500

HR 43,000 -

Non-Clinical Support 353,000 460,000

Research 18,000 -

Clinical Support 106,000 104,040

Central 682,696

Total 5,500,000 3,405,526 (2,094,474)

Key issues (FOT):

• Current Divisional forecast outturn of CIP shows a deficit of c£2m against the Divisional plan of £5.5m

Divisional CIP by workstream (M11 and YTD)

Division Workstream Sum of Feb 19 Sum of YTD Total

CSUP Careful Money Management 8 73

Workforce - 20

CSUP Total 8 94

CWAMH Careful Money Management 218 431

Enablers -

Service Development 2 19

Workforce 85 85

CWAMH Total 305 535

Estates Enablers 14 75

Estates Total 14 75

Finance Careful Money Management 69

Finance Total - 69

MEDicine Careful Money Management 7 145

Enablers 21

Workforce 57

MEDicine Total 7 224

Non-Clinical inc IMT Workforce 50 219

Non-Clinical Total - 219

PDG Careful Money Management 3 21

Improving Flow 7 72


Workforce 21 220

PDG Total 67 650

S&CC Careful Money Management 9 119

Enablers 108


Workforce 25 187

S&CC Total 34 424

Central Careful Money Management 35 2,202

Central Total 119 2,202

Grand Total 246 4,492



8

Summary Activity Income Expenditure CIP Agency Cash Run Rate Forecast Divisional

AGENCYEXPENDITURE AGENCYEXPENDITURE-Narrative

Key issues:

• Agency spend for the year to date is £1.43m (exc. NHSP) which is a significant improvement compared to 2017/18 run rate.

•Agency admin and clerical has decreased considerably in 2018-19 due to the conclusion of the admin review and subsequent substantive recruitment.

•The NHSI Trust ceiling is £3.441m with a ytd value of £2.687m. The Trust is currently tracking well within this requested ceiling with a ytd expense of £1.43m.

Key actions:

•Direct engagement with current Medical agency staff commenced in October 2018 (VAT savings built into FOT).

Medical Staff25%

Nursing staff41%

Allied Health Proffesionals

0%

Professional & Technical

1%

Admin & Clerical

30%

Ancillary Staff3%

Analysis of Agency Spend by Type YTD

Expenditure to dateTotal Pay Spend £ Substantive/NHSP Pay £ Agency Spend YTD £ NHSI Target YTD £ NHSI Target £

MEDICINE £35,538,702 £35,205,863 £332,839 £917,439 £1,000,842SURGERY & CRITICAL CARE

£29,647,476 £29,498,801 £148,675 £818,113 £892,487

COMMUNITY SERVICES& WAMH

£21,689,625 £21,145,674 £543,951 £555,044 £605,503

DIAGNOSTICS &PHARMACY

£13,378,565 £13,364,858 £13,707 £350,858 £382,754

FINANCE £1,603,342 £1,481,108 £122,233 £39,953 £43,585HUMAN RESOURCES £6,088,287 £6,079,048 £9,239 £151,280 £165,033CLINICAL SUPPORT £4,800,833 £4,692,512 £108,321 £112,338 £122,550NON CLINICAL SUPPORT £5,314,012 £5,160,568 £153,444 £187,863 £204,941RESEARCH INNOVATION& PROJECTS

£1,120,738 £1,120,738 £0 £21,363 £23,305

Total £119,181,580 £117,749,171 £1,432,409 £3,154,250.00 £3,441,000



9


Key Risks• 2018/19 projected closing cash balance of £13.5m is

maintained

• Q4 PSF achievement

• Year end income position uncertain, dependant on activity performance in month 12

• Large Capital invoices on pre-close payment run (e.g. Simons £0.6m)

• Ability to cover operating costs (liquidity) diminishing

• 2019/20 capital programme limited to essential spend

• Creditor payment terms being stretched, impacting on supplier relationships

• Limited ability to influence NHS debt due to widespread systemic cash flow issue

• £1.6m unprocessed creditor invoices not in finance position (reduced in month by circa £1m)

Key(1) Current Assets / Current Liabilities – ability to pay debts as fall due (Ideal: 1<>2)(2) Current Assets (less inventories) / Current Liabilities –per above, less liquid assets removed(3) Loan debt / equity – amount of existing equity required to pay of debts(4) Working Capital Balance / Operating Expenses x Days - Days of operating costs held in cash /cash equivalents(5) Available revenue / debt repayments, PDC dividend & finance costs - ability to cover debts

Forecast projection based on submitted NHSI plan Downside cash balance: excludes CIP achievement (£7m) & PSF achievement (£1.8m)

CashPosition

Metric Score NHSI Risk Rating 17/18 Comparator TargetLiquidity (Days)

(4) 12.1 1 28.4 - Capital Service Cover (Ratio) (5) 1.1 4 1.1 1.7

NHSI Metrics

Ratio Score P / O Target

Current Ratio (1) 1.26 P 1<>2Quick Ratio (2) 1.16 P 1<>2

Gearing (3) 65% O 25-50%

Ratios

Payables £'m

Outstanding Debt 9.29Receivables

Outstanding Credit 5.79

Net Due -3.50

Cash Due

Month 11 £'mCash balance b/f 14.37Surplus/(Deficit) -0.68(Increase)/Decrease in receivables -0.24Increase/(Decrease) in creditors 0.45(Increase)/Decrease in inventories 0.05Capital exp.additions 1.07Depreciation/impairments 0.47PDC dividend payments 0.11Loan/interest payments 0.08Other movements -0.93Cash balance c/f 14.75

Indirect Cash Flow Summary

28th Feb In Month Movement, £'m

Total In YTD Total Out YTD Movement YTD Ave Monthly Gain / (Loss)

14.76 0.39 176.84 183.03 -6.20 -0.56Cash Balance, £'m

21.8

7

20.9

5

17.7

7

16.2

5

15.4

0

17.7

8

17.4

2

16.4

9

16.5

0

15.6

7

16.2

7

14.3

6

14.7

6

13.5

8

13.4

7

13.4

0

13.0

8

13.4

6

13.0

4

12.3

4

12.9

9

13.1

9

13.1

6

13.3

7

12.8

7

11.9

2

-

5.00

10.00

15.00

20.00

25.00

Feb

Mar Ap

r

May

June Ju

l

Aug

Sept Oc

t

Nov

Dec

Jan

Feb

Mar Ap

r

May

June July

Aug

Sept Oc

t

Nov

Dec

Jan

Feb

Mar

2018 2019 2020

£'m



10


CASHFLOW FORECAST

Month Ending Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar

£'m £'m £'m £'m £'m £'m £'m £'m £'m £'m £'m £'mRECEIPTS

Monthly block Contract Payments 12.59 12.96 12.96 12.96 12.96 12.96 12.96 12.96 12.96 13.74 13.05 13.05

Learning Development (PGME) 0.37 0.37 0.37 0.51 0.37 0.00 0.98 0.40 0.51 0.00 0.93 0.40

VAT Recovery 0.47 0.00 0.14 0.05 0.10 0.26 0.05 0.00 0.19 0.09 0.09 0.11

Provider Sustainability Funding (performance related) 3.63 0.52 0.70 1.05

Other Income (Contract Performance, Labs, R&D, Charity) 1.13 3.12 2.15 0.77 1.89 1.75 2.08 1.46 2.47 2.16 2.22 3.83

PDC Drawdown 0.00 0.00 0.00 0.00 0.00 0.00

General Office cash receipts 0.62 0.07 0.04 0.12 0.08 0.04 0.11 0.10 0.05 0.07 0.05 0.08

Loan Receipts 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Petty Cash Floats 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

RBS Interest 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01

Total Receipts 15.19 16.54 15.68 18.04 15.42 15.55 16.19 14.93 16.90 16.06 16.35 18.52

PAYMENTS

General Office miscellaneous salary deduction payments 0.01 0.01 0.00 0.01 0.01 0.02 0.03 0.01 0.01 0.01 0.01 0.01

Manual Cheque / Cheque run creditor payments 0.01 0.00 0.01 0.01 0.00 0.01 0.00 0.00 0.00 0.02 0.01 0.01

Payroll Deductions 0.05 0.03 0.03 0.03 0.03 0.03 0.03 0.03 0.03 0.00 0.03

General Office petty cash payments 0.00 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01

Co-Op Bank miscellaneous payments 0.07 0.04 0.03 0.04 0.02 0.02 0.03 0.05 0.05 0.05 0.05 0.05

Creditor Payments (inc capital spend) 7.59 6.80 5.86 4.74 4.61 4.03 5.16 4.05 5.09 6.64 5.02 7.16

Monthly Salaries 5.96 5.95 6.00 6.06 6.38 6.15 6.19 6.20 6.22 6.24 6.23 6.23

PAYE / NI Payments 2.67 2.58 2.56 2.54 2.62 2.84 2.66 2.69 2.76 2.66 2.68 2.71

Superannuation Payment 1.82 1.78 1.79 1.77 1.82 1.96 1.83 1.88 1.88 1.87 1.88 1.88

Capital Additions 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

NHSLA 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.00

Computershare 0.05 0.05 0.05 0.05 0.05 0.05 0.05 0.05 0.05 0.05 0.05 0.05

Loan Repayments - Principal 0.40 0.01 0.53 0.00 0.40 0.00 0.12 0.01 0.53

Loan Repayments - Interest 0.19 0.20 0.00 0.33 0.00 0.19 0.00 0.08 0.00 0.33

Bank Charges & Interest Payable 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

PDC Dividend 0.23 0.00 0.70

Carbon Reduction 0.07

Total Payments 18.38 18.05 16.53 15.66 15.77 16.48 16.18 15.76 16.30 17.97 15.95 19.70

Net receipts less payments -3.19 -1.51 -0.85 2.38 -0.36 -0.93 0.01 -0.83 0.60 -1.91 0.39 -1.18

Total cash brought forward from previous month 20.95 17.77 16.25 15.40 17.78 17.42 16.49 16.50 15.67 16.27 14.36 14.76

Total cash carried forward to next month 17.77 16.25 15.40 17.78 17.42 16.49 16.50 15.67 16.27 14.36 14.76 13.58

Breakdown of closing month end balances :

Co-op Reserve 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Co op 0.10 0.06 0.04 0.06 0.06 0.05 0.06 0.07 0.03 0.04 0.03

General Office Petty Cash 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01

RBS 17.65 16.18 15.36 17.71 17.35 16.44 16.43 15.60 16.23 14.32 14.72

17.77 16.25 15.40 17.78 17.42 16.49 16.50 15.67 16.27 14.37 14.76 0.00

2018 2019



11


Debtor Analysis

Key:

Receivables Turnover: Revenue / Ave. Receivables Balance

28th Feb In Month Movement, £'m NHS Overdue Non-NHS Overdue

5.79 -0.30 4.50 39% 1.29 75%Debtors Balance, £'m

In Month Previous Month YTD Average 17/18 Comparator

11 12 13 13

Debtor DaysRatio Score

Receivables Turnover 24 17/18 Comparator 22

Movement

Ratios

0

5

10

15

20

25

30

Ap

ril

May

Jun

e

July

Au

g

Sep

t

Oct

No

v

De

c

Jan

Feb

- 500

1,000 1,500 2,000 2,500 3,000

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

De

c-1

8

Jan

-19

Feb

-19

Overdue NHS Aged Sales Ledger Balances, £'m

Over Term 31-90 Days Over Term 91-150 Days

Above 151 Days

- 200 400 600 800

1,000 1,200

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

De

c-1

8

Jan

-19

Feb

-19

Overdue Non NHS Aged Sales Ledger Balances, £'m

Over Term 31-90 Days Over Term 91-150 Days

Above 151 Days

Key Debtor Balances Beyond TermNHS (Trust to Trust) £'m Issue ActionSheffield Teaching 1.28 Creditor bal Trust to Trust resolutionRotherham 0.12 Cash flow Approved pay dates being secured by Sales LedgerGreat Ormond St. 0.10 Query Under investigation

Non-NHS £'m Issue ActionUni. of Sheffield 0.34 Stephenson Unit Trust actively pursuing via Finance/EstatesUni. Hosp. Wales 0.07 Labs, slow payer Sales Ledger to escalate to Cash Mgmt CommitteeM&M insurance 0.05 Private Patient Update req'd from Paying Patients Manager



12


Creditor Analysis

28th Feb In Month Movement, £'m NHS Overdue Non-NHS Overdue Unprocessed Invoices (not

in position)

9.29 0.83 3.90 78% 5.39 49% 1.61Creditors Balance,

£'m

BPPC % of invoices paid within 30 day target In Month Previous Month Movement

By volume 61% 63%By value 68% 69%

By volume 45% 46%By value 37% 39%

By volume 62% 64%By value 75% 75% -

Non-NHS

NHSI Better Payment Practice Code

NHS

120

125

130

135

140

145

150

155

160

April May June July Aug Sept Oct Nov Dec Jan Feb

In Month Previous Month YTD Average 17/18 Comparator

141 134 146 68

Creditor Days

Key Creditor Balances Beyond TermNHS (Trust to Trust) £'m Issue ActionSheffield Teaching 2.45 Invoices in dispute Trust to Trust resolution req'dY&H Ambulance 0.15 Awaiting signature Trust to sign off once agreedDoncaster & B'law 0.10 Lead Unit - issue unknown Pay o/s invoices

Non-NHS £'m Issue ActionSimons 0.60 Resolved Approved for payment in MarchRowlands Pharmacy 0.37 Awaiting signature Trust to sign off nce agreedWYG Engineering 0.14 Barred



13


Comments

• 2018/19 Capital programme remains significantly below planned investment• Forecast year end position £3m lower than anticipated at opening• Schemes with unutilised in year allocation: Aspetic suite, Theatres equipment, Eye Dept

expansion• Declining Trust cash position benefitting from lower capital spend • A restricted 2019/20 capital programme is currently being devised based on a priority rating,

with clinical risk and time sensitive projects being given precedence • Funding over and above depreciation will be allocated dependant on the evolution of the Trust’s

cash position

-

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000Ap

ril

May

June July

Aug

Sept

Oct

Nov

Dec Jan

Feb

Mar

£'00

0

Month

2018/19 Cumulative Capital Expenditure

Actuals (Cumulative)

Forecast y/e (Cumulative)

Revised Plan (Cumulative)

NHSI Plan (Cumulative)

0% 50% 100%

Charity

Estates

General

IM&T

PDG

SCC

Cap

ital S

chem

e O

wne

r Sum of Spend toM11% Committed/Forecast SpendTotal Budget



14


Key issues:

• Divisional positions have failed to recover as per the M10 mitigations.

• CWAMH and Non Clinical support divisions are £0.2m away from their agreed FOT position.

Key actions:• CWAMH and Non Clinical support

Divisions to provide assurance around reaching their previously stated FOT values with mitigations to return to agreed position.

Owner:• AD of CWAMH and Non Clinical

support divisions along with Head of Financial Management.

Plan Actual Variance (deficit)/surplus Plan Actual Variance

(deficit)/surplus

Medicine (1.55) (1.37) (0.18) (17.01) (13.81) (3.19)

SCC (1.16) (0.53) (0.63) (10.72) (9.53) (1.19)

CWAMH (0.26) (0.41) 0.15 (2.73) (2.56) (0.17)

PDG 0.52 0.53 (0.01) 6.37 6.41 (0.04)

Finance 0.43 0.45 (0.02) 4.87 5.03 (0.16)

HR 0.22 0.02 0.20 2.51 2.41 0.10

Non Clinical 0.60 0.60 (0.01) 6.82 7.35 (0.54)

Research 0.02 0.02 (0.00) 0.19 0.18 0.02

Clinical support 0.71 0.76 (0.06) 7.86 7.89 (0.03)

M11 18-19 £'000 M11 YTD 18-19 £'000

Divisional position versus plan 2018/19

FOT Position at Month 11

YTD variance to Control Total £(1.3)mTarget gap to Control Total at Year end £(1.5)mDeterioration available in M12 £(0.2)m

FOT gap at M11 £(3.39)mKnown adjustments prior to year end: £1.34mFOT after known adjustments £(2.05)m

Target and previously forecast £(1.50)mDeterioration in FOT at £(0.55)m

Reason for deterioration:Additional Waste costs £(0.15)mCWAMH division deterioration £(0.11)mIMT position £(0.09)mOther £(0.20)m


8. 65/19 QUALITY COMMITTEE

EXECUTIVE SUMMARY

Title

Quality Committee Report to

Board of Directors (Part 1)

Date 26 March 2019

Executive Sponsor

Author

Ms Patricia Mitchell, Non-executive Director, Chair of the Quality Committee

Purpose of report

To present to the Trust Board of Directors the key issues arising from the 11 March 2019 Quality Committee.


Approval Assurance √ Information


All reports are available for members of the Board to view on Convene.

The following reports were noted by the Quality Committee for information/assurance; Progress Update on Central Transition Database Monthly Clinical Quality Dashboard Update on Serious Incidents Update on Outstanding Clinical Guidelines and Policies Month 10 Integrated Performance Report Well Led Follow Up action Plan Progress Quality Strategy Quality Impact Assessments CQC Action Plan Amendment to the Mental Health Act Scheme of Delegation Pharmacy, Genetics and Diagnostics Update Report Quarterly Report from the Mortality Review Panel

From the Committee’s consideration of agenda items presented for discussion it was agreed that the following would be reported to the Trust Board:

Quality Strategy The committee received an outline plan to develop a standalone Quality Strategy. Historically the trust had used its quality accounts as its quality priorities; however a standalone strategy was important to support quality of care, the trust’s strategic aims as well as standardising governance arrangements within divisions. Key strands from the 2018/19 quality accounts would be the starting objectives with refinement made through engagement work to enhance the work already happening within the trust, to produce an overarching document. The positive momentum created by the recent CQC unannounced inspections would be fostered to drive this work forward. Transition Update The committee received a further update on work to develop a central database for all

TRUST BOARD PART 1 8. 65/19 QUALITY COMMITTEE Page 70 of 197

patients on transition plans, noting the extent of the challenge following scrutiny of a report on the number of patients, by specialty, with open referrals not seen within the past 18 months, for patients 18+ both with and without a transition plan. Initial anecdotal feedback from the recent CQC unannounced inspection of transition services was positive in that the CQC had recognised the increase in resource put in place, progress made since 2016 and that this continued to be work in progress. The committee recognised this was an ongoing challenge and validation was key in operational management of the issue. Whilst this would remain an area of focussed work, and in order to get further understanding of the ongoing position the committee requested monthly reporting to enable it to identify what support and resources might be required to address the backlog. Outstanding Clinical Guidelines and Policies In its ongoing oversight of the issue the committee received a report which gave assurance that progress was being made to review out of date clinical guidelines and policies, and the committee requested the backlog of out of date policies was cleared by the end of March. The number of guidelines held within the emergency department handbook was highlighted as an area of concern by the committee. It was unclear whether these guidelines had been recently updated and further investigation would be undertaken by the medical director to confirm this. Serious Incidents The committee noted the serious incident report, and was informed of a recent potential never event. Nationally the guidance around local invasive procedure processes was not straightforward, and the incident was being considered further in line with the guidance. Until further clarity had been sought the incident would remain open. Should the incident be classified as a never event this would give 3 never events in year, whilst this was comparable to previous years this was a concern. The committee was assured that no patient had come to harm in each of the never events. The committee raised concern on where the detail of incidents was scrutinised and requested a report on the level of detail, and well as qualitative information relating to outstanding actions, which division had responsibility and how long the investigations had been ongoing, to a future meeting.

There were no actions for the committee to accept on the cross working actions arising report. During the Any Other Business item on the agenda, Mr Green briefed us on the creation of a new time limited sub-committee to drive forward the CAMHS transformation programme agenda. He will act as chair for this meeting and it will report into Quality Committee. Board is asked to endorse this as a course of action and delegate the finalisation of its terms of reference to Quality Committee.

How this report impacts on current risks or highlights new risks Links to the Board Assurance Framework:

Failure to effectively deliver healthcare impacts on the safety and quality of patient experience, regulatory compliance and loss of confidence of the wider community


The Trust Board is asked to:

(i) Note the items for escalation from the meeting held on 11 March 2019. (ii) Endorse the decision to create a CAMHS Transformation Programme Sub-committee which

will report into Quality Committee and delegate agreement of its terms of reference to Quality Committee.

TRUST BOARD PART 1 8. 65/19 QUALITY COMMITTEE Page 71 of 197

9. 67/19 APPOINTMENT OF DEPUTYCHAIR

EXECUTIVE SUMMARY

Title Appointment of Deputy Chair

Report to

Board of Directors Date 26 March 2019

Author

Matthew Kane, Associate Director - Corporate Affairs

Purpose of report


Approval X Assurance Information


Following discussion during the recent NED appraisal process, this paper seeks Board’s approval to appoint Peter Lauener as Deputy Chair with effect from 1 April 2019, replacing Patricia Mitchell. This proposal reflects a desire by the Chair to more equitably spread Board-level responsibility amongst her non-executive team as well as a recent change in Mr Lauener’s circumstances which allows him to spend more time on Trust’s business. Ms Mitchell continues to perform her non-executive role to a high standard and remains significantly committed to the Trust. The principle function of the Deputy Chair is to act as Chair where the Chair has died, has ceased to hold office or where they have otherwise been unable to perform their duties as Chair owing to illness or any other cause. This would include chairing Board and Council of Governors where the Chair was unavailable as well as other meetings such as the Remuneration and Recruitment Committee in cases where both the Chair and Senior Independent Director were unavailable. Increasingly, the Deputy Chair will be required to deputise in PLACE and system level meetings as well as be an ambassador throughout the Trust. As required by the Trust’s Standing Orders the appointment is for the remaining portion of Mr Lauener’s term (up to 31 August 2019) whereupon he may be reappointed as Deputy Chair subject to Council of Governors approving his second term as Non-executive Director.

TRUST BOARD PART 1 9. 67/19 APPOINTMENT OF DEPUT... Page 73 of 197

How this report impacts on current risks or highlights new risks N/A

Recommendations and next steps That the Board appoints Peter Lauener as Deputy Chair with effect from 1 April 2019, up until the end of his current term as non-executive director.

TRUST BOARD PART 1 9. 67/19 APPOINTMENT OF DEPUT... Page 74 of 197

10. 68/19 QUARTERLY REPORT FROMTHE GUARDIAN OF SAFE WORKINGHOURS

EXECUTIVE SUMMARY

Title Quarterly Report from the Guardian of Safe Working Hours Report to

Trust Board (Part 1) Date 26 March 2019

Executive Sponsor Dr J Perring, Medical Director

Author Dr N West, Safe Working Hours Guardian

Purpose of report

To present to the Trust Board of Directors an update on the trust compliance with working hours for junior doctors and to highlight any areas of concern.


Approval Assurance √ Information √


There continue to be a number of gaps in rotas across the trust, particularly in medicine

which may impact safe working and training going forward. There has been a vast improvement in engagement in the Junior Doctor’s forum. There has been an improvement in the numbers of exception reports. There has been a resolution of the issues around the distribution of log ins. There has been an improvement in supervisor engagement with the exception reporting

process

How this report impacts on current risks or highlights new risks Link to Board Assurance Framework

Failure to effectively deliver healthcare impacts on the safety and quality of patient experience, regulatory compliance and loss of confidence of the wider community

Failure to ensure that the Trust has a motivated, suitably trained and engaged workforce impacts on operational performance, transformational change and achievement of strategic objectives.



The Board is asked to note the content of the report from the Safe Working Hours Guardian and agree any actions required.

TRUST BOARD PART 1 10. 68/19 QUARTERLY REPORT ... Page 76 of 197

1

QUARTERLY REPORT ON SAFE WORKING HOURS:

DOCTORS IN TRAINING SHEFFIELD CHILDREN’S NHS FOUNDATION TRUST (1 December 2018 – 1 March

2019)

Executive summary

There continue to be a number of gaps in rotas across the trust, particularly in medicine which may impact safe working and training going forward.

Locum usage remains consistent.

Introduction

High level data

Number of doctors in training (total): 130

Number of doctors in training on 2016 TCS (total): 80

Amount of time available in job plan for guardian to do the role: 1 PAs / 4 hours per week

Admin support provided to the guardian (if any): 0 WTE

Amount of job-planned time for educational supervisors: 0 PAs per trainee (not routinely included in this trust)

a) Exception reports (working hours and educational)

There have been 32 exception reports from 1 December 2018 to date. 23 of these exception reports are due to hours and rest. 23 of the exception

reports are for hours and rest have been generated by trainees in the Medical Specialty Rota (14 reports), General Pediatrics FY2 and ST1-3 (6

reports), ED GP ST1-3 (3 reports) and 9 are related to education.

All the exception reports have been actioned and closed. HR will process payments for March payroll.

TRUST BOARD PART 1 10. 68/19 QUARTERLY REPORT FROM THE GUARD... Page 77 of 197

2

Exception reports by Division (Hours and Education)

Division No. exceptions raised No. exceptions closed No. exceptions outstanding

MEDicine 32 32 0

Surgery 0 0 0

Total 32 32 0

Exception reports by rota

Specialty No. exceptions raised No. exceptions closed No. exceptions outstanding

Medicine Specialities ST1-2 10 10 0

Medicine specialty ST1-3 18 18 0

Emergency Medicine GP’s and ST1-3 4 4 0

Themes of working hour’s exception reports

20 early starts, late finishes, unable to take a break

3 Difference in working pattern

Themes of educational exception reports

1 Teaching cancelled

5 Unable to attend clinic/theatre/session

3 Unable to attend scheduled teaching/training

b) Work schedule reviews

Despite requests for work schedule reviews, none have been received.


3

c) Agency Locum bookings

All External locum spend from 1 December 2018 to 1 March 2019 by Grade

Grade Count of Shift From

Sum of Estimated Quantity

Sum of Estimated Cost

Core Trainee 76 £642 £34,061 StR (ST3-8) 203 £1,940 £107,766 Grand Total 279 £2,583 £141,828

Internal locum for staff grades has been included, it remains unclear if this is

replacing a middle grade gap in eating disorders

All Internal locum spend from 1 December 2018 to 1 March 2019 by Grade

Grade Count of Shift From



StR (ST3-8) 111 £923 £72,195 Staff Grade 1 £24 £1,493 Grand Total 112 £947 £73,688

£0

£20,000

£40,000

£60,000

£80,000

£100,000

£120,000

£140,000

£160,000


StR (ST3-8)

Core Trainee

£71,000

£71,500

£72,000

£72,500

£73,000

£73,500

£74,000


Staff Grade

StR (ST3-8)


4

External locum spend from 1 December to 1 March 2019 by Specialty

Specialty

Count of Shift From



Anaesthetics and Paediatrics 14 £137 £10,275 EMBRACE 22 £262 £19,613 T&O 1 £17 £1,275 Paediatric A&E 71 £600 £32,833 Paediatric ICU 4 £36 £2,633 Paediatric Orthopaedics 6 £110 £8,213 Paediatric Surgery 19 £203 £13,742 Paediatrics 62 £531 £25,893 CAMHS 5 £88 £4,400 Paediatric Haematology 64 £512 £16,352 Paediatric Oncology 11 £88 £6,600 Grand Total 279 £2,583 £141,828

Internal locum spend from 1 December 2018 to 1 March 2019 by Specialty

Specialty Count of Shift From



EMBRACE 3 £37 £3,138 Paediatrics 44 £352 £28,804 Eating Disorders 65 £558 £41,746 Grand Total 112 £947 £73,688

£0

£20,000

£40,000

£60,000

£80,000

£100,000

£120,000

£140,000

£160,000


Paediatric Oncology

Paediatric Haematology

CAMHS

Paediatrics

Paediatric Surgery

Paediatric Orthopaedics£0

£10,000

£20,000

£30,000

£40,000

£50,000

£60,000

£70,000

£80,000


Eating Disorders

Paediatrics

EMBRACE


5

Internal spend from 1 December 2018 – 1 March 2019 by Reason

Reason

Count of Shift From



Compassionate/Special leave 2 £24 £1,512 Deanery Gap 35 £348 £23,759 Exempt from On Calls 2 £25 £1,838 Extra Cover 69 £547 £22,879 Paternity Leave 1 £13 £975 Sick Absence 58 £532 £32,220 Study Leave 1 £6 £378 Vacancy 111 £1,088 £58,268 Grand Total 279 £2,583 £141,828

External spend from December 2018 – 1 March 2019 by Reason

Reason Count of Shift From



Deanery Gap 1 £24 £1,493 Sick Absence 2 £24 £2,055 Vacancy 109 £899 £70,140 Grand Total 112 £947 £73,688

£0

£20,000

£40,000

£60,000

£80,000

£100,000

£120,000

£140,000

£160,000


Vacancy

Study Leave

Sick Absence

Paternity Leave

Extra Cover

Exempt from On Calls£0

£10,000

£20,000

£30,000

£40,000

£50,000

£60,000

£70,000

£80,000


Vacancy

Sick Absence

Deanery Gap


6

d) Vacancies

Specialty Changeover date

Trainees in establishment

Actual no. allocated (trainees) Fellows No of current gaps

Paediatric Medicine F1 –

ST3

December 18 (FY1’s/2)

August (ST’s)

13 ST 1-3 12.2

0.8 WTE gaps as below:

0.4 WTE neuro and 0.4 WTE Community

2 F1 2

1 F2 1 Paediatric Medicine GPSTPs

December 18 6 6 WTE 0.5 gap but from April will be full staffed

Paediatric Medicine ST4 + February 19 23 20 WTE 1 (doing gastro/

general Paeds)

2 WTE gaps as below:

0.5 Gap in Community Paeds

1.5 Gap in General Paeds

There may be some small discrepancies with some slot shares

being 60-% and 60% for example.

Anaesthesia - Higher February 19 7 7 WTE

2 WTE upcoming Gaps: 1 WTE gap from March due to mat leave

1 WTE gap from May due to mat leave

Embrace February 19 6 4 1 1 WTE gaps at the moment: 1 trainee starting in May 19 so there will be a full complement

PICU February 19

4 – ST1-3 4

1

2.5 WTE gaps from April due to maternity leave

7 – ST4-8 5 2.6 WTE gaps from April (1 trainee deferred placement to next year, 1 training leaving in April and 0.6 trainee going on mat leave)


7




Paediatric Surgery February 19

2 F1 2

1

1 F2 1 1 trainee is supernumerary

ST’s and Core trainees - 7 trainees 7

Paediatric Surgery – Higher October 18 5 4 2

ED – Core February 19

CT3 – 5 4

1 WTE Gap Core trainee

GPSTPs – 3 3

Paed trainees - 3 2 1 WTE gap

ED - Higher Jan-19 ST4 + - 4 4

0.4 WTE gap due to trainee being LTFT Grid – 2 1.6

ENT Oct-18 1 0 1 Fellow is 60% LTFT so 0.4 WTE gap

Trauma and Orthopaedics Oct-18 4

2 plus

5

1 MTI Ongoing recruitment of fellows and trainees left, so unsure 100% of gaps

CAMHS – Core February 2019 4 4

CAMHS - Higher February 2019 6 4 2 WTE gap – 1 due to mat leave and 1 unfilled


8




Radiology October 2018 4 4

Histopathology February 2019 1 1

Clinical Genetics Aug-18 2 2

Haematology Aug-18 1 1

e) Fines

None to date

Qualitative information

There has been a vast improvement in engagement in the Junior Doctor’s forum, with improved attendance and a wider range of specialty representation,

this has been consistent over the last 3 JDFs and seems to be true engagement and acknowledgement of the value of the meeting.

There has been an improvement in the numbers of exception reports following the resolution of the issues around the distribution of log ins. There has

been better engagement from Clinical/ Educational Supervisors in closing exception reports in a timely manner and for the first time all have been closed.

There has been concern that the exception reports received do not represent the working practices at the Trust. The Trust has been very busy over the

winter period and although there have been a number of exception reports in the Medical specialties the expectation was that the number of exception

reports would be higher than had been received. This now seems to have improved over the last month with the number of exception reports increasing as

doctors are encouraged to exception report when required.


9

Issues arising

There are issues with the medical paediatrics workforce, particularly around daytime workload, however without robust monitoring data and due to the

trainees largely remaining on the “old” contract this is not reflected in the exception reporting process. HR have been proactive to achieve monitoring data

in this group. The next monitoring round is from 11 – 31 March 2019.

Actions taken to resolve issues

GSW would encourage the trust make training in exception reporting mandatory for all consultants.

Regular meetings with the MD and deputy CE have been embedded.

Summary GSW/ updates

The numbers of exception reports continue to fluctuate, and as a trust we have been very supportive of trainees reporting concerns (we have also

facilitated the BMA to attend junior doctor induction to reiterate our support).

The trust should be encouraged by the improvement in supervisor engagement, which may reflect an increased familiarity and confidence with the process.

The JDF has seen a consistent improvement in attendance and engagement.


11. 69/19 DEVELOPING OUR QUALITYSTRATEGY FURTHER

EXECUTIVE SUMMARY

Title Proposal for the Development of a Quality Strategy

Report to

Trust Board Date 26 March 2019

Executive Sponsor

Sally Shearer, Director of Nursing & Quality

Author

Sally Shearer, Director of Nursing & Quality

Purpose of report

To present plans for the implementation of a Trust-wide Quality Strategy


Approval Assurance X Information


The report outlines plans to develop a Trust-wide Quality Strategy that will provide a systematic and embedded approach to quality improvement. The report considers the evidence for this new approach and details the proposal for the development of the strategy, and reflects the considerable work already undertaken. Our next steps will be to engage with staff, patients and families in the development of the strategy.

How this report impacts on current risks or highlights new risks It is hoped that the implementation of the strategy and embedded approach will deliver higher benefits in terms of patient safety, clinical effectiveness and patient experience.

Recommendations and next steps The Board is asked to approve the Strategy, which outlines quality improvement over the next 3 years.

TRUST BOARD PART 1 11. 69/19 DEVELOPING OUR QUAL... Page 87 of 197

1

ENHANCING OUR QUALITY STRATEGY

1. Introduction Over the last year the Trust has refreshed the strategy ‘Caring Together ‘ which is supported by four divisional strategies. These documents outline the direction of travel towards becoming a high quality organisation. This work has been developed further with a series of underpinning strategies, aligned to the achievement of the CQC (2018) Well Led framework standards. The development of a Quality Strategy forms part of that response. It is common for Trusts to produce a Quality Strategy, many of which have been reviewed as part of this preparatory work. Sheffield Children’s currently sets out it’s direction for quality within it’s Quality Accounts as the key quality priorities, Sign Up To Safety indicators and clear objectives for clinical effectiveness and patient experience are outlined in this document. Progress against these priorities is reported quarterly to the Quality Committee. To date this document has provided the vision and direction for the Trust’s quality ambitions. It should be noted that the review of Quality Strategies from other organisations revealed that several of those documents were simply a rearrangement of the contents of their Annual Quality Account. A review of the literature has demonstrated that whilst single improvement projects to address an area of quality concern have clear benefits for the organisation, a systematic and embedded approach to Quality Improvement has higher benefits in terms of patient safety, clinical effectiveness and patient experience. This paper considers that evidence and outlines a proposal for building on the foundations of the priorities sets out in the Quality Accounts. 2. What is a Quality Strategy ? Quality The 2008 Darzi NHS Next Stage Review (Department of Health 2008) defined quality in the NHS in terms of three core areas:

patient safety clinical effectiveness the experience of patients.

Strategy A short, focused, motivational document used to describe the direction of travel (NHSE 2013) A Quality Strategy could therefore be described as a plan through which the Trust focuses on the quality of care to ensure that it continually improves the service it provides. 3. Why do we need a Quality Strategy? Trusts that have embarked on a quality improvement journey cite prompts such as curiosity, a serious adverse event or system complexity for


2

developing their strategy. Others feel a growing awareness that improvement founded upon one or two key individuals, or a handful of disparate projects, is not sustainable in an increasingly complex healthcare landscape. In simple terms, it is widely understood that in any walk of life, the achievement of an ambitious goal is only realised if there is a clear plan in place for delivery, and a system to track and monitor progress. There is an abundance of literature available on quality improvement, defined as the redesign and reworking of systems and processes that deliver healthcare, to improve patient outcome and potentially save cost. However, the literature warns that excellence does not occur by chance, but requires investment and intentional actions by staff who are supported by leaders at all levels, equipped with the skills to bring about change (Kings Fund 2016). The CQC (2018) reinforce this view in their document ‘Quality Improvement in Hospital Trusts: Sharing learning from Trusts on a journey of QI’. This outlines the expectation that Trusts who are committed to delivering high quality care already have this underway, driven by an intrinsic desire to provide excellence in care, rather than simply a response to externally mandated standards. As a member of the South Yorkshire and Bassetlaw Integrated Care System and the Hosted Network lead for acutely unwell children and young people, the Trust is in need of a quality improvement approach that equals if not excels above that of its neighbours. The strategic discussions that have taken place have brought a sharp clarity to the need to learn from others, share information and build quality driven sustainability into systems. The Trust has a vision and ‘Caring Together’ strategy to outline the delivery of high quality care. This strategy is supported by underpinning programmes related to leadership, workforce and organisational development. A framework for tracking and monitoring the transformational progress of 10 quality focused workstreams is also in place through the Transformation Board. A Quality Strategy is therefore the final step in pulling together the considerable work contained within both the Quality Accounts, the 10 quality focused transformation workstreams and the model of Quality Improvement methodology that the Trust uses in order to meet local, regional and national drivers for patient safety, clinical effectiveness and patient experience.

4. How will this align with our Well Led work? The Quality Strategy will need to consider and align with the SCH NHSFT: Vision and Values Strategy 2018-21 ‘Caring Together’ Leadership Strategy People Strategy Nursing Strategy Care Experience Strategy


3

Integrated Performance Framework 5. What will our Quality Strategy look like? When embarking on a programme of work it can be useful to start from the desired end point. The work and those involved in its development will influence the final document, but as a guide other NHS Trusts have included the following:

Definition of quality Description of how staff can become involved Annual objectives and trajectories for improvement ( quite similar to our

Quality Accounts) Agreed Trust model / methodology for QI Achievements to date Ambitions and aspirations Assessment of current state Measurement tools and monitoring systems Indicators and proposed reductions by % and by date Patient views Local and national drivers Diagrammatical representation of the aim and how other work fits

together The 5 CQC domains A standard process for quality governance. (This is important as

inconsistency can make it harder for staff to navigate systems, as well as making it harder to monitor progress)

6. How will we take this work forward ? The intention would be to engage as many staff, patients and families in the development of the Quality Strategy as possible to optimise engagement and ensure that the plans reflect the issues of paramount importance to all groups. The following timetable has been drafted with Jude Stone, Transformation Team. Mid April to May 2019 Inform colleagues through the MD Blog.

MD and DoN walkabouts to continue post CQC to discuss with staff how the inspection felt, what they felt proud of, what they learnt and what themes for improvement they think should be addressed. Attend team meetings and events.

May 2019 Places available on the MicroSystems Coaching Academy programme. CQC report will be available in draft.


4

Recommendations will highlight some areas for development. Patient Experience Event led by clinicians on all sites, talking to children, young people and families about patient safety, what matters to them.

June 2019 Ward Manager Time Out Day. To include quality workshop with ward managers about what matters to them Patient Safety, Effectiveness and Experience Summit (60 places) at the Wilson Carlile Centre

July / August 2019 Collating responses, final draft preparation. Work with divisions on a consistent, Trust wide governance system to complement the Strategy.

September 2019 Further places MicroSystems Coaching Academy programme. 26th September Clinical Summit. Key Workstream am and pm sessions. The Quality Strategy.

31 October 2019 Launch of the Quality Strategy

November 2019 Further places MicroSystems Coaching Academy programme.

Sally Shearer March 2019.


12. 70/19 STAFF SURVEY 2018

EXECUTIVE SUMMARY

Title Staff Survey 2018

Report to


Executive Sponsor

Steven Ned, Director of HR and OD

Author

Jane Clawson, Deputy Director of HR and OD

Purpose of report

To inform the Board of Directors of the summarised results of the 2018 staff survey and next steps


Approval Assurance Information X


The staff survey 2018 results show that our results are fair, and not significantly changed from 2017. Our response rate was above average for our benchmarked group and the Trust’s highest response to date at 53.5% The results shows improvements in our staff perception and experience of bullying, harassment and violence, but show a slightly worsened perception of health and wellbeing, quality of appraisals and quality of care/service. Corporate and divisional/directorate action plans will be completed by end of April 2019 and monitored through divisional performance review meetings .

How this report impacts on current risks or highlights new risks Our staff engagement score (benchmarked as average, but an increase compared with the previous year) is relevant to the delivery of patient care. There is significant research that correlates a high engagement score will result in good and improved patient care.

Recommendations and next steps The Board of Directors are asked to note the results of the staff survey and proposed next steps to develop action plans to address the feedback of our staff.

TRUST BOARD PART 1 12. 70/19 STAFF SURVEY 2018 Page 93 of 197

SUPPORTING PAPER - REPORT FOR INFORMATION 1. Background and context

The NHS staff survey is an annual survey and a requirement for all NHS employers to survey either all or a 5% sample of their employees. We value the feedback from all our staff and all employees of the Trust are invited to participate. The survey is electronic and responses are anonymised. The survey runs for usually 6 weeks, closing at the end of November each year and the results are then shared from January the following year. The survey results are presented through a series of reports to the Trust: we are benchmarked with other NHS combined acute and community Trusts and we receive information to compare our results with the previous year as well as divisional and directorate reports. The benchmarked results are reviewed by the CQC.

2. Summary of key points

Key findings are summarised below:

2.1 Survey response rate. Our 2018 survey response rate was 53.5% (1717 staff). This is our

highest ever response rate and great news that more and more staff are taking time to tell the Trust what they think. Our response is well above the average of 41%.

2.2 Staff engagement. This is a measure of how involved, motivated and able to influence our

staff feel. Our score is 7.07 out of 10, and a slight improvement on last year at 7.04. We are average amongst the group (highest score is 7.4). More staff are reporting enthusiasm about their job and going to work. More staff are reporting that patient care is top priority for the Trust and would recommend the Trust as a place to work and be treated. Staff are reporting that it is still difficult to make improvements and influence improvements.

2.3 Morale. We are grouped as average (6.2/10). Most staff are reporting positively about feeling

involved, respected and can choose how to do their work. We have improved with helping staff manage time pressures and managing working relationships.

2.4 Equality Diversity and Inclusion – grouped with the best (we scored 9.4 out of 10 – highest

is 9.5). This is a slightly improving trend for us. More staff are reporting positively about reasonable adjustments in their work, more staff are reporting an improvement in accessing promotional opportunities and line management support. Staff continue to report discrimination from public and service users.

2.5 Health and Wellbeing – grouped as average and our trend is slightly worsening (5.9/10).

Staff report feeling less supported generally with their health and wellbeing, suffering stress and musculo-skeletal problems and opportunities for flexible working.

2.6 Immediate managers – grouped as average (6.8/10). We are showing a trend for

improvement in this area. Staff are reporting an increased feeling of good support from managers, feeling valued and involved and receiving clear feedback.


2.7 Quality of appraisals – we are amongst the worst in this group (5.2/10 where average is 5.4). Most staff are reporting that they feel their work is valued, but objectives aren’t clear and the appraisal doesn’t help them do their job.

2.8 Quality of care – we are in the worst category, 7.2/10 and just below the average of 7.4/10).

This is an improvement on last year, although the trend is static. More staff are satisfied with the care they give and are able to give the care they aspire to. Fewer staff feel that their role makes a difference to patients.

2.9 Safe environment - we are in the best category for both areas of safe environment – best for

low levels of harassment (8.6/10) and violence (9.7/10). These areas are trending improvement year on year. We have fewer staff reporting harassment or violence from public, colleagues and managers.

2.10Safety culture – we are in the average category with 6.7/10 and this shows a static trend. More staff are reporting that we deal with incidents fairly and share learning from them. Most staff feel that the organisation acts on concerns raised by staff and users.

Overall the results are fair, and we have improvements in a number of areas as well as some areas for more focussed attention.

3. How this impacts on the Trust

The changes in our results externally are not statistically significant and do not show any areas of significant concern. That said, the views of our staff are important, and there is a desire to respond to this feedback to improve the overall feeling of engagement of our staff.

4 Next steps

The full benchmarked and divisional comparison reports have been shared with TEG and JNCC. Bespoke reports will be shared with the divisions as soon as they are available so that divisions and directorate can consult with their staff to determine action plans that cover all staff groups and indicators of how the actions to be taken will be measured. These will be reviewed through divisional and corporate performance review meetings. A newly forming Staff Engagement Steering Group (incorporating the current Staff Survey Working Group) will also review and inform these action plans. A corporate action plan will focus on the three areas in most need of development – quality of appraisals, quality of care and staff health and wellbeing.


13. 71/19 BOARD ASSURANCEFRAMEWORK

EXECUTIVE SUMMARY

Title Board Assurance Framework – Quarter 4 review

Report to


Author

Matthew Kane, Associate Director – Corporate Affairs

Purpose of report


Approval Assurance X Information


This report provides at Appendix A the Q4 review of the Board Assurance Framework following review by executives. One change is proposed to ratings. BAF 10 - Failure to develop our leadership, management and governance arrangements to ensure delivery of sustainable high quality person-centred care, support learning and innovation and promote an open and fair culture prevents the Trust from demonstrating that it is a 'Well Led' organisation – is proposed to move from a Likelihood 4 to Likelihood 3 with a corresponding change to the overall risk rating from 12 to 9. This is in light of additional controls and assurance put in place to mitigate the risk including Well Led preparedness exercises, new executive decision-making arrangements, positive recent staff survey results and measures to streamline meetings. Other changes in controls, assurance, gaps and actions are highlighted in blue. Attached at Appendix B for Board oversight are details of how the BAF risks have changed over the year. While most of the risks have remained at the same level, and one has decreased, it should be noted that three have seen increases reflecting the environment within which the Trust is operating.

This is the final review of the BAF in this financial year. Risk and Audit Committee has discussed some revisions to the BAF format following feedback that the current model has become unwieldy, difficult to update and to read. The Trust Secretary has been tasked with formulating some sample pages based on models from neighbouring trusts whilst at the same time retaining the most valued aspects of the BAF. The new BAF would be implemented from April 2019 when executive team would also be invited to:

TRUST BOARD PART 1 13. 71/19 BOARD ASSURANCE ... Page 97 of 197

Decide which BAF risks remain relevant, and which can be removed.

Agree target risk ratings for BAF risks.

Decide controls, sources of assurance and any actions for the year which will

mitigate gaps.

How this report impacts on current risks or highlights new risks The BAF highlights all risks to the Trust’s strategic objectives.

Recommendations and next steps The Board is asked to note the Q4 review and year-end position and approve the proposed change to BAF risk 10.


Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated - March 2019

BOARD ASSURANCE FRAMEWORK

No. of Trust Assurances

BAF (1) DNQFailure to effectively deliver healthcare impacts on the safety and quality of patient experience, regulatory compliance and loss of confidence of the wider community. 16 8 15 25

%

98

BAF (2) CFORisk that we do not maintain financial stability due to failure to deliver our financial plan or the negative impact of movement to a system-wide financial planning regime, resulting in requirements for additional CIPs or reduction in level and standard of quality of our services.

20 16 20 17%

40

BAF (3) DHR Failure to ensure that the Trust has a motivated, suitably trained and engaged workforce impacts on operational performance, transformational change and achievement of strategic objectives. 20 10 15 12

%

34

BAF (4) DHR Failure to ensure that the Trust recruits staff in the right numbers and with the appropriate breadth of skills and competencies to deliver high quality services now and in the future. 16 6 12 9

%

27

BAF (5) CEO Risk that insufficient leadership capacity and capability prevents necessary transformational change to deliver efficient, high quality services. 20 10 20 9

%

20

BAF (6) DSO Risk to clinical service viability due to failure to meet nationally defined standards or changes to the commissioning and / or configuration of services. 16 12 16 4 11

BAF (7) CEO Failure to engage effectively with partner organisations and the local community threatens the ability of the Trust to deliver its strategic ambition. 12 8 8 14 22

BAF (8) MDFailure to engage with our clinicans prevents the development / implementation of an effective clinical strategy to deliver high quality services that responds to the needs of patients and other health / social care partners and prevents us from capitalising on the use of research, innovation and technology.

15 4 12 7%

32

BAF (9) DSOFailure to ensure that the required IT infrastructure and strategy is in place to safeguard patient safety, deliver clinical services and support clinical strategy and transformation impacts on the Trust's ability to improve quality and transform services.

16 10 15 10%

20

BAF (10) CEOFailure to develop our leadership, management and governance arrangements to ensure delivery of sustainable high quality person-centred care, support learning and innovation, and promote an open and fair culture prevents the Trust from demonstrating that it is a 'Well Led' organisation.

12 6 9 16%

41

BAF (11) DSO Operational constraints and failure to deliver transformation impact on our ability to deliver planned activity and manage demand impacting on operational efficiency, service quality and financial performance. 16 9 12 5

%

14

BAF (12) CFO Failure to maintain the Trust's cash position would result in the Trust not being able to satisfy its obligations in respect of pay and non-pay costs. 20 12 20 3 11

% one or more sources of assurance - limited or none# BAF (10) controls are collated into Well Led action plan

2018/19 Issue 1.0

BAF RISKSNo. of

Independent Assurances

Inherent R

isk

Inherent R

isk Effectiveness of Controls

Target

Risk

Current R

isk

32 10 0

6 11 2

11 3 0

6 8 0

13 3 0

2 6 1

19 4 0

20 0 0

5 6 0

3 0 0

8 4 0

5 0 0

Board Assurance Framework 1

TRUST BOARD PART 1 13. 71/19 BOARD ASSURANCE FRAMEWORK Page 99 of 197


LINKED TO STRATEGIC AIM LEAD

C L S C L S date C L S

BAF (1) Failure to effectively deliver healthcare impacts on the safety and quality of patient experience, regulatory compliance and loss of confidence of the wider community. [1] 4 4 16 4 2 8 by March

2019 5 3 15 DNQ

BAF (2)Risk that we do not maintain financial stability due to failure to deliver our financial plan or the negative impact of movement to a system-wide financial planning regime, resulting in requirements for additional CIPs or reduction in level and standard of quality of our services.

[1] & [4] 5 4 20 4 4 16 by March 2019 5 4 20 CFO

BAF (3) Failure to ensure that the Trust has a motivated, suitably trained and engaged workforce impacts on operational performance, transformational change and achievement of strategic objectives. [1] & [2] 5 4 20 5 2 10 by March

2020 5 3 15 DHROD

BAF (4) Failure to ensure that the Trust recruits staff in the right numbers and with the appropriate breadth of skills and competencies to deliver high quality services now and in the future. [1] & [2] 4 4 16 3 2 6 by March

2020 3 4 12 DHROD

BAF (5) Risk that insufficient leadership capacity and capability prevents necessary transformational change to deliver efficient, high quality services. [3] & [4] 5 4 20 5 2 10 to be

agreed 5 4 20 CEO

BAF (6) Risk to clinical service viability due to failure to meet nationally defined standards or changes to the commissioning and / or configuration of services. [1] & [4] 4 4 16 3 4 12 to be

agreed 4 4 16 DSO

BAF (7) Failure to engage effectively with partner organisations and the local community threatens the ability of the Trust to deliver its strategic ambition. [3] & [4] & [5] 4 3 12 4 2 8 in line 4 2 8 CEO

BAF (8)Failure to engage with our clinicans prevents the development / implementation of an effective clinical strategy to deliver high quality services that responds to the needs of patients and other health and social care partners and prevents us from capitalising on the use of research, innovation and technology.

[1] & [3] & [4] 5 3 15 4 1 4 to be agreed 4 3 12 MD

BAF (9)Failure to ensure that the required IT infrastructure and strategy is in place to safeguard patient safety, deliver clinical services and support clinical strategy and transformation impacts on the Trust's ability to improve quality and transform services.

[1] & [3] & [5] 4 4 16 5 2 10 by March 2019 5 3 15 DSO

BAF (10)Failure to develop our leadership, management and governance arrangements to ensure delivery of sustainable high quality person-centred care, support learning and innovation and promote an open and fair culture prevents the Trust from demonstrating that it is a 'Well Led' organisation.

[1] & [2] & [4] & [5] 3 4 12 3 2 6 by March

2019 3 3 9 CEO

BAF (11) Operational constraints and failure to deliver transformation impact on our ability to deliver planned activity and manage demand impacting on operational efficiency, service quality and financial performance. [1] & [4] 4 4 16 3 3 9 to be

agreed 3 4 12 DSO

BAF (12) Failure to maintain the Trust's cash position would result in the Trust not being able to satisfy its obligations in respect of pay and non-pay costs. [4] 5 4 20 4 3 12 by March

2019 5 4 20 CFO

Consequence (C) x Likelihood (L) = Risk Score (S)

3 or less = Low Risk4 to 7* = Medium Risk

targets and achievement dates under discussion

CURRENT RISKBOARD ASSURANCE FRAMEWORK 2018/19 INHERENT RISK (no controls)

Risk Score Colour Coding

TARGET RISK (under development)

8 to 14* = High Risk15 to 25 = Very High Risk




Strategic Aims 2018/19

Aim (1) Provide high quality patient experience and outcomes

Aim (2) Employ motivated and compassionate staff

Aim (3) Lead improvements in paediatric care

Aim (4) Build clinical and financial sustainability

Aim (5) Discover new ways of improving child health through research, innovation and technology

Control Ratings Assurance Ratings (from Internal Audit Opinions)

Values 2018/19

1. Excellence

2. Accountability

3 Compassion

4. Teamwork

5. Integrity

Evidence of regular monitoring available

No controls in place

SignificantControl process is not delivering adequate assuranceSignificant Assurance can be provided that there is a generally sound system of control designed to meet the system’s objectives. However, some weakness in the design or inconsistent application of controls put the achievement of particular objectives at risk.

RED

AMBER

Shared ownership of controls means Trust not fully 'in control' / concerns about processes outside the Trust's Control

Limited Assurance can be provided as weaknesses in the design or inconsistent application of controls put the achievement of the system’s objectives at risk in the areas reviewed.

GREENResults of monitoring satisfactory / majority positive

Not controlled

Control recently introduced, not fully embedded

NoneNo Assurance can be provided as weaknesses in control, or consistent non-compliance with key controls, could result [have resulted] in failure to achieve the system’s objectives in the areas reviewed.

No evidence available

FullFull Assurance can be provided that the system of internal control has been effectively designed to meet the system’s objectives, and controls are consistently applied in all areas reviewed.

Limited



Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated - January 2019

What controls are in place to assist in securing the delivery of the objective?

INTERNAL

EXTERNAL

Performance management of operational and quality targets INTERNAL

Participation in patient experience surveys to benchmark quality of care

Implement and deliver care experience strategy2. Lack of Quality Straetgy

Performance management of Infection Prevention & Control measures G

Agreement and monitoring of Quality priorities and targets (Quality Report / CQUINS)

Implementation of Safeguarding Strategy

Section 11 compliance arrangements 4a. Implementation of three month trial of use of cards to collect FFT feedback.

Process in place to review learning from outside the Trust and implement relevant recommendations

Subject to external regulation by the Care Quality Commission

Subject to external regulation by NHSI 4c. Implementation of FFT action plan.

DN

Q

actioned

Continuation of Care Experience Strategy

DN

Q

Mar-195. Recruitment to post frozen

6. Scrutiny process at DPR

DN

Q

Aug-19

1. Implementation of Pathway to Excellence Scheme

2. Develop and implement Performance Management Framework including Divisional Escalation Framework - agreed to base on CQC Well Led domains. Discussion scheduled for January's Exec Brief. Divisional IPRs in place and reporting to February's FRC.

DSO

/ CFO

Mar-19

Control rating

RISK OWNER: DNQ

C x L

Inherent

Risk Score C

Current

By w

hen

Lead

Action plans (or reference to action plans) to meet gaps in control or assurance

Control - do the assurances identify that any of the controls are not working or not fully implemented? Are further controls required?

Assurances (see separarate sheet for detail)

BAF (1) Failure to effectively deliver healthcare impacts on the safety and quality of patient experience, regulatory compliance and loss of confidence of the wider community

[1]

1. Lack of consistency in quality standards across wards

Key Risk Controls Gaps in control or assuranceLink to Strategic Objective

Action to meet gaps / drive risk score to agreed target score

Link to Strategic ObjectiveHow does this risk link to the Trust's objectives and priorities?

Target

Ref # of entry of high level risk on corporate / divisional risk registers

Risk Register Cross Ref

Evidence that shows risks are being managed and objective being delivered

Assurance - are there controls where no assurance is available?

4 by 4 = 164 by 3 = 12

Trust Board Quality and Operational Performance Reports

Assurance Reports from Sub Groups / Divisions into Board Committees as per workplans

3. Variation / lack of sustainabilty of ward cleanliness scores

5. Capacity issues within clinical support dvision

6. Lack of assurance around divisional quality indicators.

Ward level Quality Dashboards

Quality Report Priorities & Monitoring Reports

4 by 2 = 8 by March 2019

R750 R770 R828 R842 R904 R922 R925 R927 R934 R937 R957 R964 R971 R977 R986 R994

R1018 R1047 R1052 R1055 R1036 R1057 R172 R174 R214 R219 R220 R221

Executive Review of KPI's via Performance Management

Framework / Divisional Performance Reports

4. FFT responses and recommend rates improving but further work required

3. Increased monitoring by Deputy Director of Nursing. Time out for strategy development and recruitment to DNQ vacant post.

DN

Q

Jan-19

4b. Discussion taking place with Volunteer Co-ordinator around availability of increased number of volunteers to support collection of FFT feedback. Improving flow, modernising outpatients and well prepared surgery.

actioned

DN

Q




RISK OWNER: DNQ

C x L

Risk Score C

By w

hen

Lead





Link to Strategic Objective


Co-ordination of schedule of Internal assessments of care environment inc mock CQC inspection programme

G Reports following review of significant external events

DN

Q

actioned

Safer staffing nursing establishments agreed and monitored

Policies and Standard Operating procedures

7. 30% of policies are out of date.

7. Plan in place to address policy progress to be discussed at Board. Reduced to 16% as of 27.2.19.

DN

Q / M

D

Mar-19

Management of Sickness absence rates8. QIA process slow to submit 8. Process to be updated to include development of early

warning systems to monitor impact of schemes implemented

DN

Q

Mar-19

Mandatory training programme in place to ensure that staff have appropriate skills

Policies provide framework for staff to operate within Key appointments / job descriptions

Clinical audit programme in place which identifies shortfalls in best practice

Participation in External Peer Review Programme

Subject to external accreditation / review of relelevant services

Participation in Civil Eyes benchmarking service

Quality impact assessment of all CIPs Terms of References

Trust incident reporting policy and process Self Assessments / Internal Reviews i.e Section 11

11a. Extend Ward based newsletters implemeinted May 2018

DN

Q

actioned

SUI action plan update and exception reporting from corporate risk register reviewed by risk and audit committee

Strategy Documents & Plans 11b. DON lessons learned sheet. Review of learning underway.

Complaints monitoring at DPR

Self Assessment against IG Toolkit 11c. Implement learning and sharing system to proactively collate feedback and process

DN

Q

Mar-19

Board self assessment against Monitor's Well Led Framework

EXTERNAL

12a. Action plan for review.

CEO

actioned

5. Recruitment to post frozen

6. Scrutiny process at DPR

achieved

DN

Q

10. Implementation of Internal Audit Reports (monitored through Trust tracker reported to Risk & Audit Committee)

various

9a. Implementation of Handover App within eDMS platform (will also address IG issues) M

D

9b.Actions to be taken forward as part of improving work flow - 'no discharge summary no discharge' work to go to February's FRC. Update also to February's QC.

10. Internal Audit Reports identify recommendations for implementation

11. Evidence of reporting of shared learning / external review recommendations still to be embedded

Department Show Cases / Patient Stories / Back to the Floor

Programme

Statutory Declarations & Regulatory Submissions inc Self

Cerfifications

Project Management Documentation including workplans

/ action plans / risk registers

4 by 4 = 164 by 3 = 124 by 2 = 8 by M

arch 2019

5. Capacity issues within clinical support dvision

6. Lack of assurance around divisional quality indicators.

9. Underachievement against targets for completion of discharge summaries

R750 R770 R828 R842 R904 R922 R925 R927 R934 R937 R957 R964 R971 R977 R986 R994

R1018 R1047 R1052 R1055 R1036 R1057 R172 R174 R214 R219 R220 R221

DN

Q

actioned

12. External Development review of leadership and governance arrangements due (Well Led)

Reports from representation at External Partnership Delivery

Forums / DiscussionCQC PIR process

DSO

Mar-19




RISK OWNER: DNQ

C x L

Risk Score C

By w

hen

Lead







Performance Management of compliance with PDR completion Internal Audit Reports

Duty of Candour understood by all staffArrangements in place for staff to raise concerns in confidence

13. Gaps in EDS2 DN

Q/D

HR

OD

Jan-19

Equality & Diversity System 2 annual submission 14. Duty of candour understanding across the Trust is inconsistent.

DN

Q

Mar-19

Programme in place for embedding of Trust values

Weekly quality meeting with MD, DON, Risk and Safety Managers G

Review / quality impact assessment of significant service changes arising from changes in commissioning / funding arrangements

NHSI Monitoring Reviews & SOF Rating

New Build project management arrangements include operational group to focus on transfer of services

Risk Assessment of fire safety arrangements G

17. Care planning on acute site may not deliver sufficient detail for litigation / SI review

17. Appointment to B7 transformation post. Frozen.

DN

Q

Mar-19

Emergency Planning Survey Results18. No system for forward look for new guidance

18. Set up horizon scanning and plan process. DN

Q

Mar-19

Infrastructure / Resource in place to support integrated governance

19. BCP not in sufficient detail to meet stanadard.

19. Action plan in place. Progress reported through RAC. DN

Q

Mar-19

Implementation of Seven Days Services Action Plan20. Medical mediation training 20. Mediation training delivered and action plan to be

developed

DN

Q

actioned

Development and application of IT systems to increase patient safety / improve patient flow (patient experience & efficiency)

CCG CQRM Reports21. Assurance re CQC improvements required in MH services

21a. Improvement plan in place. Establishment review commencing April 2019.

DN

Q

Mar-19

12b. Agree scope and commission external / further review

4 by 4 = 16

4 by 2 = 8 by March 2019

4 by 3 = 12

Independent Reports / Management Consultancy

Reviews

National Benchmarking reports

15. Baseline audit underway

DN

Q

actioned

13. Gaps to be plugged.

13/14. Training underway

12. External Development review of leadership and governance arrangements due (Well Led)

16. Recent assessment against Infection Prevention & Control responsibilities reported to June 2018 Trust Board highlighted key gaps .

15. LD standard not fully compliant.

NHSE EPRR Statement of Compliance

Peer Reviews / Accreditations

16. At VCP storage

CQC Inspection / Deep Dives / MHA Reviews

CQC PIR Process

Regulation 28 Action Plan

DN

Q

Mar-19

CEO

actioned




RISK OWNER: DNQ

C x L

Risk Score C

By w

hen

Lead







Trial of Electronic PEWs on Ward21b. Recruiitment to recovery team posts underway.

DN

Q

Mar-19

e-booking pilot21c. Weekly meeting system in place.

DN

Q

achieved

e-outcome formBed monitoring systems (BeMS) to be implemented

within new wardEDMS roll out (Dec 18)

Planning to ensure robustness of service delivery and maintainance of appropriate levels of quality across winter months

G

Managemet of families in conflict with clinicians

Back to the Floor VisitsDON Professional visits

4 by 4 = 16

4 by 2 = 8 by March 2019





INTERNAL

EXTERNAL

Clearly defined business planning process (control rating turned amber from green in Jul 17) INTERNAL 1a. Deliver CIP workplan and embed revised governance

arrangements - ongoing

CFO

actioned

Management of Financial performance (control rating turned amber from green in Jan 2017)

Board Financial Peformance Report

1b. Develop and implement Performance Management Framework including Divisional Escalation Framework - paper taken to FRC in February

DSO

/ C

FO

Mar-19

Divisional Performance Managament Framework in place

Monitoring of delivery of activity/income planControl of costs

Business Case processesVacancy Control panel

Agency Spend ControlsEffective pay controls

Capital

Transformation & Efficiency Programme 18/19

Robust planning of 2018/19 CIPs

Transformation & Efficiency PMO

Review of CIP Governance / Delivery / Assessment of Resouces to deliver discussed by

FRC

Use of external consultancy support to increase productivity

Assurances (see separarate sheet for

detail)

Project Management Documentation including

workplans / action plans / risk registers

2. Significant risk around forecast cash position


Gaps in control or assurance Action to meet gaps / drive risk score to agreed target score

1. Lack of delivery of cost improvement programme

CFO

2b. Continue review of additional charitable funding options

Assurance Reports from Sub Groups / Divisions into Board Committees as per workplans

Mar-19

3. Financial Plan for 2018/19 includes undentified CIPs

3a. Identify & agree content of combined transformation and recovery plan - Medicine and Surgery on weekly monitoring

2a. Explore potential sources of cash funding (loans) - application submitted to ITFF and external funders

DSO

/ CFO

actioned

3b. Deliver combined Transformation & Recovery Plan - inc 1c and 1a

3c. All prospective cost and capital under review against risk based criteria

CFO

2c. Continue discussions around ICS capital funding - but understanding that this will be nil C

FO

Executive Review of KPI's via Performance Management

Framework / Divisional Performance Reports

Policies & Standard Operating Procedures (including SOFIs)

Statutory Declarations & Regulatory Submissions inc

Self Cerfifications

BAF (2) Risk that we do not maintain financial stability due to failure to deliver our financial plan or the negative impact of movement to a system-wide financial planning regime, resulting in requirements for additional CIPs or reduction in level and standard of servicesRISK OWNER: CFO

[1] & [4]

InherentC

urrentTarget

Lead


R726 R842 R904

R1047

Risk Register Cross RefC x L

Risk Score


Assurance - are there controls

where no assurance is

available?

4 by 4 = 16 by March 19


Control rating

Key Risk Controls


How does this risk link to the Trust's objectives and priorities?

By w

hen

DSO

/ CFO

actioned

1c. Deliver opportunities identified within external consultancy reports (FourEyes / Deloitte / Civilise) - incorporated within R&T workstreams and other benchmarking work

actioned

DSO

/ CFO

Mar-19

5 by 4 = 205 by 4 = 20





detail)



Lead


Risk Score


Key Risk Controls

By w

hen

Performance management of delivery efficiencies at Trust and divisional level Terms of Reference

Assessment of Trust position against Carter Recommendations. Work taking place on Model

Hospital.see 1a above

Capital Investment Team / TEG review and prioritisation of capital funding

4a. Develop effective communications plan in relation to recovery and transformation agenda. Some communications in place including a newsletter. Meeting with Communications arranged.

DSO

Contingency level identified within Trust financial plan R Trust Internal Communications 4b. Paper from Capital Investment Team re restriction on

capital spend to be presented to TEG April

CFO

actioned

Commissioning of independent review of internal financial controls

Planning & Strategic Development Documentation

4c. Ensure financial information accurately reflects financial position and is available in timely position for managers to review and implement changes.

CFO

Jan-19

Cash Management Strategy in place with a more thorough focus on the 13 week cash flow forecast, working capital management and a loan application to ITFF.

Self Assessments / Internal Reviews 5a Review structure and operation of cash committee

CFO

actioned

Robust joint QIPP planning approach and commitments in place with commissioners built into the contract so therefore less risk

EXTERNAL 5b. Revise monthly financial reports to include fuller debt and cash position

CFO

actioned

Contracting arrangements in place with commissioners Internal Audit Reports

Effective contract managament arrangements in place National Benchmarking reports

Partnership arrangements in place

Engagement with national tariff agenda

Involvement through Alliance in specialist paediatric tariff top up representations

6b. Develop action plan to support achievement of financial governance objectives:

Prudent assumptions within financial plan around charity income

- NHS Improvement action plan agreed and submitted

Tight financial controls in place NHSI - Financial Governance Assement

- Consideration by FRC

(turned amber from green Feb 18) - Actions being taken forwards

3. Financial Plan for 2018/19 includes undentified CIPs

actioned

3b. Deliver combined Transformation & Recovery Plan - inc 1c and 1a

3c. All prospective cost and capital under review against risk based criteria

6a. Implementation of Internal Audit Reports (monitored through Trust tracker reported to Risk & Audit Committee)

Mar-19

CFOIndependent Reports /

Management Consultancy Reviews

Reporting from representaion on External alliances /

partnership forums

NHSI Monitoring Reviews & SOF Rating

4. Financial performance reports indicate expenditure controls not effectively embedded


DSO

/ CFO

Mar-19

5. Strengthen cash flow forecasting reporting / cash committee

actioned

CFO

5 by 4 = 205 by 4 = 204 by 4 = 16 by M

arch 19





detail)



Lead


Risk Score


Key Risk Controls

By w

hen

Collaborative approach re imminent national reconfiguration of Genetic Laboratories in order to mitigate financial risk re loss of service.Implementation of appropriate Trust Investment Strategy

CFO





INTERNAL

EXTERNAL

Workforce Objectives sitting within deliverables from Operating Plan routinely monitored and reported INTERNAL

Action plan in place to develop a Strategic Workforce Strategy

Trust Board Workforce KPI Reports

Management of sickness absence rates including divisional breakdown of long term sickness absence and implementation of sickness absence policy

Assurance Reports as per Board Ctte workplans

Mandatory training programme in place to ensure that staff have appropriate skills

Performance management of PDR completion compliance

Focus on workforce within Internal Audit Plan Divisional level Dashboards / league tables

Revalidation process for medical staff in place Policies & Standard Operating Procedures

3Participation in external accreditation / review of relevant clincial services

Statutory Declarations & Regulatory Returns inc Self

Certifications

3. Engagement with HEE self-assessment

3. HEE National Quality Framework self-assessment return

DH

R

actioned

Participation in local quality management visits from Health Education Yorkshire and Humber

4a. Agree People Strategy DH

R

actioned

Subject to external regulation - CQC

Communications Strategy in place with key objective focused on internal communications


Current



Mar-19

Lead


By w

hen

Gaps in control or assuranceC x L

Inherent5 by 4 = 20

Control rating


various

DH

R

5 by 3 = 155 by 2 = 10 by M

arch 2020Target

DH

RD

HR


1a. Continued Executive focus on PDR / MAST compliance aligned to performance management framework / divisional escalation framework to drive further improvement / achievement of targets.

1b. PDR Policy under review and PDR season being proposed.

[1] & [2]


2a. Implementation of Internal Audit Reports (monitored through Trust tracker reported to Risk & Audit Committee). Meetings taking place and focus on follow-up audits.

1. Rate of PDR and mandatory and statutory training compliance increased but stabilised just short of target



Executive Review of workforce KPI's via Performance

Management Framework

Mar-19

4b. Implement People Strategy and report progress

BAF (3) Failure to ensure that the Trust has a motivated, suitably trained and engaged workforce impacts on operational performance, transformational change and achievement of strategic objectives. RISK OWNER: DHR

Risk Score C Link to

Strategic Objective


Key Risk Controls

4. People Strategy in development

R726 R750 R828 R922 R925 R963

R1047 R1052 R1055 R214

Key appointments / job descriptions (eg Guardian of Safe

Working Hours / Freedom to Speak up Guardian





Lead


By w

hen




Strategic Objective


Key Risk Controls

Programme of Staff Engagement and Culture and Behaviour Strategy

Departmental Showcases / Back to the Floors / Programme of open

staff meetings





Lead


By w

hen




Strategic Objective


Key Risk Controls

Policies and procedures in place for staff to voice concerns / air greviances (including appointment of Freedom to Speak Up Guardian)

Revlaidation Report 5. Develop a 'pulse check' mechanism by which to measure staff engagement routinely

DH

R

Mar-19

Work programme for Embedding of Trust values in place

Trust Internal Comms / Engagement materials

Terms of Reference 6a. Develop effective communications plan in relation to recovery and transformation agenda

DSO

Mar-19

EXTERNAL 6b. Launch and Develop Culture and Behaviours Strategy

DH

R

actioned

National Benchmarking reports / Survey Results

Internal Audit Reports

Reports from external reviews / accreditations / Peer Reviews

5 by 4 = 205 by 3 = 155 by 2 = 10 by M

arch 2020

6. Rate of delivery of transformational change - CIP targets not met (engagement in transformation agenda)

5. Measurement of staff engagement limited to annual Staff Survey results



Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated -January 2019


INTERNAL

EXTERNAL

Annual Planning Cycle INTERNAL

Engagement with divisions to understand workforce requirements to feed into external workforce planning submisison to NHSI / HEE

Trust Board Workforce KPI Reports

Prioritisation of HR Support to work with divisions on Strategic Workforce Issues

Assurance Reports as per Board Ctte workplans 1b. Implement People Strategy and report progress

DH

R

Mar-19

Action plan in place to develop a Strategic Workforce Plan G

Workforce Objectives sitting within deliverables from Operating Plan routinely monitored and reported

Agency / Locum Booking Controls Divisional level Dashboards / league tables

Safer staffing establishments agreed Policies & Standard Operating Procedures

Nurse Recruitment programme Departmental Showcases / Back to the Floors

Consultant Job Planning

Consideration of new staffing models

Lead Unit for Junior Doctor traininng

1a. Agree People Strategy (timeline agreed as part of Strategy Refresh work programme)

DH

RR828 R922 R925 R966 R994

R1052 R1055 R214

Executive Review of workforce KPI's via Performance



2b. Implement new consultant job planning framework. Policy and financial assessment written. Going to LNC.

31/03/2019

MD

[1] & [2]



actioned





DH

R

31/03/2019M

ar-19B

y when

C x L

InherentC

urrentTarget





Control rating



Lead

4 by 4 = 163 by 4 = 123 by 2 = 6 by M

arch 2020

BAF (4) Failure to ensure that the Trust recruits staff in the right numbers and with the appropriate breadth of skills and competencies to deliver high quality services now and in the future. RISK OWNER: DHR

Risk Score



Key Risk Controls

3a. Continued focus on embedding recruitment KPIs through performance management framework / divisional escalation framework to drive sustainable improvement / achievement of targets.

3. Monthly variation in performance against recruitment KPIs

MD



Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated -January 2019B

y when

C x L



LeadBAF (4) Failure to ensure that the Trust recruits staff in the right numbers and with the appropriate breadth of skills and competencies to deliver high quality services now and in the future. RISK OWNER: DHR

Risk Score



Key Risk Controls

Master Vendor procurement implemented

Growing own researchers as academics w/i Academic Unit of Child Health

Planning & Strategy Development Documents

Targets set around efficiency of recruitment processes (turned amber Feb 18)


Certifications

Project Management Arrangements / Work Programmes

/ Action Plans

Trust Internal Comms / Engagement materials

Terms of Reference

EXTERNAL


Independent Reports / Management Consultancy Reviews

Regulatory Regime Inspections / Rating / Monitoring feedback

Internal Audit Reports

Reports from external reviews / accreditations / Peer Reviews

Mar-19



4 by 4 = 163 by 4 = 12

3b. Led by Learning and Development, focus being placed on streamlining and improving recruitment and induction processes. Day 1 ready project.

DH

R

3 by 2 = 6 by March 2020





INTERNAL

EXTERNAL

Action plan in place to develop a Strategic Workforce Strategy INTERNAL 1a. Embed revised transformation and recovery

programme governance arrangements - ongoing

DSO

actioned

5 by 2 = 10

Workforce Objectives sitting within deliverables from Operating Plan routinely monitored and reported

Executive Review of delivery of CIPs via Performance


1b. Develop and implement Performance Management Framework including Divisional Escalation Framework - further review scheduled. See also BAF 2

DSO

Mar-19

Effective divisional management arrangements in place


Balanced and stable Board2. Agree People Strategy

Appointment of substantive CIO

Trust Executive Group in place Key Appointments / Job Descriptions

Co-ordination of External Partnership / Strategic Focus by Executive Team

Policies & Standard Operating Procedures 3. Recruit to AD vacancy

DSO

Leadership programmes in development including Shadow Board in place

Effective Programme management skills in place

Use of external consultancy support to identify transformation opportunities G Departmental Showcases / Back to

the Floors

CEO

Refresh of Executive accountabilities / objectives overseen by Board Nominations Committee

Trust Self Assessments / Effectiveness Reviews / Well Led

[3] & [4]


Certifications

1.Year on year underperformance against cost improvement programme



Control rating



5 by 4 = 205 by 4 = 20

R726 R966

R1052 R1055 R214

Lead

By w

hen

C x LAction plans (or reference to action plans) to meet gaps in control or assurance


InherentC

urrentTarget



BAF (5) Risk that insufficient leadership capacity and capability prevents necessary transformational changeRISK OWNER: CEO

Risk Score



Key Risk Controls Assurances (see separarate sheet for detail)

Gaps in control or assurance

Nov-18

DH

R

3. Interim arrangements in place at AD level x2

4. Recruit to MD role to ensure effective handover from current postholder - appointment made / handover period pre 01 July start date

4. Recruitment process in place to fill planned vacancies on Trust Board

Chair

actionedactioned

actioned


/ Action Plans





Lead

By w

hen

C x L

BAF (5) Risk that insufficient leadership capacity and capability prevents necessary transformational changeRISK OWNER: CEO

Risk Score





Performance Management Framework agreed as an action from Board AwayDay. Presented to FRC Nov 18

G Board development programme 5. Agree OD programme - leadership development programme in place

Organisational Development Programme G Shadow BoardTransformation & Efficiency Programme - Review of CIP Governance / Delivery / Assessment of Resouces to deliver

People Strategy6. Discussion around Organisational Development priorities.

6. Board Development programme commissioned - engagement reported to June Board / delivery in progress

DH

RO

D

actioned

Membership of ICS Collaborative Board to influence system-wide transformation and identifiy resources to support (commissioning of sustainable service review)

Business case for corporate capacity


7. Implementation of Internal Audit Reports (monitored through Trust tracker reported to Risk & Audit Committee)

CFO

by March 19

Assessment against the Well Led frameworks G EXTERNALStreamlining meetings process


8. Well Led Self Assessment work in progress

8a. Complete Well Led Assessment - facilated workshop took place 20/04/18. Action plan reported to Board June 18 with oversight arrangements.Monthly confirm and challenge process in place via committees.

8b. Follow-up audit on NHSI Well Led Framework.

CEO

actioned

Internal Audit Reports 8c. Conduct an Exec gap analysis and review supporting information which will lead to targeted invterventions

CEO

Mar-19

5 by 4 = 205 by 3 = 155 by 2 = 10

5. Organisational Development Programme in development

DH

R

actioned





INTERNAL

EXTERNAL

[1] & [4] Specific Services INTERNAL

CAMHS TIER 4 SERVICES - reconfiguration of model of care by NHSE

Reporting from external partnership discussion / stakeholder

development

Regular meetings with NHSE and other provider with Exec and AD level involvement

SCH agreed as lead provider (Board approved 27/2)

Partnership Board in place oct 18 Trust Internal Comms / Engagement materials

Business Case for new model of care to secure funding Strategy and Planning Documents

3. CAMHS Tier 4 Governance arrangements to be established

3. Partnership Board to be set up with SCH chair .Completed Q1 2018/19

DSO

complete

GENETICS - NHSE tender

SCH Steering Group established including DSO. CFO and CIO

4. CAMHS New Model of Care Business Case still to be developed

4. Alternative sources of funding being explored following decision not to award capital.

DSO

Mar-19

Programme Management arrangements brought in to support GeneQ and lead tender response EXTERNAL


5. Genetics risks (including financial risks) still to be understood / quantified

5. Work ongoing and Board receiving monthly briefing from DSO. Succesful in tender and transitioning to genomics. Meetings with DOFs taking place to establish risks and benefits. Contract arrangements in place.

DSO

DSO

2. Project arrangements to be established including project resource, funding via ICS is possible. Linked to above. See also BAF (9) 1a. Not successful.

Target





Control rating

C x L

4 by 4 = 16

4 by 4 = 16

3 by 4 = 12


/ Action Plans



2. Management capacity to respond to CAMHS Tier 4 tender identified as a risk

Current

Inherent

R934 R1047 R1052 R1055 R1036 R1067 R1057 R172 R174 R220 R221

BAF (6) Risk to clinical service viability due to failure to meet nationally defined standards or changes to the commissioning and / or configuration of servicesRISK OWNER: DSO

Risk Score



Key Risk Controls Action to meet gaps / drive risk score to agreed target score

by October 2019

Personal in post / key appointments

Lead

1. Due Diligence process around CAMHS Tier 4 new care model is in development

1. Alternative sources of funding being explored following decision not to award capital.

DSO

Mar-19


By w

henactioned






C x L


Risk Score




Lead

By w

hen

Joint tender submitted and in place for GeneQ in place and SCH bid team

Project leads identified (CD and AD)6. Health Visiting specification based on reduction in funding now signed

6. Contract negotiations continue with the DNQ to agree a balance between the cost coming out and the delivery of the specifcation. May 2018

DSO

HEALTH VISITING

Formal correspondence with Local Authority outlining safety concerns and consequences of further funding

reduction

Development by Trust (HV Team) of options for service delivery specification with reduced funding

Proposal presented to Children & Young People's Health and Wellbeing Board (agreed 24/1)

Agreed priority within ACP

General

COMMISSIONER INTENTIONS

7.c. Full clinical and managerial input into the HSR process thus far. Executive Directors intrinsically involved in consversations across the ICS to determine SCH role in any future changes. Timescales for actions dependent on HSR schedule. Trust selected to be hosted network for Care of Acutely Ill Child.

DSO

by March 2019

Two year contract in place to mitigate impact of commissioning environment in 2018/19

Executive positioning within ACP partnership discussions re joint provider / commissioner

arrangements

4 by 4 = 16

4 by 4 = 16

3 by 4 = 12

DSO

Mar-19

8. Corporate Objectives / Divisional Business Plans to be developed / implemented

8. Strategy refresh has been completed at Trust level and was signed off at February Board. Clinical Divisions and Corporate Departments tasked with aligning their strategies with this.

DSO

actionedC

omplete

7.Potential impact of vacant Contracts Posts on negotiations around commissioning intentions with CCG re consultation on respite and urgent care and NHSE re Specialised Services Review

7a. Deputy Director of Strategy and Operations commenced in post in January 2018 and has been leading on this in the absence of other positions. Contract and Performance Manager being advertised March 2019. Interim arragements until then.

DSO

Mar-19

7.b Trust has responded in full to the consultation on Urgent Care and has contributed to the consultation process for respite care (out to consultation as of February 2018).Awaiting CCG response.

External reporting from partnership programmes including joint governance arrangements /

documentation

5. Genetics risks (including financial risks) still to be understood / quantified

5. Work ongoing and Board receiving monthly briefing from DSO. Succesful in tender and transitioning to genomics. Meetings with DOFs taking place to establish risks and benefits. Contract arrangements in place.

DSO

by October 2019






C x L


Risk Score




Lead

By w

hen

Executive positiong within ICS to influence priorities, example being indentification of workstreams within

HSR

Strategy refresh work being undertake to inform clinical strategy direction and decision making process

Appointment to vacancy contract posts





INTERNAL

EXTERNAL

Health Visting & Family Nurse Partnership INTERNAL

Redesign of Service to meet reduced funding (turned amber from red Jul 2017)

Development of infrastructure to deliver ICS for South Yorkshire - to emerge out of Working Together

2. Lack of complete clarity around ICS financial framework risks

Trust sign up based on lowest level of financial risk and Board acknowledgement of wider drivers with caveats made in Trust response

CFO

actioned

Corp

Accountable Care Partnership designation Strategy and Planning Documents

3. Corporate capacirty at PLACE and ICS level 3a. Corporate capacity business case approved.

3b. Discussion regarding streamlining of meetings.

CEO

Jan-19

Stakeholder Engagement with partners delivered through membership / involvement in wide range of forums / groups

4. Alignment of Shaping Sheffield with Trust's strategic direction.

Specifically - CEO holds joint Chair role of Children's Health & Wellbeing Board

5. Trust strategy to better reflect partnership working.

6 Transforming Sheffield Forum (CEO)6. Changes within Exec Team

Posts being recruited to

NHS CEOs part of Public Health Reform Agenda being led by LA

Sheffield Provider's Alliance Forum Board approval of ICS MoU

Sheffield CEOs weekly meetings

City-wide Digital Footprint Working Group (CIO)EXTERNAL

BAF (7) Failure to engage effectively with partner organisations and the local community threatens the ability of the Trust to deliver its strategic ambition.RISK OWNER: CEO

Risk Score






Lead

By w

hen

C x L

Control rating


CurrentTarget



Evidence that shows risks are being managed and objective being deliveredInherent

4 by 3 = 12

4 by 2 = 8

4 by 2 = 8

R927 R986 R994

R1047 R1055 R1067 R219

[3] & [4] & [5]

Key Risk Controls

Terms of Reference

Statutory Declarations & Regulatory Submissions inc Self

Cerfifications

Reporting from external partnership discussion / stakeholder

developmentParticipation in Working Together Programme (WTP)

Assurance Reports as per Board Ctte workplans / adhoc strategic

service updates

complete

1. Need for effective co-ordination of strategic partnership work / representation

CEO

Sep-19

4 & 5. Develop strategic themes to better align with partnership level. Over 70 staff attended stakeholder events in January and February. Outputs to come back to Exec Team.

TBA

CEO

/DSO


1. Embed Clinical Steering Group linked to Hospital Services review now in place. Terms of reference being developed.

DSO



Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated -January 2019BAF (7) Failure to engage effectively with partner organisations and the local community threatens the ability of the Trust to deliver its strategic ambition.RISK OWNER: CEO

Risk Score





Lead

By w

hen

C x L

Key Risk Controls

Commissioner relationship management

Involvement in transformation plans re the mental health and emotional wellbeing of children and young people in Sheffield / DSO member of Emotional Health and Wellbeing group

Establishment of Youth Forum

Relationship with Charity / CFO and Chair hold Charity Trustee positions

Children's Alliance - CEO / CFO / MD and DoN sub committees

Development of the Academic Unit of Child Health

Chairmanship of Local Research Network ICS Financial Framework

CLARC

Academic Health Science Network

Building strategic partnerships with industry to increase commercial income / encourage innovation

Building strategic international links to increase commercial income / Trust profile

CEO role as Chair of Partnership Board re Genomic Medical Centre and Genetic Laboratories

CEO Membership of Test Bed Prog Steering Group

Host of Operational Delivery Networks (paediatric critical care / neurosciences)

Working with Commissioners re potential role as host for Clinical Network for Children’s Surgery and Anaesthesia Continued development of effective working with Council of Governors (turned green from amber July 2017) CQC PIR

EXTERNAL

Peer Reviews / Accreditations

External reporting from partnership programmes including joint governance arrangements /

documentation

4 by 3 = 12

4 by 2 = 8

4 by 2 = 8



Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated -January 2019BAF (7) Failure to engage effectively with partner organisations and the local community threatens the ability of the Trust to deliver its strategic ambition.RISK OWNER: CEO

Risk Score





Lead

By w

hen

C x L

Key Risk Controls

Children's Health and Wellbeing Panel





INTERNAL

EXTERNAL

Management engagement with clinicans through: INTERNAL

TEG

JNCC / LNJC / Junior Doctors Forum

Programme of Executive Walkabouts

Staff Governors

Executive Team (CEO) meetings with consultants

Join the Conversation - Staff Forum Meetings

Effective divisional management arrangements in place

Project management arrangements involve clinical representation Trust Internal Communications

Implementation of internal communications and engagement plan Strategy and Planning Documents

Clinical involvement in agreeing / implementing clinical strategy

Arrangements in place to survey staff / benchmark staff feedback 3b. See BAF (3) actions 3a / 3b.

DH

R

actioned

Induction Programmes - Trust / Junior Doctors'4. Limited clinical engagement in clinical engagement forums within the Trust

4. Consideration of physicians associates and advanced practioners strategy

MD

May-19

By w

hen

C x L

InherentC

urrentTarget


Control rating




BAF (8) Failure to engage with our clinicans prevents the development / implementation of an effective clinical strategy that responds to the needs of patients and other health / social care partners and prevents us from capitalising on the use of research, innovation and technologyRISK OWNER: CEO

Risk Score







Back to the floor programme / walkarounds / Exec representation

at medical staff forums

3. Junior Doctor Shortages - system wide


[1] & [3] & [4]

R1047 R1052 R1055 R1067 R1057 R214 R221


/ Action Plans / post project reviews

Policies & Standard Operating Procedures

Assurance Reports as per Board Ctte workplans / adhoc strategic

service updates

4 by 1 = 4

5 by 3 = 154 by 3 = 12

MD

1. Gaps in control identified within Internal Audit Report


2a. Updated policy to be presented to Quality Committee in March 2019. Programme to embed through work with clinical teams

Lead

1a. Job planning review being undertaken by Clinical Director of Medicine to address recommendations within internal audit report. Report to be presented to TEG.


actioned

1b. Impementation of standardised job plans (links also to delivery of recovery and transformation plan)

MD

Apr-19

MD

Mar-19

actionedJul-19

2. Discussion at Quality Committee following review of assurance reports / reports from deep dive reviews identify need to update the Responsible Clinician Policy

MD

3a. Involvement / Leadership role within ICS / WTP workstreams, eg Acute Paediatric Surgery review and Hospital Services Review. Business cases being developed with clinical engagement. Trust is hosted network for CAIC.

MD

2b. Approved policy to be shared with LJNC (May 18) / TEG (Apr 18)



Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated - January 2019B

y when

C x L

BAF (8) Failure to engage with our clinicans prevents the development / implementation of an effective clinical strategy that responds to the needs of patients and other health / social care partners and prevents us from capitalising on the use of research, innovation and technologyRISK OWNER: CEO

Risk Score




Action to meet gaps / drive risk score to agreed target scoreGaps in control or assurance

Lead

Involvement in CIP Programme

Updated Junior Doctors / Consultant Handbook

Appointment of x1 Deputy Medicial Directors

Appointment of a Guardian for Junior Doctors Hours & Effective TY

Appointment of Freedom to Speak Up Guardian & Effective Training Champion for less than full time hours

Setting up of a Junior Doctor's Forum

Reviewing Mortality Review panel Terms of Reference

Monitoring of junior doctors training EXTERNAL

Programme of Consultant / patient safety practice briefings GMC reports

Use of Clinical Microsystems methodology

Roll out of EDMS on Acute site competed by March 17 and extended to CommunitySee BAF (8) 3a and 3b regarding clinical representation on appropriate management and operational clinical delivery networksImplementation of programme of Back to the floor visits for Board and CoG

4 by 3 = 12

Back to the floor programme / walkarounds / Exec representation

at medical staff forums


Reporting from representaion on External alliances / partnership

forums

Executive Monitoring via Performance Management Framework (inc Escalation

Framework)

5 by 3 = 15

4 by 1 = 4





INTERNAL

EXTERNAL

Programme Infrastructure / Governance in place INTERNAL1a Digital bids to NHS E. Priority digital bids approved through SY&B ICS totalling over £1.2m across 18/19 and 19/20.

DSO

actioned

IM&T Strategy Board - meets bi-monthly, forward looking for strategy alignment and oversight on

current projects


/ Action Plans / post project reviews

DSO

Mar-19

IG Committee - meets bi-monthly, assurance / oversight of operational risks re use of clinical

information, data quality & information security.


Participation of external assessment reviews of cyber security arrangements / governance

DSO

Oct-18

Detailed review of risk register with update to align with investment planning

Focus on IM&T operations and management within Internal Audit Plan (inc Cyber Issues)

Trust Self Assessments / Effectiveness Reviews



DSO

by March 19

Re-assessment of IM&T capital programme requirement to incorporate risk mitigations and also CIP objectives and to enable service transformation

Policies & Standard Operating Procedures

4. Action required to achieve GDPR compliance

4. GDPR action plan to be presented to Risk and Audit Committee to achieve compliance by late May 2018 (presentation of report actioned). Internal Audit report completed in Dec 18. Significant Assurance opinion confirmed.

DSO

actionedBAF (9) Failure to ensure that the required IT infrastructure and strategy is in place impacts on the Trust's ability to safeguard patient safety, deliver services, improve quality and transform servicesRISK OWNER: DSO

Risk Score



Key Risk Controls

By w

hen


C x L

Control rating

Inherent





4 by 4 = 16


1. IM&T Strategy in development

R964 R965 R966 R971 R977 R214 R220

CurrentTarget



Lead

1b. Agree IM&T Strategy and associated Investment Plan / Implementation Roadmap . Priority digital bids approved through SY&B ICS totalling over £1.2m across 18/19 and 19/20


Certifications

[1] & [3] & [5]

5 by 3 = 155 by 2 = 10 by M

arch 2019 2. Critical and High risks relating to Cyber Security identified by IT Health Check commissioned by NHS Digital

2. Cyber security - annual external vulnerability assessment due March 19. Report to FRC in March 19, as part of approvals process for new Data Security & Protection Toolkit self-assessment.



Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated - January 2019BAF (9) Failure to ensure that the required IT infrastructure and strategy is in place impacts on the Trust's ability to safeguard patient safety, deliver services, improve quality and transform servicesRISK OWNER: DSO

Risk Score



Key Risk Controls

By w

hen


C x L


Lead

Cyber Security Programme (all capital fully funded)

Information Governance Arrangements in Place

EDMS project in place (successful implementation / roll out) Strategy and Planning Documents

6. Definition of IM&T enabling programmes as workstream of Recovery and Tranformation Programme in progress

6a. All schemes forming Enabling Workstream within Recovery & Transformation Programme for Qtr 1 delivery defined by end Mar 17

Learning from implementation of major IT systems Terms of Reference

6b. All schemes forming enabling workstreams within Recovery and Transformation Programme for Quarter 1 delivery defined by end March 2018

Recruitment of substantive CIO - in post Aug 2016 EXTERNAL6c. IM&T schemes forming Enabling Workstream within Recovery & Transformation Programme for Qtr 2 to be fully defined

Representation on partnership groups to identify joint projects across partnership footprint Internal Audit Reports

7. Identified need for interoperability / efficient record sharing between CAMHS and Community / Acute Clinical Services and means to enable integrated care with external partner organisations

7. CAMHS EPR – Full Business Case approved by TEG in Oct 18. Linked to BAF (9) 1a. Clinical Leads are in post, go-live targeted from end March 19. Project funding - £650K being secured from NHS England national bids, endorsed and prioritised by SY&B ICS.

DSO

Mar-19

Working with Sheffield health and social care community on Digital Footprint, with assessment undertaken on Trust score on Digital Maturity Index


actioned

DSO

actioned

5. Post Project Review reports for 2017/18 IM&T Infrastructure Projects to be presented to May TEG

5 by 3 = 155 by 2 = 10 by M

arch 2019

Key Appointments / Job Descriptions

DSO

4 by 4 = 16

5. Post Project Review process not fully embedded





INTERNAL

EXTERNAL

INTERNAL

Well Led Action Plan Updates

1. Potential NED with HR/OR or clinical experience

2a. Next steps for People and C&B Strategies

EXTERNAL2b. Strategic approach to leadership and managing

talentcross reference with 1.3 on Well Led Action Plan

DoH

OD

Feb-19

Well Led Self Assessment faciliated by Internal Audit

3. Develop engagement strategy cross reference with 1.4 on Well Led Action Plan

DH

RO

D

Feb-19

Internal and external workshops on Well Led NHS I Financial Governance Review

4. Develop supporting strategies and action plans cross reference with 2.1 on Well Led Action Plan

DSO

Board pack on Well Led Follow-up assessment by Internal Audit




R1036 R1055 R1057 R214 R221

Lead

Control rating


Key Risk Controls

C x L

InherentC

urrentTarget



BAF (10) Failure to develop our leadership, management and governance arrangements to ensure delivery of sustainable high quality person-centred care, support learning and innovation, and promote an open and fair culture prevents the Trust from demonstrating that it is a 'Well Led' organisation.RISK OWNER: CEO

Risk Score





By w

hen

3 by 2 = 6 by Oct 2018

[1] & [2] & [3] & [4] &

[5]

Well Led Self Assessment process and implementation of Well Led Action Plan with Board

oversight

5.Embed and clariify values amongst staff

Chair

Jan-19

DSO

Implementation of Well Led Action Plan and routine reporting to Board with oversight of detail discussed at

relevant Board Committee

Self Assessment identified a number of key gaps including:

DH

RO

D

Feb-19

cross reference with 1.1 on Well Led Action Plan


3 x 4 = 123 x 3 = 9




LeadKey Risk Controls

C x L


Risk Score





By w

hen


7a. Develop quality strategy

7b. Ensure junior doctor values covered at induction

7c. Values based recruitment


DN

Q/M

D/D

oHR

OD

8a. Ownership of quality assurance

8b. Patient experience themes and trends


DN

Q

9a. PDR policy development

9b. Review of access to mandatory training


DoH

R

Mar-19

10. Improve staff engagement cross reference with 3.4 on Well Led Action Plan

DoH

R

Feb-19

11. EDS2 implementation cross reference with 3.5 on Well Led Action Plan

DH

RO

D

12. New peformance oversight framework cross reference with 3.6 on Well Led Action Plan

DSO

Mar-19

13. Address overdue SI actions cross reference with 4.1 on Well Led Action Plan

DN

Q

Jan-19

14. Review executive attendance at meetings cross reference with 4.2 on Well Led Action Plan

CEO

Jan-19

6. Evidence of stakeholder involvement in original strategy

work

DSO3 x 4 = 12

3 x 4 = 123 by 2 = 6 by O

ct 2018





C x L


Risk Score





By w

hen

15a.Develop divisional use of Datix

15b. Business continuity


DN

Q

Jan-19

16. Financial governance review cross reference with 5.2 on Well Led Action Plan

DSO

Feb-19

17. Performance oversight framework cross reference with 5.3 on Well Led Action Plan

DSO

Mar-19

18. Do staff receive data to support imporved performance cross reference with 6.1 on Well Led Action Plan

DSO

19. Pathway to Excellence accreditation programme cross reference with 6.2 on Well Led Action Plan

DN

Q

Apr-19

20a. Holding to account of divisions

20b. Track supporting strategies


DSO

21. IM&T Strategy cross reference with 6.5 on Well Led Action Plan.

DSO

#####

22. Develop programme of governor attendance at

committeescross reference with 7.1 on Well Led Action Plan.

Chair

Feb-19

23. Develop engagement strategy cross reference with 7.2 on Well Led Action Plan.

DoH

RO

D

Feb-19

24. Evidence staff and user engagement cross reference with 8.1 on Well Led Action Plan.

DoH

RO

D

25. Leadership and managing talent cross reference with 8.2 on Well Led Action Plan.

DoH

RO

D

3 x 4 = 123 x 4 = 123 by 2 = 6 by O

ct 2018





C x L


Risk Score





By w

hen

26. Staff encouraged to review individual and team objectives cross reference with 8.4 on Well Led Action Plan.

DoH

RO

D

27. Appraisals to look at improvement cross reference with 8.4 on Well Led Action Plan.

DoH

RO

D





INTERNAL

EXTERNAL

Clinical Operations Group established led jointly by DSO and DNQ INTERNAL

KPIs in place, Sitrep and Huddles

Winter planning

Escalation Framework in place and embedded for use internally and with other providers (including OPEL levels 1-4 with operational triggers, actions and clear roles and responsibilities)


2. ICU and HDU capacity issues due to workforce gaps

2a. Continuos review through daily huddles to reasses critical care beds throughout the winter to ensure clinical safety on the unit in line with staffing requirements. Limited refusals to the unit in peak periods.

DN

Q

ongoing

Information systems in place to understand patient flow (eg numbers of medical outliers in surgical beds impacting in planned care)


/ Action Plans

3a. Agreed move date for acute wards into the new build and plans in place to ensure successful transition.

DN

Q

actioned

Engagement with Operational Delivery Network (ODN) regarding ICU and HDU capacity to ensure network plans in place

Annual Planning Documents

3b. Strategic Accommodation meeting reconvened, chaired by the Head of Estates and overseen by the CFO. This is considering all of the options in relation to the vacated space from a clinical, strategic and financial viewpoint.

CFO

actioned

New Build ProgrammePolicies, Standard Operating Procedures and Integrated

Performance Report

3c. AD of Operation for Surgery preparing a paper to consider outsourcing options for those specialties within the division where there is an increasing risk to 18 week performance and clinical issues around a growing review list, working in partnership with STH.

DSO

actioned

Utilisation of vacated space Terms of Reference

Consideration of off-site capacity for some specialties (outsourcing in place) EXTERNAL

4 by 4 = 16

3 by 4 = 12

3 by 3 = 9

[1] & [4] DSO

actioned

3. Higher acuity of patients leading to more admissions



various

various

BAF (11) Operational constraints and failure to delivery transformation impact on our ability to deliver planned activity and manage demand impacting on operational efficiency, service quality and financial performance.RISK OWNER: DSO

Risk Score




Lead

C x LEvidence that shows risks are being managed and objective being delivered




By w

hen


Inherent


CurrentTarget


Control rating


1. Winter pressures and external pressures / Inter Trust transfers require additional mitigation / monitoring

Executive Review of KPIs via Performance Management

Framework

1a. Trust continues to deliver against the A&E target as well as the range of RTT measures despite a busy winter. Winter pressures funding been received and used where appropraite within the organisation. Extended hours of provision for resident General Paediatric Consultant in place since November 2017 in line with national standards.

R770 R828 R842 R904 R922 R934 R937 R957 R944

R1018 R1047 R1052 R1055 R1036 R172 R174 R219 R220 R221



Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated -January 2019BAF (11) Operational constraints and failure to delivery transformation impact on our ability to deliver planned activity and manage demand impacting on operational efficiency, service quality and financial performance.RISK OWNER: DSO

Risk Score




Lead

C x L


By w

hen


Outpatient and Surgery transformation schemes National Benchmarking reports / Survey Results

Activity Planning as part of annual planning cycle Internal Audit Reports

Workforce action in place to manage sickness absence rate


4 by 4 = 16

3 by 4 = 12

3 by 3 = 9

DSO

Mar-19

5. Medicine and Surgery capacity to deliver following change of waiting list payment

5. Close monitoring through DRP



Sheffield Children's NHS Foundation Trust Board Assurance Framework last updated - Nov 2018


INTERNAL

EXTERNAL

[4] R911 Regular monthly reporting to Board in conjunction with regular management reports INTERNAL

5 by 4 = 205 by 4 = 20

Newly formed cash management committee - enhanced governance control re cash management with particular focus on recovery of bad debt


Enhanced scrutiny re trades payable and receivable Terms of Reference1b. Paper from Capital Investment Team re restriction on capital spend to be presented to TEG in April (capital capped plan by April)

CFO

actioned

Performance management re major projects EXTERNAL (cross reference to BAF 2: gap 2) see BAF 2: actions 2a, 2b, 2c

CFO

Internal Audit Reports 2a Review structure and operation of cash committee. See BAF 2

CFO

actioned

National Benchmarking / Ratings 2b. Revise monthly financial reports. Board reports completed by require strengthening.

CFO

actionedactioned

BAF (12) Failure to maintain the Trust cash position would result in the Trust not being able to satisfy its obligations in respect of pay and non-pay costs

RISK OWNER: CFO

Risk Score





Lead

By w

hen

CFO self assessment within Monitor informal visit of Trust controls judged against Monitor criteria for Trusts in turnaround / recovery

4 by 3 = 12 by March 19

CFO

C x L

InherentC

urrentTarget


2. Strengthen cash flow forecasting reporting / cash committee


1a. CIT to implement cash management recommendations discussed with FRC / Board to mitigate the risk of a potential cash problem for 2018/19 including the exploration of additional funding sources. Recommendations endorsed / being actioned



Control rating




1. Current forecasting and risk assessments show cash balances could become a significant problem within the next financial year.




Acceptable Behaviour Policy T b R&A Committee Jan-18 [1] [3]

ACP Governance Arrangements Ind o Trust Board May-18 n/a [6] [7]

ACS Statement of Intent Ind o Trust Board Oct-17 n/a [7]

Agency Controls Paper to TEG T n TEG Sep-16 [2] [4]

Agency Spend Board Self Certification T a Trust Board Nov-16 [2] [4]

Agency Use (Becton) T e Trust Board Jun-17 [1] [3] [4] [10]

Annual and Mid Year Report from Research & Innovation Directorate T e TEG Nov-18 [4] [7] [8]

Annual Deanery Quality Monitoring Visit / GMC Training Survey Ind k TEG Sep-17 [3] [8]

Annual Report - Child Death Overview Panel T e Quality Committee Nov-18 [1]

Appointment to Deputy CEO role T q Board Noms Committee Apr-17 [5]

Arrangement for Managing Salary Overpayments (report to FRC) Ind e F&R Committee Jan-17 [2]

Back to the Floor Programme T d CoG Feb-19 [1] [3] [8] [10]

Bid to NHS Digital Cyber Security Fund - successful T c F&R Committee Dec-17 [9]

Board & Committee Effectiveness Reviews T l Risk & Audit Committee Jul-18 [1] [2] [3] [4] [9] [10] [12]

Board Away Day Action Plan T c Trust Board Aug-17 [5] [10]

Board Development Proposal Paper T Trust Board Sep-18 [3] [5] [10]

Board Self Certfications (Provider Licence) T a TEG May-18 [1] [2] [4] [5] [10]

Business Continuity Plan T e Risk & Audit Committee Jan-19 [1] [10]

Business Investment Policy (including post implementation review process) T b F&R Committee Sep-17 [2] [9]

Business Planning Internal Audit Recommendations Update T c F&R Committee Apr-18 [2] [10] [11]

CAMHS EPR Programme T c TEG Dec-18 [1] [9]

CAMHS Inpatient provision / partnership working - Board Update T o Trust Board Feb-18 [6] [7] [8]

CAMHS Update (MBI review) Ind m Quality Committee Nov-17 [1] [3] [4]

Capital / Cash Planning Paper T e F&R Committee Feb-19 [2] [12]

Capital Programme - final pioritised list 18/19 T n F&R Committee Jun-18 [2] [12]

Carbon Energy Fund Business Case T n Trust Board Jun-17 [2]

Care Experience Strategy T n Quality Committee Sep-17 [1] [10]

Caring Together Strategy T n Trust Board Feb-17 [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12]

Cash Committee - terms of reference / reporting T p F&R Committee monthly [2] [12]

Cashflow Implications & Modelling T e F&R Committee Jul-17 [2 [12]

CEO Blog T i Staff Apr-18 [3] [10]

Charitable Income Quarterly Report T e F&R Committee Quarterly [2]

Clinical Audit & Effectiveness Report / Clinical Audit Programme T e Quality Committee Nov-18 [1]

Clinical Coding Programme T c TEG Jan-17 [1] [2]

Clinical Microsystems Case Studies T d Trust Board Dec-17 [1] [2] [3] [5] [8]

Clinical Operations Group Terms of Reference T p TEG Oct-17 [1] [11]

Clinical Pathology Accreditation Update T e Quality Committee Feb-17 [1]

Clinical Steering Group T p TEG Feb-18 [1]

Communication Report to TEG T i TEG Feb-19 [1] [3] [8]

Communication Strategy / progress update against delivery T n F&R Committee Dec-18 [1] [3] [7] [8]

Consultation Resonse - Urgent Care T i TEG Feb-18 [1] [7] [8]

Controlled Drugs Quarterly Report T e Quality Committee May-18 [1]

Corporate Objectives - Delivery Progress Report T e Trust Board Jan-19 [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12]

Council of Governors standing orders / membership / minutes T p CoG Quarterly [8]

CQC Action Plan T c Quality Committee Mar-19 [1] [3]

CQC Deep Dive visit re Transition Ind h Quality Committee Jan-17 [1]

CQC Deep Dive visit to Becton Oct 17 Ind h Quality Committee Oct-17 [1]

CQC Report following June 2016 inspection visit Ind h Trust Board Oct-16 [1] [3] [5]

CQUIN Escalation Quarterly Report T e Quality Committee Apr-18 [1] [2]

Cyber Security Programme - Status Report T c FRC Apr-18 [1] [9]

Cycle of financial planning papers T n Trust Board monthly (Sept - May) [2]

Deep Dive review of Serious Incidents T e Quality Committee Sep-17 [1] [10]

Categorisation of

Assurance

Assurances

Received

Assurance rating

(Ind)


Trust (T) or Independent (Ind)

Mapping to BAF Risk [1] to [12]

Internal monitoring




Categorisation of

Assurance

Assurances

Received

Assurance rating

(Ind)




Internal monitoring

Deloitte Report (efficiency programme) Ind m Transformation Board Dec-17 [2] [5] [11]

Detailed review of risk register with update to align with IM&T investment planning T c Quality Committee Feb-19 [9]

Divisional Performance Reports T f DPRs monthly [1] [10]

Divisional Quality Deep Dive Presentations T e Quality Committee Apr-18 [1] [10]

Divisional Structure agreed / implemented with recruitment to fill vacancies T f TEG Jan-18 [1] [4] [5] [8] [10]

Marketing Strategy T n F&R Committee Dec-18 [1]

Drugs & Therapeutics Committee Annual Report T e Quality Committee Oct-17 [1]

EDMS Board - terms of reference / membership / benefits realisation T c TEG Nov-16 [8] [9]

EDMS Clinical Teams Deployment T c TEG Dec-17 [1] [8] [9]

Education Board Report T e Quality Committee Nov-18 [1] [3]

Effective Executive Recruitment Process - Appointment to MD vacancy T q Board Noms Committee Feb-18 [5]

Emergency Communications Plan T e Quality Committee Jul-17 [1]

Emergency Planning Statement of Compliance T a Quality Committee Nov-18 [1]

Employer Based Awards 2016 T e F&R Committee Jan-18 [3] [8]

Establishment of Committee in Common (terms of reference / joint working agreement) Ind o Trust Board Sep-17 n/a [6] [7]

Establishment of Trust Education Board / Terms of Reference T p F&R Committee Jun-16 [3]

Establishment Review (nursing) T l Quality Committee Jan-19 [1] [3] [4]

Estates Plans Update (vacated space and move from Mount) T c TEG Dec-17 [1] [11]

Estates Strategy T n F&R Committee Dec-18 [1] [2] [10]

Executive Briefing Meetings (Action Notes / Schedule of Strategic Sessions) T b Exec Briefing weekly [5]

Executive Directors objectives T q Board Noms Committee Sep-17 [5]

External accreditation / peer review visits reported within Legal & Governance Report Ind g Quality Committee Dec-17 [1] [3] [10]

Financial reporting as per SOFIs T e R&A Committee Nov-18 [2]

Financial Risk Ratings (reported within annual report) T h Trust Board May-18 [2] [4]

FourEyes Report Ind m Transformation Board Oct-17 [2] [5] [11]

Freedom to Speak Up Guardian Reports Ind e Trust Board Dec-18 [1] [3] [8] [10]

Freedom to Speak Up self-assessment Ind e Trust Board Feb-19 [1] [3] [8] [10]

Friends & Family Test Action Plan (Bd Action - email) T c Trust Board Jun-18 [1] [10]

Friends & Family Test Results Ind k Trust Board monthly [1] [10]

GDPR - Preparedness for Implementation of the General Data Protection Regulation Ind j R&A Committee Mar-18 [1] [9]

Gender Pay Gap Reporting Ind k Trust Board Mar-18 [3] [4]

Genetic Laboratory Configuration - Board Update T o Trust Board Jun-18 [6] [7] [8]

Genomics Working Group Terms of Reference T p TEG Nov-17 [6] [7]

Goddard Review Self Assessment report to CCG T l Child Protection Committee Sep-16 [1]

Grenfell - Fire Safety Risk Assessment / Executive Briefing paper T l Trust Board Jul-17 [1]

Guardian of Safe Working Hours Reporting Ind e Trust Board Jun-18 [4] [8]

Hospital Services Review Update Ind o Trust Board Jun-18 n/a [5] [6] [7] [8]

HSJ Top 100 Best Places to work placement Ind k Trust Board Jun-17 [3]

IG Committee (terms of reference / membership / minutes) T p F&R Committee Jan-18 [1] [9]

IG Status Report T e F&R Committee Jan-18 [1] [9]

IG Toolkit Self Assessment T l F&R Committee Mar-18 [1] [9]

IM&T capital programme T n IM&T Strategy Board / TEG

Jul-17 [2] [9]

IM&T Strategy Board - Terms of reference T p F&R Committee Mar-17 [9]

IM&T Strategy T n F&R Committee Expected Jan-19 [9]

Infection Prevention & Control Annual and Quarterly Reports T e Quality Committee Nov-18 [1]

Infection Prevention & Control Team: Demand & Capacity T e Trust Board Jun-18 [1] [4]

Information Commissioner review of IG Serious Incident Ind g R&A Committee Oct-17 [1] [9]

Input from cost consultants into monthly reports from Hospital Development Project Ind m Hospital Development

Project Boardmonthly [2]

Integrated Performance Report T n Trust Board Dec-18 [1] [2] [3] [4] [10] [12]

Internal Audit - Absence Management (Sickness) Ind j R&A Committee Nov-18 [3]

Internal Audit (follow up) report - Mandatory Training Ind j R&A Committee Feb-16 [3]

Internal Audit Report - Divisional Financial Management Ind j R&A Committee Dec-16 [2]

Internal Audit Report - Partnership arrangements with STH Ind j R&A Committee Jun-17 % [2]




Categorisation of

Assurance

Assurances

Received

Assurance rating

(Ind)




Internal monitoring

Internal Audit Report - Budgetary Control and KFS Ind j R&A Committee Jan-18 [2]

Internal Audit report - Business Planning Processes Ind j F&R Committee Jun-17 % [2] [10] [11]

Internal Audit Report - Capital Schemes (exc New Wing) Ind j Risk & Audit Committee May-18 % [2]

Internal Audit Report - Cash Management & Treasury Ind j R&A Committee Nov-16 [12]

Internal Audit Report - Consultant Job Plans and Management of Consultant Annual Leave Ind j R&A Committee Feb-16 % [4]

Internal Audit Report - Cyber Resilience Programme (advisory) Ind j Risk & Audit Committee May-18 n/a [9]

Internal Audit Report - Cyber Security Governance Arrangements (1) Ind j R&A Committee Nov-17 [9]

Internal Audit Report - Data Quality (Safe Staffing) Ind j R&A Committee Mar-16 [1] [4]

Internal Audit Report - Data Quality Framework Ind j R&A Committee Jan-18

Internal Audit Report - eRostering Ind j R&A Committee Mar-18 [1] [11]

Internal Audit Report - IG Toolkit Ind j F&R Committee Feb-18 [1] [9]

Internal Audit Report - Incident Management Ind j R&A Committee Oct-16 [1]

Internal Audit Report - Income and Debtors (non core income) Ind j R&A Committee Jan-16 % [2]

Internal Audit Report - Integrity of the General Ledger & Financial Reporting Ind j R&A Committee May-18 [2]

Internal Audit Report - Medical Staff Appraisal and Revalidation Ind j R&A Committee Nov-16 % [3] [8]

Internal Audit - Patient Safety Ind j R&A Committee Nov-18 [1]

Internal Audit Report - PDRs Ind j R&A Committee Nov-17 % [3] [5] [10]

Internal Audit Report - Performance Management Ind j R&A Committee Jun-17 [1] [10]

Internal Audit Report - Recruitment KPIs Ind j R&A Committee May-16 % [11]

Internal Audit Report - Remote Working Ind j R&A Committee Jan-16 [9]

Internal Audit Report - Stock Balances Ind j R&A Committee Jan-18 [2]

Internal Audit Report - Strategic Workforce Planning Ind j F&R Committee Jun-17 % [2] [4] [5] [10]

Internal Audit Report - Temporary Staffing Ind j R&A Committee Apr-16 % [2] [4]

Internal audit Report - Trust’s safeguarding arrangements Ind j R&A Committee Sep-16 [1]

Internal Audit Report - Workforce Planning (limited assurance opinion) Ind j F&R Committee Jun-16 % [3] [10]

Internal Audit Report (follow up) - Duty of Candour Ind j R&A Committee Nov-17 [1]

Internal Audit Review - patient experience Ind j R&A Committee Feb-17 % [1] [10]

Involvement of Governors Report within Annual Report T a Trust Board May-18 [7]

IT Health Check (Cyber Security Arrangements / Governance) commissioned by NHS Digital Ind m R&A Committee Oct-17 % [1] [9]

IT Support Survey Results T f CoG May-18 [9]

JNCC Terms of Reference / minutes / membership T p JNCC May-18 [3] [8]

Join the Conversation Meetings - programme / attendance / feedback themes T i Health & Wellbeing

Group Jun-18 [3] [8] [10]

Joining the ICS - financial framework Ind o Trust Board Jun-18 [2] [7]

Junior Doctor Recruitment Paper T n F&R Committee Jun-17 [1] [4] [10]

Lab Accreditation Update T o Quality Committee Feb-18 [7]

Legal & Governance Report - Quarterly T e Quality Committee Feb-19 [1] [10]

London Bridge / Manchester Terrorist Incidents - TEG papers T r TEG Jul-17 [1]

LOTA Audit T e Quality Committee Dec-17 [1]

Managing Attendance Policy T b F&R Committee Sep-17 [1] [2] [3]

MBI review of Safeguarding arrangements Ind m Quality Committee May-17 [1]

Mental Health Act Annual and Quarterly Reports T e Quality Committee Mar-19 [1]

Minutes from Acute Federation Committee in Common T o Trust Board monthly n/a [6] [7]

Mitigations outlined to Board re Legal and Governance capacity T c Trust Board Jan-18 [1]

Monthly finance report T e FRC monthly [2] [4] [11] [12]

Mortality Review - ToR / Quarterly Report T e Quality Committee Mar-18 [1] [8]

New Build Contract position reporting to FRC / Board T c F&R Committee Jun-18 [2] [12]

New Build Operational Group T c Hospital Project Board monthly [1]

New Build Project Board - terms of reference / membership / minutes T p F&R Committee monthly [8]

NHS Digital external assessment report Ind m IM&T Strategy Board Sep-17 [9]

NHSI Monthly Benchmarking Report - agency use against ceiling Ind k Trust Board monthly [2] [4]

NHSI SOF Rating = 2 (reported within annual report) Ind h Trust Board May-18 [1] [12]

Nurse Fill (Safe Staffing) reports T e Trust Board Feb-18 [1] [4] [11]

OBC for Paediatric Major Treatment & Urgent Treatment Centre T c TEG Feb-17 [1] [6] [7] [8] [11]




Categorisation of

Assurance

Assurances

Received

Assurance rating

(Ind)




Internal monitoring

ODN Annual Reports / Presentation to Board T e Trust Board Feb-16 [1] [7]

Olympic Park Legacy & Centre for Child Health Technology Update T o Trust Board Feb-18 [7] [8]

Operational Plan (workforce section) T n Trust Board Jun-18 [4] [11]

Operational Plan narrative T n FRC Jun-18 [1] [2] [4] [6]

Operationalisation of the New Wing T d Trust Board May-18 [1]

Outpatient Clinic Utilisation Business Case T TEG Nov-17 [1] [11]

Outpatient Transformation Programme T c Recovery & Transformation Board May-18 [2] [5] [10] [11]

Pathology - MOU Ind o Trust Board Feb-18 n/a [6] [7]

Patient Experience Reports T e Quality Committee Quarterly [1] [10]

Patient Stories Ind d Trust Board Feb-19 [1] [10]

Physician Associate Paper T n TEG Jun-17 [4]

Picker Patient Survey Results Ind k Quality Committee Oct-17 [1] [10]

Point of Care Testing Annual Report T e Quality Committee Apr-18 [1]

Post Project Review - Computer Room Ind c R&A Committee Nov-17 [9] [10]

Provider Collaborations Update T o Trust Board Nov-17 [6] [7] [8]

QIA paper by DNQ to CCG for assurance T b Quality Committee Oct-16 [1]

Quality Dashboards T f Quality Committee monthly [1]

Quality Impact Assessment Reports (Standing Agenda item) T b Quality Committee monthly [1] [2]

Quality Report / Accounts T a Trust Board May-18 [1]

Quality Report priorities - Quarterly Update T e Quality Committee May-18 [1]

Quarterly Care Experience Report T e Quality Committee Nov-18 [1] [10]

Quarterly NHSI Review Meeting / Outcome Letters Ind h Trust Board May-18 [1]

Quarterly Safeguarding Report T e Quality Committee Nov-18 [1] [3]

Quarterly Update on the Medical Equipment Management Group T e Quality Committee Apr-18 [1]

Recovery and Transformation Board Governance Structure T c F&R Committee Mar-18 [2] [5] [8] [10] [12]

Recovery and Transformation Board Update T e F&R Committee Jun-18 [2] [5] [8] [10] [12]

Recruitment & Induction (Streamlining Project - Excellent Together) T c Recovery & Transformation Board May-18 [2] [3] [4]

Recruitment & Induction (Streamlining Project - Excellent Together) T c TEG Jan-17 [4]

Reference Costs Ind k F&R Committee Feb-18 [2]

Responsible Clinician Policy - revision T b Quality Committee Jun-18 [1] [8]

Restrictive Interventions Report T e Quality Committee Apr-18 [1]

Resusitation Committee Annual Report T e Quality Committee Nov-18 [1]

Revalidation Annual Report T a Trust Board Sep-17 [3]

Review of balance of the Board T q Board Noms Committee Jan-19 [5] [10]

Review of Charity Working Arrangements T o Trust Board Jan-19 [7]

Review of Trust Insurance Arrangements T e F&R Committee Jun-18 [2]

Risk Assessment of Fire Safety Arrangements - response to NHSI T a Trust Board Jul-17 [1]

Safe Care Implementation T c Clinical Operations Group Feb-18 [1]

Safeguarding Patient Safety through winter planning paper T c Trust Board Oct-17 [1] [11]

Schedule of DPR meetings / action notes T f DPRs monthly [1] [2] [3] [4] [10]

Self Assessment within Monitor informal visit of Trust controls judged against Monitor criteria for Trusts in turnaround / recovery (95% in place) T l Board [2] [5]

Serious Incidents Update T e Quality Committee monthly [1] [10]

Seven Day Services - Update T e Quality Committee Mar-18 [1]

Shadow Board T c Trust Board Nov-18 [3] [4] [5] [10]

Sheffield PLACE based Plan Ind o Trust Board Jan-17 n/a [7]

SID appointment approved T q CoG CoG Sept 2016 [1]

Situational Awareness for Everyone (SAFE) implementation T c Quality Committee Oct-16 [1] [8]

South Yorkshire & Bassetlaw Pathology MOU Ind o Trust Board Feb-18 n/a [7]

Spotlight Presentations T d Trust Board Jan-18 [1] [3] [10]

Staff Awards T d Trust Board Mar-18 [3] [10]

Staff Leavers and Overpayment Report T e F&R Committee Dec-17 [2]

Staff Survey Action Plan / update T c F&R Committee May-18 [4] [8] [10]

Staff Survey Results Ind k F&R Committee Mar-17 [4] [8] [10]




Categorisation of

Assurance

Assurances

Received

Assurance rating

(Ind)




Internal monitoring

Statement within Annual Report re Completeness / Balance of Trust Board T a Trust Board May-18 [5] [10]

STH MOU ind o Trust Board Mar-17 [2] [7]

STP Acute Federation Vanguard DashBoard Ind o Trust Board Oct-17 n/a [7]

STP Collaborative Board Minutes Ind o Trust Board monthly n/a [5] [7]

STP Collaborative Board Terms of Reference / MOU Ind o Trust Board Jun-17 n/a [5] [7]

STP Memorandum of Understanding Ind o Trust Board Nov-18 n/a [7]

Strategic Accomodation Group - terms of reference / minutes T p TEG ??? [11]

Submission of Digital Maturity Index T a IM&T Board (16/1/16) [9]

Submission of High level IM&T plans / plans for universal capabilities T n IM&T Board (16/4/16) [9]

Submission of Local Digital Roadmap T o IM&T Board (19/5/16) [9]

Theatre Checklist Audit T e Quality Committee Dec-17 [1]

Transition Report - Quarterly Update T e Quality Committee Nov-18 [1]

Trust Executive Group in place (ToR / Membership / Minutes) T p TEG Jun-17 [5] [8] [10]

Trustee Postions with The Children's Hospital Charity (DNQ / Chair) - Chair's report into Board T o Trust Board monthly [7]

Update on Clinical Accountability for Safeguarding (learning from Family B report) T r Quality Committee Apr-18 [1] [10]

Update on Regulation 28 Action Plan T e Quality Committee Apr-18 [1]

Update to Board re Children's Alliance focus / discussion (adhoc) T o Trust Board Jan-18 [2] [7]

Updated Root Cause Analysis Process T b Quality Committee Jun-18 [1] [10]

Updates on ACP discussions (Board Minutes) T o Trust Board monthly [6] [7]

Updates on ICS discussions (Board Minutes) T o Trust Board monthly [6] [7]

Updates re 0-19 Service / LA funding T o Quality Committee Apr-18 [1] [7]

Ward accreditation Scheme T c Trust Board Jan-18 [1] [3]

Ward Cleanliness and Hand Hygiene T e Trust Board Mar-18 [1]

Well Led Action Plan T c Committees Jan-19 [1] [5] [10]

Well Led Self Assessment Ind j Trust Board Dec-18 [1] [3] [5] [7] [8] [10]

WHO Surgcal Checklist 2016 Audit T e Quality Committee Sep-17 [1]

Workforce Information Report - Quarterly T e Trust Board Dec-18 [1] [3] [4] [11]

Workforce Planning Internal Audit Recommendations Progress Update T c F&R Committee Dec-17 [3] [10]

Workforce Planning Submission to NHSI / Health Education England T a TEG Mar-18 [4]

People Stratetgy - Position Paper T n F&R Committee Feb-19 [3] [4] [10]

Workplan re emergency prepardness, resilience and response T c Trust Board Oct-18 [1] [3]

WRES action plan update reported to FRC T c F&R Committee Apr-18 [1] [3]

WRES Report Ind k F&R Committee Jun-17 % [1] [3] [10]

WTP Informatics Leads representation - ToR / minutes Ind o IM&T Board Bi-monthly n/a [9]

Youth Forum (terms of reference) T p Care Experience Board [1] [7] [10]

Assurances Groupings

abcdefghijkl

mnopqr

Internal Audit Report (360 Assurance)

National Benchmarking / Survey Results

Trust Self Assessments / Effectiveness Reviews


Planning & Strategy Development Documentation

Reporting from External Partnership Discussion /Stakeholder Development

External Reviews / Accreditations / Peer Reviews

Regulatory Regime Inspections / Rating / Monitoring Feedback

Trust Internal Communications / Engagement Materials

Terms of Reference

Personnel in post / appointments / job descriptions

Board review via Performance & Assurance Reports through Board Governance Framework

Executive Monitoring via Performance Management Framework (inc Escalation Framework)

Statutory Declarations / Self Certifications / Mandatory or Regulatory Submissions

Policies & Standard Operatings Proceedures

Learning from national reviews / reports

Project Mananagement Arrangements / Work Programmes / Action Plans / Post project reviews

Departmental Showcases / Patient Stories / Back to the Floors / Staff Stories




Number Risk Title Risk Register Current Risk Score

Risk Level Change

R172 Inability to achieve activity (medicine) Corporate 20 [1] [6] [11]

R174 Pharmacy provision to CWAMH division Corporate 12 ↔ [1] [6] [11]

R726 Transformation Agenda Corporate 12 ↔ [2] [3] [5]

R750 Pharmacy - aseptic department capacity Divisional 20 ↔ [1] [3]

R770 Pharmacy Weekend Service Divisional 12 ↔ [1] [11]

R828 Lack of ability to fill junior rotas - No action plan received Divisional 16 ↔ [1] [3] [4] [11]

R842 Underperformance of activity and income (surgery) Corporate 15 ↔ [1] [2] [11]

R911 Sustainable cash resources Corporate 15 ↔ [12]

R922 Staffing levels within theatres (nurses and ODPs) to accomondate capacity plans Divisional 12 ↔ [1] [3] [4] [11]

R925 Nurse staffing levels in inpatient areas - No action plan received Corporate 12 ↔ [1] [3] [4]

R927 Transition from childrens' to adult services Corporate 6 [1] [7]

R934 TP2000 LIMS - risk to service as the result of the failure of virtual environment, hardare housed in laboratory environment Divisional 12 [1] [6] [9] [11]

R937 Neurodisability Service Risks - service is under significant pressure due to a rapid increase in referrals and workload and lack of capacity to deal with this Divisional 16 ↔ [1] [11]

R957 Paediatric Neurology Psychology Service Significant Patient Waiting Times Divisional 15 ↔ [1] [7] [11]

R964 Cyber Security Corporate 15 ↔ [1] [9]

R965 E-mail migration Corporate 15 ↔ [9]

R966 ICT Resource Capacity, Infrastructure Leads Corporate 12 [4] [5] [9]

R971 Unsupported software Corporate 6 [1] [9]

R977 Introduction of Datix Corporate 16 [1] [9]

R986 Length of patient wait from first assessment to agreed patient pathway (CWAMHS) T3 Divisional 20 ↔ [1] [7]

R994 Insufficient capacity for the Community Safeguarding team to respond to all requests for health contribution in the multi-agency Safeguarding Hub implemented in April 2017 Divisional 15 ↔ [1] [4] [7] [11]

R1018 Significant Patient Waiting Times - Paediatric psychology service Divisional 15 ↔ [1] [11]

R1036 Risk of delivery of flexable endoscope services Divisional 20 ↔ [1] [6] [10] [11]

R1047 Divisional risk to deliver capacity plan 2018-19 - Surgery and Critical care Divisional 20 [1] [2] [3] [6] [7] [8] [10] [11]

R1052 Short staffing resuliting in reduced service within orthopaedics, PLRS, sipinal surgery, burns and plastics Divisional 15 ↔ [1] [3] [4] [5] [6] [8] [11]

R1055 0-19(Health Visiting and School Nursing) work force establishment and the ability to fully dliver the commisioned Healthy Child Programme Divisional 12 ↔ [1] [3] [4] [5] [6] [7] [8] [10] [11]

R1057 Out of date policies Corporate 12 ↓ [1] [6] [8] [10]

Risk Register Key - All Open Risks mapped to Strategic Objectives with a risk score > 12

Link to BAF Risk [1] to[12]




Number Risk Title Risk Register Current Risk Score

Risk Level Change Link to BAF Risk [1] to[12]

R1067 Access, exit and security at Becton Centre (T4 CAMS) Divisional 5 â [6] [7] [8]

R214 EU Exit - Workforce Corporate 12 NEW [1] [3] [4] [5] [8] [9] [10]

R219 EU Exit - Supply of Medicines and Vaccines Corporate 12 NEW [1] [7] [11]

R220 EU Exit - Supply of non-clinical consumables, goods and services Corporate 12 NEW [1] [6] [9] [11]

R221 EU Exit - Supply of Medical Devices and Clinical Consumables Corporate 12 NEW [1] [6] [8] [10] [11]

R687 Loss of Neurosurgical services to the Trust and resulting implications Corporate closed [6] [7]

R867 New Build - Slippage in main programme dates Corporate closed [1] [2] [10]

R904 STH provision of additional capacity as outlined in capacity plan Corporate closed [1] [2] [11]

R905 Waiting list for paediatric dentisty Divisional closed [1] [4] [7] [11]

R913 The absorbtion of six General Paediatric Doctors into the Secretariat Divisional closed [1] [2] [3] [4] [8]

R916 Pressure on contingency funds due to escalating costs impact of increased project costs on funding available for equipment Corporate closed [1] [10]

R962 ENT RTT Performance - Gap in consultant rota Divisional closed [1] [3]

R976 Working Environment Embrace Divisional closed [1]

R987 Staffing Levels in Theatres Divisional closed [1] [11]

R1007 Winter Resilience Corporate closed [1] [11]

R881 Lack of specialist trainees impacting on abilty to provide 24/7 PCCU service continuity inc Embrace Divisional 9 ↓ [1] [4] [11]

R973 Ambulance Replacement Divisional 9 ↓ [1] [7]

Closed Risks since last quarter

Risks with scores reduced to below 12 since last quarter



BAF risk scoring 2018-19

Ref Risk Link to

strategic aim

Q1 Q2 Q3 Q4 Direction of Travel

BAF (1)

Failure to effectively deliver healthcare impacts on the safety and quality of patient experience, regulatory compliance and loss of confidence of the wider community.

[1] 12 12 15 15

BAF (2)

Risk that we do not maintain financial stability due to failure to deliver our financial plan or the negative impact of movement to a system-wide financial planning regime, resulting in requirements for additional CIPs or reduction in level and standard of quality of our services.

[1] & [4] 20 20 20 20

BAF (3)

Failure to ensure that the Trust has a motivated, suitably trained and engaged workforce impacts on operational performance, transformational change and achievement of strategic objectives.

[1] & [2] 15 15 15 15

BAF (4)


[1] & [2] 12 12 12 12

BAF (5)

Risk that insufficient leadership capacity and capability prevents necessary transformational change to deliver efficient, high quality services. [3] & [4] 15 15 20 20

BAF (6)

Risk to clinical service viability due to failure to meet nationally defined standards or changes to the commissioning and / or configuration of services.

[1] & [4] 16 16 16 16

BAF (7)

Failure to engage effectively with partner organisations and the local community threatens the ability of the Trust to deliver its strategic ambition.

[3] & [4] & [5]

8 8 8 8

BAF (8)

Failure to engage with our clinicans prevents the development / implementation of an effective clinical strategy to deliver high quality services that responds to the needs of patients and other health and social care partners and prevents us from capitalising on the use of research, innovation and technology.

[1] & [3] & [4]

10 12 12 12

BAF (9)

Failure to ensure that the required IT infrastructure and strategy is in place to safeguard patient safety, deliver clinical services and support clinical strategy and transformation impacts on the Trust's ability to improve quality and transform services.

[1] & [3] & [5]

15 15 15 15


BAF (10)

Failure to develop our leadership, management and governance arrangements to ensure delivery of sustainable high quality person-centred care, support learning and innovation and promote an open and fair culture prevents the Trust from demonstrating that it is a 'Well Led' organisation.

[1] & [2] & [4] & [5]

12 12 12 9

BAF (11)

Operational constraints and failure to deliver transformation impact on our ability to deliver planned activity and manage demand impacting on operational efficiency, service quality and financial performance.

[1] & [4] 12 12 12 12

BAF (12)

Failure to maintain the Trust's cash position would result in the Trust not being able to satisfy its obligations in respect of pay and non-pay costs. [4] 20 20 20 20


14. 72/19 EXECUTIVE DECISIONMAKING

1

EXECUTIVE SUMMARY

Title Executive decision-making and governance

Report to


Executive Sponsor

John Somers, Chief Executive

Author

Matthew Kane, Associate Director – Corporate Affairs

Purpose of report


Approval X Assurance Information


As part of a development session in January, Executive Team requested a review of its existing arrangements for decision-making. This followed views expressed that the existing arrangements lacked an appropriate degree of formality and clarity and were not sufficiently agile to respond to situations that required swift decision-making in the interests of the Trust and service users. The review has resulted in a proposal to move to a clearer and more structured approach around three groups:

A weekly minuted Executive Team focussed on executive operational decision-making which would also involve clinical directors once per month.

A monthly minuted Management Board focussed around information giving and engagement on strategic and clinical issues to include Heads of Nursing and Head of Estates in addition to the current membership of the Trust Executive Group (TEG).

A quarterly Leadership Forum focussed around information giving, culture and behaviours and developmental work which would include a wider group of senior leaders from across the Trust.

Attached as an appendix are the terms of reference for the new bodies. In agreeing to these, the Board effectively delegates responsibility for executive decision-making. Consequential changes to the Scheme of Delegation are required as a result of the changes (see recommendation 2). A delegation is also sought to amend the memberships of each group to allow the bodies room to evolve over time.

TRUST BOARD PART 1 14. 72/19 EXECUTIVE DECISION... Page 143 of 197

2

The new arrangements are supported by the Executive Team and the existing TEG membership. The planned implementation date for the new arrangements is 1 April 2019.

How this report impacts on current risks or highlights new risks Pros and cons associated with changing the current model are given in an appendix to the main report.

Recommendations and next steps Board is asked to: (1) Approve the changes to executive decision-making and governance as set out

in the report and appendices.

(2) Amend the document known as Standing orders, Reservation of Powers to

the Board and Delegation of Powers and Standing Financial Instructions, replacing all uses of the term “Trust Executive Group” with “Executive Team”.

(3) Delegate to the Chief Executive power to amend memberships of the three groups where considered appropriate.


3

Appendix A to Board of Directors report

26 March 2019

Executive decision-making and governance

1. The Trust’s governance arrangements for executive decision-making currently comprise:

Executive Team which meets weekly (known as Executive Brief) and includes all executive

directors and the Chief Information Officer; and Trust Executive Group (TEG) which includes

all members of Executive Brief and a wider group of staff including clinical directors and their

associate directors as well as some associate directors from corporate areas.

2. It is good practice for decision-making bodies to review their performance against the

requirement of their terms of reference and assess their effectiveness on an annual basis. In

view of this, a short and sharp review of the role and purpose of the Trust’s executive

decision-making arrangements was undertaken during January and February 2019.

3. Feedback was received from executive directors and members of the wider TEG. In addition,

discussions have also taken place as part of the internal review of Recovery and

Transformation and as part of NHSI’s external review of financial governance around better

clarity of decision making. Essentially, the key points can be distilled into four themes:

Executive Brief was always intended to be informal, has no defined terms of

reference and no detailed record of its decisions. One of the advantages of this is

that it facilitates the honest and free-flow of information between executives but it

also means that its role beyond informal information sharing is less clear and

defined. Despite this lack of clarity, it routinely makes operational decisions.

TEG tries to be a decision making body, an information sharing session and a holding

to account forum and it is questionable whether it can do all of this within the time

it has available each month. Because of this TEG often struggles with agenda

management, prioritising items for approval, the over-presentation of reports, giving

early items too long and then rushing the rest of the agenda.

There is a lack of clarity over decision-making, and fundamentally whether TEG has

or should have responsibility for certain decisions. Some respondents reported that

the chain of approval is not clear and often negated. The number of people involved

in TEG is more conducive to engagement rather than decision-making.

There are issues around quoracy and voting members needing to leave before the

business is concluded which can impact on whether or not decisions are approved.

Where this has been an issue, authors have to wait for the next quorate TEG which

is a month away. This then impacts on timeliness of actions.


4

4. During discussions with Executive Team and operational associate directors, there was

support for much clearer and faster decision-making so long as it preserved TEG as a forum

for clinical and corporate engagement. In any case, TEG’s existing decision-making role is

limited. This partly reflects practicalities since many operational and executive-level

decisions cannot wait for a meeting a month hence. Its terms of reference highlight

decision-making responsibility in relation to capital and revenue cases within certain limits

(although the revenue limits are not clear), approval of policies (although the latest Policy

for the Development of Trust Policies allocates TEG no specific policies for approval),

approval of the capital programme (although in practice this is a Board of Directors decision)

and receipt of annual divisional and corporate business plans.

5. The question as to whether TEG should/can have responsibility for executive decision-

making is worth exploring since Schedule 7 to the NHS Act 2006 states that the constitution

of an FT must provide for all the powers of the corporation to be exercisable by the board of

directors on its behalf but may provide for any of those powers to be delegated to a

committee of directors or to an executive director. The term “director” means exclusively

executive and non-executive directors and this definition accords with the one adopted

within the Trust’s own constitution (where director is defined as “a member of the Board of

Directors”). It is therefore questionable whether TEG has the power to exercise decision-

making since the existing TEG membership includes clinical and other directors as voting

members who are not “directors” in the legal sense.

6. One of the ways to address Executive Team and ADs’ desire for clearer and swifter decision-

making, and to tidy up the governance point about who has authority to make executive

decisions, would be to seek to consolidate responsibility for operational decision-making

within the Executive Team since this meets weekly, is a “committee of directors” in the legal

sense and can effectively discharge all of those decisions that are not already delegated to a

board committee or executive director. Clinical input would be provided by the Medical

Director and Director of Nursing who, once per month, would be joined by the four clinical

directors to take decisions on cross-divisional matters and provide senior leadership to the

Trust.

7. This proposal would allow TEG – newly branded as Management Board to differentiate itself

from Executive Team – to play a much clearer engagement and strategic development role

in relation to the Executive Team with a clearer and more manageable workload. The

current membership of TEG would be maintained with some additions (e.g. Head of Estates

and Heads of Nursing) and over time the agenda would be divided into corporate and clinical

sections with a clinical director chairing the clinical section. Consideration would be given to

supporting and developing CDs in this role via the Director of Strategy and Operations and

Corporate Affairs.


5

8. It is also recognised that the current arrangements do not lend themselves well towards

information cascading so the proposal would be to provide an additional quarterly meeting

known as the Trust Leadership Forum for briefing back on Executive Team and Management

Board issues, as well as an opportunity to consider and develop thinking about future service

developments and provide a greater focus on cultural leadership and management

challenges. Such a meeting would take a more informal approach, include a larger group of

staff including deputy corporate directors, involve external speakers and would need to

meet in a bigger space (e.g. the Lecture Theatre or Becton).

9. The model proposed is in use at neighbouring trusts, albeit the groups are called by different

titles. Appendix A highlights the pros and cons of the existing and proposed arrangements.

Proposed terms of reference are attached as Appendix B.

10. If supported by Board of Directors the new arrangements would come into force from April

2019.


6

Appendix A

Current Proposed

Pros 1. Provides continuity 2. Maintains current levels of engagement 3. Seen as more ‘democratic’ decision-making 4. Lack of audit trail at Exec Brief provides more freedom for confidential discussions

1. Faster decision-making 2. Decision-making in line with spirit of the legislation 3. Ameliorates most conflicts of interest 4. In line with other trusts in ICS 5. Ensures ongoing linkage with senior clinical management 6. Opportunities for CDs to co-chair MB and TLF bringing personal development and ownership 7. Potentially brings Exec Team and MB business to a wider platform (Head of Estates, DDs etc.) 8. Complements Trust’s work around inspiring positive culture and behaviours

Cons 1. Concerns remain over decision-making, quoracy, etc 2. Potential for challenge over decision-making 3. Membership of TEG too large, unwieldy 4. Lack of clarity and audit trail over Exec Team decision-making

1. More change only 18 months after the last review 2. Confidentiality in Exec Team would need to be managed 3. Creates another meeting at a time when the Trust is trying to streamline

TRUST BOARD PART 1 14. 72/19 EXECUTIVE DECISION MAKING Page 148 of 197

TERMS OF REFERENCE

EXECUTIVE TEAM & CLINICAL EXECUTIVE TEAM

Version Status Date Issued / Amended Summary of Changes

1 February 2019 New document

Review Date February 2020


2 Version 1

1. AUTHORITY

1.1. Executive Team is constituted as a committee of the Sheffield Children’s NHS Foundation Trust’s

Board of Directors. Its terms of reference shall be as set out below, subject to amendment at

future Board of Directors’ meetings.

1.2. Executive Team is authorised by the Board of Directors to consider any activity within its terms of

reference. All members of staff are directed to co-operate with any request made by the Executive

Team.

2. ROLE 2.1. Executive Team undertakes executive work on behalf of the Board of Directors. It is responsible

for managing the Trust and holding to account those who have delegated responsibilities for the

performance of the Trust.

2.2. The Executive Team involves clinicians in the management of the Trust through the Medical

Director and Director of Nursing and Quality. Once per month, following their ordinary meeting,

Executive Team will meet with the Trust’s four Clinical Directors to consider matters of a clinical

nature requiring a decision or discussion.

3. DUTIES As Executive Team

3.1 Approving business cases within the limits set out within the Trust’s standing orders, scheme of

delegation and standing financial instructions.

3.2 Approving business plans and divisional budgets.

3.3 Determining the Trust’s planning and investment priorities, and recommendation of these to the

Board of Directors where appropriate.

3.4 Approving appropriate frameworks to support the delivery of organisational objectives e.g. grip

and control, accountability and accreditation frameworks.

3.5 Determining any matter that ensures the successful day-to-day management of the Trust.


3 Version 1

3.6 Determining any matter not explicitly reserved for the Board of Directors or which is not

specifically delegated to an executive director or a committee of directors.

3.7 Providing a corporate view on Trust and system-wide issues.

As Clinical Executive Team

3.8 Providing effective and coherent leadership for the Trust as a whole.

3.9 Considering new strategic or operational issues which require a consistent approach across the

divisions / wider organisation and cascading these as appropriate.

3.10 Determining any matter felt to be relevant and appropriate to the performance of the clinical

divisions.

4. MEMBERSHIP

4.1. The meeting will be chaired by the Chief Executive or their deputy.

4.2. The membership of Executive Team is all executive directors (each of whom hold one vote) and

the Chief Information Officer.

4.3. Clinical Executive Team is all executive directors (each of whom hold one vote), the Chief

Information Officer and clinical directors.

4.4. A quorum in each case is four Executive Directors. Members must nominate a deputy to attend

for all or part of the meeting, if they are absent. 5. FREQUENCY OF MEETINGS

5.1. Executive Team will meet weekly on a Thursday morning or as determined by the Executive

Team.

5.2. Clinical Executive Team will meet monthly on a schedule determined at the start of each year.

6. DOCUMENTATION


4 Version 1

6.1. The agenda will be managed by the Director of Strategy and Operations in conjunction with

Corporate Affairs.

6.2. Documents for Executive Team are sent via email to the relevant contact in Corporate Affairs and

should be submitted in the relevant Executive Director’s name. No documents are accepted from

other sources.

6.3. Papers should be submitted along with the Executive Team control sheet which will clearly

identify who will present the item, how long is required and any consultation that has already

taken place. The Chair will ascertain at the commencement of the meeting whether any

negotiation over timing of items is required.

6.4. The deadline for submission of documents is no later than 12.00noon on the Wednesday of the

week of the meeting.

6.5. In the absence of a member of Executive Team, deputies should attend and must be fully briefed

to contribute on the relevant issues.

6.6. Directors will present their own agenda items where possible and attendance of staff in support of

agenda items is by exception.

6.7. Documents are preferably no more than six sides of A4 including an executive summary at the

front stating clearly what is requested from Executive Team.

6.8. The agenda will be ordered with items for approval first, followed by items for assurance and then

items for information.

6.9. The minutes of all meetings of the Executive Team shall be formally recorded by Corporate Affairs

and reported into the Board of Directors (Part 2).

6.10. The Chief Executive will bring to the attention of the Board of Directors any items that the

Executive Team feels that the Board should be aware of through a monthly escalation item.

7. REPORTING GROUPS

8.1 The following groups report into the Executive Team:

Management Board

Trust Leadership Forum


5 Version 1

Divisional Performance & Quality Reviews

Corporate Planning

Vacancy Control Panel

Strategic Accommodation Group

Trust Reaction Group

Joint Negotiation Consultative Committee

Estates and Facilities Group

Clinical Operations Group

Private Patients Steering Group (Under development)

Business Planning

Capital Investment Team

8. REVIEW

8.1. The terms of reference of Executive Team shall be reviewed annually and approved by the Board

of Directors.


TERMS OF REFERENCE

MANAGEMENT BOARD





2 Version 1

1. AUTHORITY

1.1. Management Board is constituted as a sub-committee of the Sheffield Children’s NHS Foundation

Trust’s Executive Team. Its terms of reference shall be as set out below, subject to amendment

at future Executive Team meetings.

1.2. Management Board is authorised by the Executive Team to consider any activity within its terms

of reference. All members of staff are directed to co-operate with any request made by the

Management Board.

2. ROLE 2.1. Management Board brings together the Executive Team, clinical directors and others to provide

advice to the Board of Directors and the Chief Executive on the direction and management of the

Trust.

3. DUTIES

3.1 Giving broad clinical and managerial perspective to enable planning and delivery of safe

services.

3.2 Providing insight into operational and financial performance and plans.

3.3 Providing leadership and role-model behaviours to support the Board’s Purpose, Vision and

Values.

3.4 Contributing to the Trust’s strategy direction and development including the enabling strategies,

Accountable Care Partnership and the Integrated Care System.

3.5 Reviewing and developing the strategic direction and collaborative working with partners.

3.6 Contributing to the capital investment planning of the Trust.

3.7 Reviewing business cases for significant developments.

3.8 Monitoring the implementation of capital and service developments through the post-

implementation review process.


3 Version 1

3.9 Monitoring progress against organisational objectives.

3.10 Providing a forum for policy or service development and consultation on key clinical or corporate

proposals or schemes.

4. MEMBERSHIP

4.1. The first half of the meeting will focus on corporate and system issues and be chaired by the Chief Executive or their deputy. The second half of the meeting will be chaired by a clinical director and focus on clinical matters including issues raised by divisions.

4.2. The membership of Management Board comprises:

Executive Directors Chief Information Officer Clinical Directors Director of Research and Innovation Associate Directors for Clinical Divisions, Research and Innovation, Strategy and

Transformation, Communications, Corporate Affairs and Legal and Governance Heads of Nursing Head of Estates

4.3 Members may nominate a deputy to attend for all or part of the meeting. 4.4 Members must attend at least 75% of meetings each year. 4.5 Chairmanship of the clinical section of the meeting will rotate between divisions each year. 5. FREQUENCY OF MEETINGS

5.1. Management Board will meet monthly as part of a schedule agreed annually.

6. DOCUMENTATION

6.1. The agenda will be managed by the Director of Strategy and Operations in conjunction with Corporate Affairs.

6.2. Documents for Management Board are sent via email to the relevant contact in Corporate Affairs

and should be submitted in the relevant Executive Director’s name. No documents are accepted

from other sources.

6.3. Papers should be submitted along with the Management Board control sheet which will clearly

identify who will present the item, how long is required and any consultation that has already

taken place. The Chief Executive will ascertain at the commencement of the meeting whether

any negotiation over timing requirement is required.


4 Version 1

6.4. The deadline for submission of documents is no later than 12.00noon on the Friday of the week

prior to the meeting.

6.5. In the absence of a member of Executive Team, deputies are permitted to attend and must be

fully briefed to contribute on the relevant issues.

6.6. Directors will present their own agenda items where possible and attendance of staff in support of

agenda items is by exception.

6.7. Documents are preferably no more than six sides of A4 including an executive summary at the

front stating clearly what is requested from Management Board.

6.8. The minutes of all meetings of the Management Board shall be formally recorded by Corporate

Affairs and reported into the Executive Team.

7. REPORTING GROUPS

8.1 None.

8. REVIEW

8.1. The terms of reference of the Management Board shall be reviewed annually and approved by

Executive Team.


TERMS OF REFERENCE

TRUST LEADERSHIP FORUM





2 Version 1

1. AUTHORITY

1.1. The Trust Leadership Forum is constituted as a sub-committee of the Sheffield Children’s NHS

Foundation Trust’s Executive Team. Its terms of reference shall be as set out below, subject to

amendment at future Executive Team meetings.

1.2. The Trust Leadership Forum is authorised to consider any activity within its terms of reference. All

members of staff are directed to co-operate with any request made by the Trust Leadership

Forum.

2. ROLE 2.1. The Trust Leadership Forum brings together the senior operational and clinical managers and

members of Management Board for the purposes of developing the organisation.

3. DUTIES

3.1 Acting as a sounding board for key issues affecting the divisions and corporate departments.

3.2 Review and development of strategic direction and collaborative working with partners.

3.3 Facilitating Trust-wide communications ensuring that key messages are disseminated within the

organisation.

3.4 Encouraging greater coordination and integration between divisional areas.

3.5 Supporting shared learning ensuring risks and lessons learned are identified, shared and

managed consistently throughout the Trust.

3.6 Developing and providing leadership for system, strategic and operational decisions facing the

Trust.

3.7 Providing an environment to consider and develop thinking about future service development.

3.8 Contributing to operational plans and giving ownership and championing of these plans.

4. MEMBERSHIP


3 Version 1

4.1. The meeting will be chaired by the Chief Executive or their deputy and comprise the following:

Executive Directors Chief Information Officer Clinical Directors Director of Research and Innovation Deputy Directors for corporate and clinical divisions Head of Estates Head of Learning and Organisational Development Heads of Nursing Divisional Deputy Directors Associate Directors for corporate and clinical departments

4.2 Members must attend at least 75% of meetings each year.

5. FREQUENCY OF MEETINGS

5.1. The Trust Leadership Forum will meet quarterly following Management Board on a schedule

agreed annually.

6. DOCUMENTATION

6.1. The agenda will be managed by the Director of Strategy and Operations in conjunction with Corporate Affairs.

6.2. Any documents for Trust Leadership Forum are sent via email to the relevant contact in Corporate

Affairs and should be submitted in the relevant Executive Director’s name.

6.3. The deadline for submission of documents is no later than 12.00noon on the Wednesday of the

week prior to the meeting.

6.4. Deputies are permitted to attend and must be fully briefed to contribute on the relevant issues.

6.5. The minutes of all meetings of the Trust Leadership Forum shall be formally recorded by

Corporate Affairs and reported into the Executive Team.

7. REPORTING GROUPS

7.1 None.

8. REVIEW


4 Version 1

8.1. The terms of reference of the Trust Leadership Forum shall be reviewed annually and approved

by Executive Team.


15. 73/19 ICS FINANCE ANDPERFORMANCE REPORT AND ACPREPORT

EXECUTIVE SUMMARY

Title

ICS FINANCE & PERFORMANCE REPORT

Report to

TRUST BOARD (PART 1) Date 26 MARCH 2019

Executive Sponsor

JOHN SOMERS, CHIEF EXECUTIVE MARK SMITH, CHIEF FINANCE OFFICER

Author

Purpose of report


Approval Assurance Information x


The paper from the South Yorkshire and Bassetlaw Chief Executive provides an update on the work of the South Yorkshire and Bassetlaw Integrated Care System (ICS) over the last month, and Month 10 finance position. A paper from the Accountable Care Partnership (ACP) Directors Report is also presented for information. The attached reports cover the following issues at system level: Finance Report:

o The ICS financial position is reporting a year to date favourable variance against plan of £10.1 million excluding Provider Sustainability Funding (PSF); but is forecasting a £2.3 million adverse variance against outturn, however, there remains residual system PSF risk of £2m due to the adverse forecast outturn.

o The Trust’s financial position remained the biggest risk within the system. ICS Chief Executive Report, key areas highlighted are:

o Governance approach o Hospital Services Review update o Legislation proposals and engagement from NHS Improvement and NHS England

Performance Scorecard: o While SY&B ICS position on A&E performance continues to be one of the best in the North,

it is still not on target, and has dropped since last month (from 89.5% to 87.4%). We are performing well on diagnostics (2 weeks), 2 week waits and the three improving access to mental health standards but red for 32 day and 62 day cancer standards, referral to treatment (RTT) and two week breast waits. While disappointing, the data being reported (December 2018) does not reflect the commitments made in January by partner Chief Executives to deliver an improved position by the end of March 2019.

TRUST BOARD PART 1 15. 73/19 ICS FINANCE AND PE... Page 163 of 197

o The Trust achieved all these performance targets. ACP Director’s Report:

o Shaping Sheffield update o Update from each workstream o Cross cutting risks of the high level programme from the highlight reports

How this report impacts on current risks or highlights new risks Finance: There is a risk of loss of System PSF if the system does not meet its quarterly phased system

improvement plan value up to an annual cap of £5.7m. The Trust’s financial position remains the biggest risk within the ICS.


- To note the contents of the ICS finance report. - To note the ICS CEO report and performance scorecard. - To note the ACP Director’s report


1. Integrated Care System (ICS)

The March CEO Report for the ICS in South Yorkshire and Bassetlaw is attached at appendix A for information.

2. Performance scorecard South Yorkshire and Bassetlaw ICS’ performance against key performance indicators are included within the report. These compare the ICS’ performance against the first wave ICS, ICS in the North and at Place level for February (December data).

3. Finance Report The South Yorkshire and Bassetlaw ICS’ month 10 finance report is included within the report. This outlines the risks to achievement of the system improvement plan value and the further discussion that is required with NHSI on the assessment of system financial performance.

4. Accountable Care Partnership (ACP)

The March report provides headlines from the progress of the Accountable Care Programme, and overview of ACP Programme Activities by the Programme Director for the purpose of each partner board and is attached at Appendix B.


1

South Yorkshire and Bassetlaw Integrated Care System CEO Report

SOUTH YORKSHIRE AND BASSETLAW INTEGRATED CARE SYSTEM

March 2019

Author(s) Andrew Cash, Chief Executive, South Yorkshire and Bassetlaw Integrated

Care System

Sponsor Is your report for Approval / Consideration / Noting For noting and discussion Links to the STP (please tick)

Reduce inequalities

Join up health and care

Invest and grow primary and community care

Treat the whole person, mental and physical

Standardise acute hospital care

Simplify urgent and emergency care

Develop our workforce

Use the best technology

Create financial sustainability

Work with patients and the public to do this

Are there any resource implications (including Financial, Staffing etc)? N/A Summary of key issues This monthly paper from the South Yorkshire and Bassetlaw Integrated Care System (SYB ICS) Chief Executive provides an update on the work of the South Yorkshire and Bassetlaw Integrated Care System over the last month. The SYB ICS Collaborative Partnership Board will meet again on 8 March 2019 so given the timing this paper also gives an update on activities from December 2018 to February 2019. Recommendations The Collaborative Partnership Board partners are asked to note the update and Chief Executives and Accountable Officers are asked to share the paper with their individual Boards, Governing Bodies and Committees.

Paper B TRUST BOARD PART 1 15. 73/19 ICS FINANCE AND PE... Page 166 of 197

2

South Yorkshire and Bassetlaw Integrated Care System CEO Report

SOUTH YORKSHIRE AND BASSETLAW

INTEGRATED CARE SYSTEM

March 2019 1. Purpose

This paper from the South Yorkshire and Bassetlaw Integrated Care System (SYB ICS) Chief Executive provides an update on the work of the South Yorkshire and Bassetlaw Integrated Care System over the last month. The SYB ICS Collaborative Partnership Board will meet again on 8 March 2019 so given the timing this paper also gives an update on activities from December 2018 to February 2019. 2. Report – March 2019 2.1 Performance Scorecard The attached scorecards show our collective position at February 2019 (using December 2018 data) as compared with other areas in the North of England and also with the other nine advanced ICSs in the country. While our position on A&E performance continues to be one of the best in the North, it is still not on target and has dropped since last month (from 89.5% to 87.4%). We are performing well on diagnostics (2 weeks), 2 week waits and the three improving access to mental health standards but red for 32 day and 62 day cancer standards, referral to treatment (RTT) and two week breast waits. While disappointing, the data being reported (December 2018) does not reflect the commitments made in January by partner Chief Executives to deliver an improved position by the end of March 2019. The ICS financial position is reporting a year to date favourable variance against plan of £10.1 million excluding Provider Sustainability Funding (PSF); but is forecasting a £2.3 million adverse variance against outturn. 2.2 Governance Approach

South Yorkshire and Bassetlaw Integrated Care System (SYB ICS) has evolved from the establishment of a Sustainability and Transformation Partnership in January 2016, an Accountable Care System in April 2017, to then becoming one of the first and most advanced ICS systems in England and working arrangements have changed little over this time period. In September 2018 our Partnership supported a review of governance and ways of working Following the review and comments on draft proposals, it has been agreed that interim governance will start from April 1, 2019 for a twelve month period covering the 2019/2020 financial year. Whilst some final details are still being resolved, this includes:

Establishing interim governance arrangements for NHS collaboration which will work alongside much of our existing system collaborative forums. It includes:

o System Health Oversight Board (HOB) - a quarterly joint forum between health

providers, health commissioners, NHS England, NHS Improvement and other national arms’ length bodies (ALBs), to respond to the national policy direction for health and implementation of the NHS Long Term Plan. It builds on the SYB ICS Partnership working on strategic health priorities requiring closer working across systems. It facilitates a maturing of relationships and system


3

working, building on collaborative working locally in Places and across SYB collaborative health groups of Joint Committee of CCGs (JCCCG), Committees in Common (CsiC), Mental Health Alliance (MHA) and Primary Care Federations.

o System Health Executive Group (HEG) - a monthly meeting of Chief Executives, Accountable Officers and other health partners, building on the work locally in each Place and collaborative health groups across the system, including JCCCG, CsiC, MHA and Primary Care Federations.

Continuing to work with our Local Authority partners to inform and shape how our system health and care partnership arrangements might be organised including a revised Collaborative Partnership Board as set out in the NHS Long Term Plan. The next step for this will be a series of workshops led by Local Authority CEOs. System partnership working will of course be developed taking due account of existing partnership arrangements in Barnsley, Bassetlaw, Doncaster, Rotherham and Sheffield.

Maintaining our current Collaborative Partnership Board meeting on a bi monthly basis

which will be reviewed in due course in the light of the work above. 2.3 Hospital Services Update The Hospital Services Review Programme has focused on two main areas. These are Hosted Networks and the development of clinical models on maternity, paediatrics and gastroenterology. NHS Trusts have agreed to work together through a number of Hosted Networks, which will be the vehicle for collaboration around workforce, clinical standardization and reconfiguration. Each NHS Trust will host one of the Networks. Barnsley Hospital NHS Foundation Trust will be the host for urgent and emergency care, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust will be the host for gastroenterology, The Rotherham NHS Foundation Trust for maternity, Sheffield Children’s NHS Foundation Trust for paediatrics and Sheffield Teaching Hospitals NHS Foundation Trust for stroke. Each Host will bring together clinicians and workforce leads from all the NHS Trusts to support more consistent care for patients across South Yorkshire and Bassetlaw. The Clinical Working Groups for maternity, paediatrics and gastroenterology have met monthly to develop clinical models to support greater sustainability of services in South Yorkshire and Bassetlaw. In particular, they have looked at ways to address interdependencies between maternity and paediatrics. 2.4 Hyper Acute Stroke Unit (HASU) Update Work is progressing to enable the new model of hyper acute stroke care (HASU) in South Yorkshire and Bassetlaw, with 24 hours hubs in Doncaster, Sheffield and Wakefield. A phased approach to the implementation has been previously agreed by both NHS commissioners and NHS providers, with the proposal that Rotherham ceases to be a HASU first (from 1 July 2019), followed by Barnsley shortly thereafter (1 October 2019). A HASU Implementation Group is coordinating all the necessary aspects, including communication and engagement, planned changes to estates, workforce planning and recruitment. Workforce planning is now a key area of focus and it is anticipated that SYB HASUs will soon be in a position to recruit additional nursing and therapy staff. Briefings with existing staff are taking place and there is a commitment to supporting existing staff and maintaining expertise in SYB. Collaborative planning has also been initiated for joint medic posts.


4

2.5 Legislation proposals and engagement from NHS Improvement and NHS England

NHS Improvement and NHS England have asked for views on how targeted amendments to the law could help local and national health organisations work together more effectively to improve services for patients. At their joint board meeting, they approved a series of proposals for legal changes which they believe would help local health leaders deliver on the improvements for patients set out in the NHS Long Term Plan. The suggestions include changing the law to:

Encourage local health organisations to work more closely together, towards a shared goal of improving the health of the communities they serve, the quality of services, and the sustainability of the NHS.

Reduce delays and costs associated with current procurement processes, while

maintaining patient choice and introducing a new ‘best value’ test to ensure value for money for taxpayers.

Allow different health organisations, such as hospitals, groups of GPs and voluntary groups

and social enterprises, to come together to provide joined-up services which better meet the needs of local people in partnership with local government.

Remove the barriers to greater coordination between the national NHS organisations,

creating a single national voice for the NHS and making it easier to work together on the most important issues facing the health service, such as prevention, the workforce, and harnessing the opportunities presented by digital technology.

The engagement period will run until 25 April 2019 and the responses will help to develop a set of final recommendations to Ministers and Parliament later in the year. 2.6 ICS update - December 2018 to February 2019 2.7 ICS Place Conversations The first place-based conversation to understand the good practice happening in Place and explore issues or areas where additional support would be helpful took place in Doncaster in the last quarter. The conversation, which was focused on understanding the key issues and aspirations at a local level, was positive and has helped to inform the process for future discussions with the other local areas in South Yorkshire and Bassetlaw. All the Place conversations will focus on building on what is working well and bringing about improvements through local support and mutual accountability. Arrangements for future conversations across SYB are underway for 2019/20. 2.8 Capital Bids The Department of Health and Social Care announced the expected £1 billion funding for capital projects. Unfortunately, none of our bids received funding and SYB ICS will therefore not be receiving any additional national monies in this round. This was disappointing news as we had some excellent bids that connected care and services across our partnership and the opportunity to bring further benefits for our patients and population has been missed. Nonetheless, it is also a good time to remember that our populations are already starting to benefit from our collective bidding success


5

last year when we were awarded almost £20 million for projects across the region. As a reminder, our successful bids were:

The additional CT scanner at Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust (£4.8m)

The new hub for Yorkshire Ambulance Services NHS Trust in Doncaster (£7m) The co-location of the children’s emergency department and assessment unit at Barnsley

Hospital NHS Foundation Trust (£2.5m) Improvements to the configuration of hyper acute stroke unit at Sheffield Teaching

Hospitals NHS Foundation Trust (£4.6m)

In this context, it is perhaps not a surprise that we have not benefited from more funding from this recent bidding. As we are not expecting any further rounds of allocations now until 2020/21, partners are discussing the next steps on our ambitions that were connected to the bids. 2.9 ICS Focus Meeting with NHS England and NHS Improvement The quarterly South Yorkshire and Bassetlaw Integrated Care System (SYB ICS) Focus meeting with NHS England and NHS Improvement took place in November 2018 and covered areas such as leadership and governance, working with the new regions and meeting the strategic challenges. Discussions also centred around how the ICS is approaching the challenges and opportunities within care, health and wellbeing, the workforce and finance. We highlighted our work on population health management and the service improvement and efficiency workstreams as ways in which we are collectively tackling some of the issues. Performance and operational management were also covered, recognising the importance of ensuring all constitutional standards are delivered in order to free up time to concentrate on our transformation priorities. In summary, the SYB ICS was acknowledged as one of the most advanced systems nationally and with a strong focus on delivery. Whilst there are risks and challenges still to address – for example in improving A&E performance, reducing activity and extended length of stay, and delivering cancer Transforming Care and financial targets - we continue to have a sound approach to improvement. 2.10 Commissioning Review Following a review of the commissioning opportunities in SYB, a set of priority areas have been identified for collaborative commissioning where there is an opportunity for standardisation, financial efficiency and improved population outcomes. The SYB Clinical Commissioning Group (CCG) Governing Bodies are currently agreeing the priorities and will shortly be approving a work plan. The 2019/20 strategic commissioning priorities include services and contracting for 999/111, tariff and payment reform, the QUIT in hospital scheme, developing quality outcomes incentives based contracting, perinatal mental health, among others, They also include medicines optimisation in some primary care standard policies, commissioning policies and commonality of quality standards and outcomes and some service transformation. A Collaborative Commissioning Agreement (CCA) is also being developed to ensure clear and robust arrangements are in place for strategic commissioning which will set out how the 5 CCGs will work together to commission once with clarity on roles, responsibilities, expectations and communication and engagement processes between CCGs, Governing Bodies, CCG memberships and the ICS and wider partners across the system.


6

2.11 The NHS Long Term Plan

The NHS Long Term Plan was published on 7 January 2019. The Plan is clear that ICSs will play a central in the delivery of the commitments while bringing together organisations to redesign care and improve population health and deliver integration across primary and specialist care, mental and physical health services and health with social care. The NHS Long Term Plan also describes the actions that will need to be taken at local, regional and national level to make this ambitious vision a reality.

1. Joining up the NHS so patients don’t fall through the cracks, such as by breaking down the barriers between GP services and those in the community.

2. Helping individuals and families to help themselves, by taking a more active role in

preventing ill-health, such as offering dedicated support to people to stop smoking, lose weight and cut down on alcohol.

3. Tackling health inequalities by working with specific groups who are vulnerable to poor

health, with targeted support to help homeless people, black and minority ethnic (BAME) groups, and those with mental illnesses or learning disabilities.

4. Backing our workforce by increasing the number of people working in the NHS,

particularly in mental health, primary care and community services. We will also create a better working environment by offering better training, support and career progression and we’ll crack down on bullying and violence at all levels.

5. Bringing the NHS into the digital age, rolling out technology such as new digital GP

services that will improve access and help patients make appointments, manage prescriptions and view health records on-line.

6. Spending this extra investment wisely, making sure money goes where it matters

most. The NHS will continue to reduce waste, tackle variations and improve the effectiveness of treatments.

It sets out how every ICS will have:

A partnership board, drawn from and representing commissioners, trusts, primary care networks, and local authorities, the voluntary and community sector and other partners

Sufficient clinical and management capacity drawn from across constituent organisations to enable the implementation of agreed system-wide changes

Full engagement with primary care, including through a named accountable Clinical Director of each primary care network

A greater emphasis by the Care Quality Commission (CQC) on partnership working and system-wide quality in its regulatory activity, so that providers are held to account for what they are doing to improve quality across their local area

All providers within an ICS contributing to ICS goals and performance, backed up by a) potential new licence conditions (subject to consultation) supporting NHS providers to take responsibility, with system partners, for wider objectives in relation to use of NHS resources and population health; and b) longer-term NHS contracts with all providers, that include clear requirements to collaborate in support of system objectives


7

Clinical leadership aligned around ICSs to create clear accountability to the ICS. Cancer Alliances will be made coterminous with one or more ICS, as will Clinical Senates and other clinical advisory bodies. ICSs and Health and Wellbeing Boards will also work closely together

Now the Plan has been published, we need to decide how best to take the ambitions it contains and turn them into real improvements in services over the next few years, building on the progress we have already made in recent years by working more closely together. We will be producing our South Yorkshire and Bassetlaw five year plan in response by Autumn 2019. And just as the national plan was developed in partnership with patients, staff, local councils and others, so will our own local plan. More details about opportunities to help shape those plans will be shared shortly. In the meantime, to read a copy of the national plan and find out more, visit www.longtermplan.nhs.uk 2.12 Clinical Engagement Event In conjunction with NHS England, we ran a clinical engagement event on January 15th, to build on the leadership development and engagement needs of our clinical colleagues. Themes from the pre-event survey and day highlighted the good work that’s already been taking place and a strong appetite for more and better involvement at a system and emerging partnership level. Led by our Medical Director, Professor Des Breen, the event heard from Dr Claire Fuller from Surrey Heartlands Health and Care Partnership, highlighted the emerging themes and gathered feedback from facilitated discussion which will inform an action plan for the coming year. 2.13 Administration costs Following the commitment from NHS England and NHS Improvement of a further targeted reduction of administration costs limit of 20% by 2020/21, Clinical Commissioning Groups have been asked to deliver the same. Nationally this is expected to free up a total of more than £320 million a year, compared to 2017/18, and which will be reinvested in improving patient care and supporting transformation of services as part of the long term plan. 2.14 Visit from NHS England Chair, Lord David Prior

In January, we hosted a visit from Lord David Prior, Chair of NHS England. The visit showcased examples of working together to wrap support, care and services around people as individuals and brought ‘integrated care’ to life. The overriding theme from all the visits was that getting rid of organisational barriers and putting the needs of people first changes lives. The visit highlighted the integrated work taking place in neighbourhoods, at Place and across the system. GP Partner, Dr Steve Kell, from Larwood Health Partnership, talked through their Primary Care Home, services “under one roof” and how working together differently at a local community level had made a positive difference to patient care. The Doncaster Complex Lives Alliance, made up of local public sector and voluntary sector partners, works together to help some of the most disadvantaged people living in the town who are often dealing with a combination of multiple issues including homelessness, drug and alcohol addiction, offending behaviour, mental ill-health and poor physical health. The team explained that by working across traditional organisational boundaries they were able to make a difference to the lives of those who may not know how to, or for many reasons don’t usually, access health and care support. The final part of the visit was at specialist cancer hospital, Weston Park, as part of Sheffield Teaching Hospitals NHS Foundation Trust. Here Lord Prior heard about how specialist services


http://www.longtermplan.nhs.uk/

8

work at a system-level, providing a service not only to Sheffield residents but to those from across the region requiring specialist treatment and care. Lord Prior was very positive about the initiatives and it was another opportunity for us to highlight ourselves on a national level, showing how we are developing as a first wave integrated care system. 2.15 ICS Integrated Primary Care event Colleagues from Clinical Commissioning Groups, GP Federations, GP Practices, Community Pharmacy, Voluntary Sector, Local Authorities and NHS England came together at an event on January 16th 2019 to discuss Integrated Primary Care. Each of the five South Yorkshire and Bassetlaw Places showcased their developing primary care systems and their plans for the coming year, including ways to tackle workforce challenges which most provider organisations are currently facing. The event helped to develop delegates' understanding of the way in which primary care infrastructure, workforce and service delivery is evolving and raised awareness of the potential opportunities by sharing best practice. 2.16 New GP Contract and Primary Care Network Contract The NHS Long Term Plan committed £4.5 billion more for primary medical and community health services by 2023/24 to support better care for patients outside hospital in their local communities. Last month, NHS England and the British Medical Association’s General Practitioners Committee agreed a five-year GP (General Medical Services) contract framework from 2019/20. The new contract framework marks some of the biggest general practice contract changes in over a decade and will be essential to deliver the ambitions set out in the NHS Long Term Plan through strong general practice services. The contract increases investment and more certainty around funding and looks to reduce pressure and stabilise general practice. It will ensure general practice plays a leading role in every Primary Care Network (PCN) which will include bigger teams of health professionals working together in local communities. It will mean much closer working between Networks and the Integrated Care System. In summary:

Core General Practice funding will increase by £978 million per year by 2023/24. A PCN contract will be introduced from 1 July 2019 as a Directed Enhanced Service

(DES). It will ensure General Practice plays a leading role in every PCN and mean much closer working between Networks and their Integrated Care System. This will be supported by a PCN Development Programme which will be centrally funded and locally delivered.

By 2023/24, the PCN contract is expected to invest £1.799 billion, or £1.47 million per typical Network covering 50,000 people. This will include funding for around 20,000 more health professionals including additional clinical pharmacists, physician associates, first contact physiotherapists, community paramedics and social prescribing link workers. Bigger teams of health professionals will work across PCNs, as part of community teams, providing tailored care for patients and will allow GPs to focus more on patients with complex needs.

A new shared savings scheme for PCNs so that GPs benefit from their work to reduce avoidable A&E attendances, admissions and delayed discharge, and from reducing avoidable outpatient visits and over-medication through a pharmacy review.

A new state backed indemnity scheme will start from April 2019 for all General Practice staff including out-of-hours.


9

Additional funding of IT which will allow both people and practices to benefit from the latest digital technologies. All patients will have the right to digital-first primary care, including web and video consultations by 2021. All practices will be offering repeat prescriptions electronically from April 2019 and patients will have digital access to their full records from 2020.

A new primary care Fellowship Scheme will be introduced for newly qualifying nurses and GPs, as well as Training Hubs.

Improvements to the Quality and Outcomes Framework (QOF) to bring in more clinically appropriate indicators such as diabetes, blood pressure control and cervical screening. There will also be reviews of heart failure, asthma and mental health. In addition there will be the introduction of quality improvement modules for prescribing safety and end of life care.

Extra access funding of £30 million a year will expand extended hours provision across PCNs and from 2019 see GP practices taking same-day bookings direct from NHS 111 when clinically appropriate.

Andrew Cash Chief Executive, South Yorkshire and Bassetlaw Integrated Care System Date 6 March 2019


This page is intentionally blank


TRUST BOARD PART 1 15. 73/19 ICS FINANCE AND PERFORMANCE ... Page 176 of 197

of 7

FINANCE UPDATE

SOUTH YORKSHIRE AND BASSETLAW INTEGRATED CARE SYSTEM

26 February 2019

Author(s) Jeremy Cook, ICS Director of Finance

Sponsor Will Cleary-Gray, ICS Chief Operating Officer

The report is for approval OR noting

Noting

Links to the STP (please tick)

Reduce inequalities

Join up health and care

Invest and grow primary and community care

Treat the whole person, mental and physical

Standardise acute hospital care

Simplify urgent and emergency care

Develop our workforce

Use the best technology

Create financial sustainability

Work with patients and the public to do this

Are there any resource implications (including Financial, Staffing etc)?

There is a risk of loss of System PSF if the system does not meet its quarterly phased system improvement

plan value up to an annual cap of £5.7m.

Previously, the ICS has reported that YTD position shows that Q3 system PSF has been secured with a YTD

favourable variance at M9. This means that £3.7m of the £5.7m system PSF is secure.

As at M10, the YTD position continues to be favourable, however, there remains residual system PSF risk of

£2m due to the adverse forecast outturn.

Summary of key issues

Key messages

1. The ICS financial position is reporting a year to date favourable variance against plan of £10.1m excluding PSF; but is forecasting a £2.3m adverse variance against outturn. This is due to one organisation forecasting a deficit and clarification in January that the benefit of improved plans cannot be used to offset deficits at a system level. This creates a system-PSF achievement risk of £2m. In addition, there are some emerging risks in providers which are currently being discussed with organisations, systems and regulators.

2. As per previous reports, during January the ICS became aware that in addition to the improved plans not being allowed to offset deficits in other organisations that the assessment of system performance would also be impacted as the guidance states that the system improvement plan value will be rebased


of 7

to reflect the improvement in plans.

3. This means that where organisations go off-plan there is limited ICS headroom to offset deficits which would result in the system failing to deliver against the rebased System Improvement Plan value and the system losing in whole or in part Q4 PSF funding of £2m in addition to PSF lost at organisational level.

4. There is current ongoing dialogue with regulators on this issue.

5. The forecast as reported shows a deficit against the rebased system improvement plan value of £2.3m although this assumes that SCH achieve plan. SCH are managing a number of risks which could result in an adverse variance at the year end and increase the £2.3m system variance.

6. Doncaster and Bassetlaw Teaching Hospitals have declared a forecast off-plan position of £3.7m which

includes a prior year depreciation change of £3.9m. The Trust and system has managed a number of risks to get to this forecast including mitigation of the lost CIP on the Wholly Owned Subsidiary of £3.25m. A proposal to NHSI to exclude the £3.9m prior year item from assessment of financial performance has not been successful. As a result the Trust would lose £5.7m of PSF in Q4 including system and A&E PSF.

7. There remains ongoing dialogue with NHSI on this issue.

8. CIP & QIPP schemes are forecast behind plan, materially in Sheffield CCG (which is reporting a QIPP shortfall of £2.9m) and DBHT (which is reporting a CIP shortfall of £5.8m). Some organisations are reporting CIP and QIPP overachievement including Sheffield Teaching Hospitals, Doncaster CCG, Bassetlaw CCG and Rotherham CCG.

9. There are a number of grounds where the ICS believes the guidance issued by NHSI should be challenged. These are outlined in 9 below.

Recommendations

The Committee is asked to note the position at Month 10, the risks to achievement of the system improvement plan value and the further discussion that is required with NHSI on the assessment of system financial performance.


of 7

South Yorkshire and Bassetlaw ICS Finance Report Month 10 – January 2019

Financial reporting

1. Performance against System Improvement Plan:

2. Where organisations have agreed to deliver an improved financial position (both providers and commissioners), there has been transacted as a change to the organisational control total. This means that the organisation needs to deliver its revised financial plan rather than a surplus against its original plan.


of 7

3. The adjustment for plan changes is shown below:

Organisation Plan movement £m

Sheffield Health and Social Care FT 1.3

RDASH 2.1

Barnsley Hospital 0.3

Provider Sub Total 3.7

Barnsley CCG 1.0

Rotherham CCG 2.0

Doncaster CCG 2.0

Commissioner Sub Total 5.0

Grand Total 8.7

4. During January the ICS became aware that in addition to the improved plans not being allowed to

offset deficits in other organisations that the assessment of system performance would also be impacted as the guidance states that the system improvement plan value will be rebased to reflect the improvement in plans. As a result the table has been adjusted in 1 above to reflect this rebasing. So whereas previously the ICS had assumed that the system was ahead of plan this is no longer the case and the latest forecast shows that the forecast as reported at month 10 shows an adverse variance of £2.3m. This assumes that SCH achieves plan. SCH has a number of risks which could result in an adverse variance against plan at the year end.

5. A shortfall against the rebased system improvement plan would also result in lost system PSF in Q4 of up to £2m. Therefore a maximum system deficit against plan of £1.3m would result in a loss of £2m system PSF at £1.50:£1

6. Doncaster and Bassetlaw Teaching Hospitals have declared a forecast off-plan position of £3.7m. This includes a prior year depreciation charge of £3.9m. The Trust has managed a number of risks to get to this forecast including mitigation of the lost CIP on the Wholly Owned Subsidiary of £3.25m. Following the M9 key data submission Cathy Kennedy (Business Director Yorkshire & Humber) sent a proposal for consideration to Elizabeth O’Mahony (Director of Finance NHSI) that this be excluded from assessment of the Trust’s financial performance. This case was not supported and as a result the Trust would lose £5.7m of PSF in Q4 including system and A&E PSF. This decision results in the £3.9m prior year adjustment counting against system performance even though it relates to periods prior to the ICS being formed.

7. There are a number of areas where the guidance that has been applied requires to be challenged on the following grounds:

That the system signed up to being managed to deliver against a system improvement plan value deficit of £82.5m in the MoU.

That boards and governing bodies who signed up to improved plans were not made aware that this would have a detrimental impact on system performance and some had assurance from NHSI either verbal or in writing that this would not be the case.

The ICS had not had formal notification that it’s system improvement plan value will be rebased


of 7

That system financial performance currently includes a prior year item of £3.9m at Doncaster & Bassetlaw Teaching Hospitals even though the item relates to before the ICS was in existence. As a result this should be excluded from assessment of system financial performance.

That the ICS is likely to exceed the system improvement value set out in the MoU yet under the rules as outlined would result in lost PSF at DBTH of £5.1m , potentially £1.1m at SCH if they fail to achieve plan in Q4 and lost system PSF of £2m, a total of £7.2m.

8. System Performance including PSF :

9. Sheffield Teaching Hospitals has reported non-achievement of PSF in Q1, Q2 and Q3 as A&E

performance was worse than in 17/18. The forecast assumes that no A&E PSF is earned resulting in lost PSF of £7.8m.


of 7

Efficiency

10. Efficiency Plan analysis is provided below:

11. Based on the information reported to NHSE/NHSI, efficiency plans are YTD £3.0m ahead of plan overall (£6.9m last month), but forecasting a £4.5m under delivery (£2.9m last month). Both movements therefore are adverse.

12. Forecast for QIPP at year end is £0.5m favourable against plan (£0.1m adverse last month) due to increased FOT for Rotherham and Doncaster CCGs.

13. Forecast CIP has over performance has reduced by £2.6m due to reduction in forecasts for SCH (£1.6m)

and STH (£1.1m).

14. CCGs are required to submit monthly monitoring returns to NHSE before full contract monitoring and prescribing data is available, which means the return is based on estimates using prior month data. This can mean revised positions are reported to CCG Governing Bodies when a full data set is available for the relevant month.

15. Delivery of efficiency plans represents the single largest financial risk to the system in 2018/19. During the year, new risks have emerged including:

The treatment of prior-year items impacting the system control total


of 7

Changes to NHS guidance affecting delivery of planned Wholly-Owned Subsidiaries

Clarifications of regulator approach to handling of organisational control totals as part of the incentive scheme versus the system control total.

16. In line with the proposed financial framework, forecast positions are planned to be managed initially by organisations and then by places before system-escalation.

17. The System Efficiency Board has worked to identify Key Lines of Enquiry for system-wide efficiency and has developed prioritisation criteria for the schemes for priority development of business cases in partnership with stakeholders and utilising the expertise of the clinical workstreams. Briefing notes have been circulated separately to ESG members. The next meeting of the SYB SEB is 13 March 2019. Deloittes continue to support the process.

18. The NHS England weekly CCG bulletin identified BRONZE support for ICSs although SYB consider that this has already been undertaken through the work of the System Efficiency Board and RightCare/Model Hospital/GIRFT. We would seek to request access to the GOLD STANDARD NHSE Diagnostic Pack process (12 weeks of NHSE support) rather than the standard BRONZE offer (2 weeks). This will require to be discussed with the Regional Director.

19. As part of 19/20 planning, ICS DOFs have received a number of papers which propose different approaches to risk management in 19/20 given the high level of financial risk in the system both through CIP/QIPP delivery (including identification of unidentified schemes) and alignment. A working group has been convened to discuss the options in more detail.

Jeremy Cook Director of Finance South Yorkshire & Bassetlaw ICS 26 February 2019


1

Sheffield Children’s NHS Foundation Trust Sheffield Clinical Commissioning Group

Sheffield Health and Social Care NHS Foundation Trust Sheffield Teaching Hospitals NHS Foundation Trust

Programme Director Report

For Partner Boards

Sheffield Accountable Care Partnership (ACP)

For Sheffield Children’s Hospital NHSFT Board on March 26th 2019

Author(s) Rebecca Joyce

Sponsor Kevan Taylor (Chair of EDG) & John Somers (Chief Executive of SCH NHSFT)

1. Purpose a. To provide headlines from the progress of the Accountable Care Programme. b. To provide an overview of ACP Programme Activities.

2. Introduction / Background A short written overview of the Programme activities is provided by the Programme

Director for the purpose of each partner board.

3. Is your report for Approval / Consideration / Noting For noting

4. Recommendations / Action Required by Accountable Care Partnership See attached actions within the report.

5. Other Headings N/A

Are there any Resource Implications (including Financial, Staffing etc.)?

N/A


2

Programme Director Report

Sheffield Children’s Hospital NHSFT Board Meeting, March 26th 2019

1. Strategic Update

a) The ‘Shaping Sheffield: The Plan’ workshops took place late January/ early February as part of the staff and public consultation to feed into an action plan, which will outline the work of the Sheffield Accountable Care Partnership for the next 5 years. This action plan will provide tangible outcomes to focus on our agreed aims and priorities. Over 300 staff and members of the public attended across the ACP partner organisations. The events focused on the 5 priorities for 19/20. Key themes from these workshops included: Workforce: staff capability to work differently and the capacity to implement new ways of working, morale and culture, leadership and management capabilities, empowering and listening to staff were all raised multiple times across the 5 workshops. A strong message from the smoking and obesity & physical activity groups in particular, was around maximising the opportunity to focus on supporting staff across the system in stopping smoking and becoming more physically active.

Funding: there was a strong call for integrated commissioning and an investment in prevention activities, including support for the voluntary sector. The issue of short term funding and concerns around the short-term thinking this promotes was raised multiple times.

Person-centred approaches: incorporating flexibility to tailor approaches and support as appropriate at the individual and community levels, addressing issues around access and lack of awareness and using co-production techniques to ensure that care models and future plans have the public at their centre.

Integrated working: a lot of references to silo working and ‘inward looking’ practices, with a call for more holistic, better-coordinated services. Co-location was cited numerous times, along with the need for digital interoperability and the development of trust between organisations.

Full feedback will be shared with delegates and other stakeholders.

b) The ACP team are working with colleagues a draft Shaping Sheffield: The Plan for the end of April. This will bring the work together into a more coherent whole, acknowledging that the overall fit is not yet transparent. This will be supported by refreshed delivery plans. Each partner executive team will meet with the ACP team through April to feedback on the draft plan and ensure a set of shared goals. A system dashboard to measure progress has been agreed and will track progress.


3

2. Delivery

a) MH & LD and Children’s and Maternity workstreams held a joint programme workshop on 7 December 2018 around developing an all age mental health care model. The workshop was an excellent event with very high levels of engagement from all stakeholders. Joint governance arrangements across the progammes are now being discussed.

b) EDG and ACP Board at their February meetings considered a summary of proposals to

establish a Joint Commissioning Committee between Sheffield City Council (SCC) and the Clinical Commissioning Group (CCG). The paper summarised proposals for a joint commissioning plan, and identified the priority areas for commissioning new preventative services that will seek to reduce inequalities, increase the capacity of community based services and reduce demand on acute services. ACP partners were fully supportive of the plan.

c) The new models of care for multi-morbidity / admission prevention was supported in

principle by all ACP partners and work will now commence on mobilising this. This will underpin the joint commissioning priority of “frailty”.

d) The Quarterly CQC Local System Review update was considered by Board, with good

progress noted. All partners should be considering this report within their agreed internal governance routes.

e) November EDG supported greater ownership from the ACP on next steps relating to urgent

primary care, following the CCG consultation between September 2017 and January 2018. There is a question as to whether this is CCG led or ACP owned. Current workshops are taking place across the system to understand the problem, and consider the next steps in light of this. This will return to EDG in April.

f) Organisational Development – The Leading Sheffield Cohort 2 (formerly known as Liminal

Leadership) commences in March and NHS Leadership Academy funds have been secured for a Shadow Board.

g) Integrated Care Record and Digital Agenda: The Integrated Care Record project remains at Amber/Red status. Whilst it is acknowledged that there are busy operational organisational digital agendas, Sheffield is losing pace on the system wide agenda compared to a number of other care economies. Kevin Connolley, CIO at SCH, has offered to prepare a proposal outlining what a digital workstream could look like on behalf of the CIOs.

Cross-Cutting Risks

A set of high level programme risks are taken from the highlight reports:

Risk Mitigation UEC have raised the risk of operational pressures impeding transformation work.

Review of links between transformation and performance aspects of workstream taking place

Primary care workforce as a key risk to deliver the ambition of the primary care workstream. More broadly, whilst we are developing

Team linking with SY Workforce Hub and LWAB on this issue. CEOs have agreed to review this theme through their monthly private meetings.


4

some integrated workforce approaches, we are not yet set up to mobilise workforce strategy effectively across the system. Project/ programme management support to help drive programmes forward identified as risk in a number of programmes (MH & LD- for dementia, psychiatric decision unit, neighbourhood health and wellbeing service).

Overall, this risk has reduced with the appointment of a number of posts, but risk still apparent and is slowing progress in some areas. We need to start re-shaping some of our collective resource in line with ACP priorities in order to accelerate the system wide work

System digital transformation is a key risk of the programme and we do not currently have system wide capacity or dedicated leadership working on this adequately.

CEOs have committed to getting underneath this as a priority. Whist it is acknowledged that there are significant organisational operational digital agendas, Sheffield is losing pace on the system wide agenda compared to a number of other care economies.


16. 74/19 USE OF THE TRUST SEAL

EXECUTIVE SUMMARY

Title USE OF THE TRUST SEAL

Report to

Board of Directors Part 1 Date 26 March 2019

Executive Sponsor

Mr M Smith, Chief Finance Officer

Author

Mr M Kane, Associate Director of Corporate Affairs

Purpose of report

To inform the Board on the use of the Trust Seal


Approval Assurance Information √


The Trust seal has been used twice since the Board of Directors last received a report on its use. For the lease and licence for alterations between Sheffield Children’s NHS Foundation Trust and WH Smiths Hospitals Limited. Details of the Lease are:

The lease is a 7 year agreement with WH Smiths Hospitals Limited to occupy a retail unit within A floor

The primary details of the lease were reported to both Finance and Resources Committee and Trust Executive Group and approved accordingly.

The lease is therefore the formalisation of the Heads of Terms and agreement between our two organisations.

The lease includes the provision of a break after 5 years for clinical needs, and the costs agreed include VAT and insurance.

How this report impacts on current risks or highlights new risks Not applicable.

Recommendations and next steps That use of the Trust Seal be noted.

TRUST BOARD PART 1 16. 74/19 USE OF THE TRUST SEAL Page 193 of 197

----------------------------------------------------------------------------------------------------------------------------

Use of the Trust Seal

This Trust Seal has been used in respect of the following leases:

Lease for WH Smiths Hospitals Limited and Licence for Alteration Date seal applied: 12 March 2019 Between: (1) Sheffield Children’s NHS Foundation Trust (2) WH Smiths Hospitals Limited Signatories: John Somers, Chief Executive and Mark Smith, Chief Finance Officer Location of sealed document: Estates Department, SCH Signed under delegated authority to the Chief Finance Officer

TRUST BOARD PART 1 16. 74/19 USE OF THE TRUST SEAL Page 194 of 197

17. 75/19 ANY OTHER BUSINESS

18. 76/19 DATE OF NEXT PUBLICMEETING: Tuesday 30 April 2019, 08:30hours in the Boardroom

19. Matters arising from previous meeting