agenda - dchs home · 213 monitor self-cert q1 188 214 consent 215 fraud policy owner: chris sands...

Derbyshire�Community�Health�Services

Board

Board�Public�Session�-�30�July�2015

30�July�2015�-�09:00

Belper�Town�Football�Club,�Christchurch�Meadow,�Bridge�Street,�Belper,�DE561BA

AGENDA

9.00�amAmber�Valley�–�Services�and�Future�Developments

188 9.30�amPART�1�–�Public�Session

189 INTRODUCTORY�ITEMS

190 Introductions�and�WelcomeOwner:�Chairman

Verbal

191 Apologies�for�Absence:�William�Jones,�Carolyn�WhiteOwner:�Chairman

Verbal

192 Declarations�of�InterestOwner:�Chairman

Verbal

193 Questions�from�the�PublicOwner:�Chairman

Verbal�

194 Carer's�StoryOwner:�Jo�Hunter

Paper�for�Information

194�Carer's�Story 6

http://www.eshareuk.com

195 Draft�Minutes�of�the�meeting�held�on�25�June�2015Owner:�Chairman

Paper�for�Decision

195�Minutes 9

196 Matters�ArisingOwner:�Chairman

Verbal

197 Actions�MatrixOwner:�Chairman

Paper�for�Information

197�Actions�Matrix 18

198 Chairman’s�ReportOwner:�Chairman

Verbal

199 QUALITY�AND�GOVERNANCE

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

Paper�for�Assurance

200�QSC�Summary�Report�and�PEEG�Annual�Report 23

201 Audit�and�Assurance�Summary�Report�including�Annual�ReportOwner:�Nigel�Smith


201�AAC�Summary�Report�inc�Annual�Report 38

202 Council�of�Governors�Summary�ReportOwner:�Prem�Singh


202�Council�of�Governors�Summary�Report 52

203 Quality�ReportOwner:�Jo�Hunter

Paper�for�Assurance�and�Information�

203�Quality�Report 56

204 Healthcare�for�All�and�Monitor�Risk�Assessment�FrameworkOwner:�Amanda�Rawlings

Paper�for�Information�and�Assurance

204�Healthcare�for�All�and�Monitor�Risk�Assessment 95


205 Board�Assurance�Framework�Quarter�OneOwner:�Kirsteen�Farrar

Paper�for�Assurance,�Information�and�Decision

205�Board�Assurance�Framework�Q1 100

206 Amendment�to�ConstitutionOwner:�Kirsteen�Farrar

Paper�for�Decision

206�Amendment�to�Constitution 125

207 STRATEGY

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

Verbal

209 PERFORMANCE

210 Quality�Business�Committee�Summary�ReportOwner:�Ian�Lichfield


210�QBC�Summary�Report 127

211 Performance�ReportOwner:�Chris�Sands/�Amanda�Rawlings/�Jo�Hunter/�William�Jones


211�Performance�Report 131

212 Financial�Performance�ReportOwner:�Chris�Sands


212�Financial�Performance�Report 175

213 Monitor�Self-Certification�Quarter�OneOwner:�Kirsteen�Farrar

Paper�for�Assurance,�Information�and�Decision

213�Monitor�Self-Cert�Q1 188

214 CONSENT

215 Fraud�PolicyOwner:�Chris�Sands

Policy�for�Decision

215�Fraud�Policy 197

216 CONCLUDING�ITEMS


217 Any�Other�Urgent�BusinessOwner:�Chairman

Verbal

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

Verbal

219 Questions�from�the�public�relating�to�today's�board�businessOwner:�Chairman

Verbal

220 Date�of�Next�Meeting:Owner:�Chairman

Thursday�24�September�2015�at�Alfreton�Hall,�Church�Street,�Alfreton,�Derbyshire�DE55�7AH.��The�PublicSession�will�commence�at�9.00am�and�following�completion�of�business�on�the�public�agenda�the�Boardwill�move�to�a�Private�Session


Index194�Carer's�Story.docx......................................................................................................................6

195�Minutes.docx..............................................................................................................................9

197�Actions�Matrix.docx..................................................................................................................18

200�QSC�Summary�Report�and�PEEG�Annual�Report.pdf............................................................. 23

201�AAC�Summary�Report�inc�Annual�Report.docx....................................................................... 38

202�Council�of�Governors�Summary�Report.docx.......................................................................... 52

203�Quality�Report.docx................................................................................................................. 56

204�Healthcare�for�All�and�Monitor�Risk�Assessment�Framework..................................................95

205�Board�Assurance�Framework�Q1.pdf.....................................................................................100

206�Amendment�to�Constitution.docx........................................................................................... 125

210�QBC�Summary�Report.docx.................................................................................................. 127

211�Performance�Report.pdf.........................................................................................................131

212�Financial�Performance�Report.pdf......................................................................................... 175

213�Monitor�Self-Cert�Q1.docx..................................................................................................... 188

215�Fraud�Policy.docx.................................................................................................................. 197


TRUST BOARDDocument Title: Carer’s Story

Presenter/Title:Louise, Mother of CalebMary Heritage, Assistant Director of Quality & Professional Lead for Allied Health Professions

Contents of Paper were previously discussed by:Author/Title: Lee Allen, Public & Patient Involvement OfficerContact Email and Telephone Number: [email protected]

Date of Meeting: 30 July 2015 AgendaItem No: 194/15

No of pagesinc. this one: 4

Document is for:(more than one box can be ticked) Information Decision Assurance

Purpose of PaperTo share the experience of a Mother (Louise) and father (Fraser) taking their Son, Caleb, to the Minor Injuries Unit (MIU), at Ripley Hospital, following a fall from his high chair, in the family Kitchen.

To highlight the experience of Fraser, Louise and Caleb’s care and treatment at the Minor Injuries Unit, at Ripley Hospital, on Saturday 26th July 2014.

To highlight the experience of Louise in relation to the Complaints process.

Background InformationMore than two million children under the age of 15 experience accidents in and around the home every year, for which they are taken to accident and emergency units. Those most at risk from a home accident are the 0-4 years age group. Falls account for the majority of non-fatal accidents. Injuries are associated with heat-related accidents and falls from a height. The largest number of accidents happen in the living/dining room however, the most serious accidents happen in the kitchen and on the stairs:

0-4-year-olds have the most accidents at home Boys are more likely to have accidents than girls

Information taken for The Royal Society for the Prevention of Accidents (ROSPA) 2015.

RecommendationsIt is recommended that the Board note the following:

The challenges faced by parents of young children Sensitivities of executing our responsibilities in safeguarding The experience of making a complaint in Derbyshire Community Health Services

Foundation Trust That lessons have been learned from the direct experience of Louise’s and Caleb’s

treatment at the MIU at Ripley Hospital, and that a range of improvements have been made to ensure we routinely consider the additional needs of our parents and their young children.

194�Carer's�Story.docxOverall�Page�6�of�211Page�1�of�3


Board Assurance Framework Risk Reference

1.3.1

Financial Impact

None identified

Further Information and Appendices

The experience of Fraser and Louise taking their Son, Caleb, to the Minor Injuries Unit (MIU), at Ripley Hospital, following a fall from his high chair, in the family Kitchen

On Saturday 26 July 2014, Louise visited MIU with Caleb, as he had fallen from his high chair and banged his head. Caleb appeared unaffected by the fall but he had a slight bump to his forehead. Louise felt that he should be checked over by health care professionals.

Caleb was seen by two different nurses whilst at the unit. The outcome being that there were no concerns about Caleb because of his accident. Louise was given a leaflet about head injuries and told to return the next morning to have Caleb checked by a Doctor, as he is less than one year of age. This was standard practice.

Later on the same day Louise received a telephone call from the on-call Social Worker, at Derbyshire Health United (DHU). The social worker explained that Louise had been referred to social care following a referral from the MIU team at Ripley Hospital. Concerns had been raised due to a discrepancy between the two stories Louise had told the two nurses she had seen whilst in MIU referencing Caleb’s fall from his high chair. The social worker informed Louise that she would need to contact the Doctor following Caleb’s appointment. This was to check if Caleb had recovered from his fall and any further actions would be taken.

Louise was extremely upset and annoyed that the referral had happened and they had not been informed of this. She was still deeply upset and worried, primarily from her son’s fall and then to be told she had been referred to Social Care. This was just not right. She replayed in her mind the two conversations she had with the two nurses she had seen. What had she said to get them to contact Social Services?

On 27 July 2014, Fraser and Louise took Caleb to see the Doctor at the MIU Ripley. The doctor had no concerns about Caleb. They explained to the Doctor their worries about the referral to Social Care. They reiterated they could not understand why this had happened. The Doctor again informed then there was discrepancies in what Louise had told the nurses. It was documented that Louise told the first nurse that she had unstrapped Caleb and he launched himself from his chair. The second nurse recorded that Louise had unstrapped Caleb, left the room and he fell from his chair. Louise was very angry to hear this. She had not left the kitchen; she had not said this to the second nurse.

Fraser and Louise had to chase Social Care for an update. After waiting for over a day they were told that Social Care would not be taking any further action.

The reasons they felt they needed to make a complaint?Fraser and Louise believed this to be a totally inappropriate referral. The family had experienced a great deal of stress and upset because of this. It had left them with a number of issues and concerns about the incident.The family should have been informed of the reasons for the referral to Social Care. They had



not been informed.A full investigation was initiated to look into Fraser and Louise’s concerns raised through the complaint.

What was your experience of making the complaint?The complaint investigation findings came back and very quickly Fraser and Louise were offered a meeting with the Matron, Senior Sister and a Complaints Manager.

Fraser and Louise described the experience of making their complaint as very positive. They feel they were listened to; their concerns were taken on board. As a result of their complaint actions have been taken to avoid this happening again. They are reassured the action plans developed have been shared with all staff in the MIU team in relation to their complaint. Things could and should have been done better and this has been acknowledged and taken forward.

Lessons have been learnedA detailed action plan has been developed and can be provided to verify this.

Monitoring Information Brief Summary

What are the Governor involvement implications?

Patient Stories are discussed at the Council of Governors meetings. Governors have a key role in overseeing steps taken to improve the quality of DCHS’ services. Our Governors will want to be assured that Trust board uses patient stories for learning and to put the patient at the heart of every Board meeting.

What are the Equality and Diversity implications?

The patient in this story is Caleb whose protected characteristic is his age. DCHS has a legal responsibility to take additional steps to put his needs first through effective safeguarding and through effective communication with his family.

What are the Patient, Public, Staff, Member and Stakeholder involvement implications?

This story highlights the need for clear and concise communication and documentation between DCHS staff and patients and their families Listening to the experiences of patients and involving them in identifying improvements is an important tool in quality improvement.

Risk Register

Is the issue on the current Risk Register? No If yes, what is the Risk Number?

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



Minutes of the DCHS Board Meeting held on Thursday 25 June 2015 Bay A, Speedwell Development Centre, Walton Hospital, Whitecotes Lane, Chesterfield

Name Job titlePrem Singh PS ChairmanTracy Allen TA Chief ExecutiveIan Lichfield IL Non-Executive DirectorMelanie Curd MC Acting Trust SecretaryWilliam Jones WJ Chief Operating OfficerRick Meredith RM Medical DirectorAmanda Rawlings AR Director of People & Organisational EffectivenessChris Sands CS Director of Finance, Information and StrategyNigel Smith NS Non-Executive DirectorBarbara-Anne Walker BAW Non-Executive DirectorCarolyn White CW Chief NurseChris Bentley CB Non-Executive DirectorTony Okotie TO Non-Executive Director

Present

Kirsteen Farrar KF Trust SecretaryTim Broadley TB Associate Director of Strategy

Apologies

Jim Austin JA Associate Director of TransformationDeborah Brennan DB Legal Services ManagerDenise Sanderson DS Head of Continence Service

In Attendance

Rachel Robinson RR Head of Continence Service

Item Description Action

158/15 PART 1 – Public Session

159/15 INTRODUCTORY ITEMS

160/15 Introductions and WelcomePS welcomed everyone to the meeting.

161/15 Apologies for Absence Apologies were noted as above.

162/15 Declarations of InterestThere were no Declarations of Interest.

163/15 Questions from the PublicMC confirmed no formal questions from the public had been received.

195�Minutes.docxOverall�Page�9�of�211Page�1�of�9



164/15 Patients StoryCW introduced the story as she had shadowed RR on a visit to this patient, Sally, and witnessed the complexities faced by the Continence Service.

DS provided an overview to the Board explaining that the service operates on a county wide basis. She explained that they undertake a full assessment of each patient and they are not just there to provide incontinence pads.

RR then summarised her contact with Sally who was a 44 year old lady suffering from mental health problems since her partner left and this coincided with her undergoing a below knee amputation. This led to problems with mobility and weight. RR identified at the initial assessment that Sally wanted to regain her independence and, together with other health disciplines, they set goals and monitored these.

RR reported that she was able to gain trust from Sally to help her with her weight and diet and she has improved her continence without the aid of pads.

A discussion took place on the subject of incontinence and it was recognised that the holistic approach taken by the service resulted in the positive outcome for Sally. In addition, it was noted by BAW and PS that this approach and linking the patient to other services enabled her to receive a positive patient journey within DCHS.

CB questioned how the county wide service would be affected now that we are moving to locality groupings and TA responded to state that as this was a specialist clinical service it would be better for patients if this remained county wide.

The Board thanked DS and RR for attending to tell the story.

165/15 Draft Minutes of the meeting held on 28 May 2015 The minutes of the meeting held on 28 May 2015 were confirmed as accurate.

166/15 Matters ArisingThere were no Matters Arising.




167/15 Actions MatrixAction 142/15 with a deadline of June was noted as complete.

Action 104/14 relating to Go Low cars was noted as being complete however, PS asked how the Board would be informed of the conclusion. CS agreed to pick this up with TB.

Action 80/15 – NS requested an explanation as to why this action had been deferred from July to September 2015. WJ explained that the process of rolling out authorisation to clinical staff out of hours has been more challenging than expected but progress is being made.

CS

168/15 Chairman’s ReportPS explained that the national position is now clear, following the general election in that the NHS will deliver the plans behind the efficiency, health and quality gaps captured in the Five Year Forward View. There is more detail on this within the Chief Executive’s Report on the agenda. The challenge is to set out how the £22billion could be delivered and this will require every Board to be clear about its plans and contributions. Therefore, our strategic theme today is ‘Time to Deliver’.

PS said it was a pleasure to attend the Whitworth Hospital open day on 20 June 2015, which was a 125th celebration. The public were able to see the newly refurbished facilities and enjoy other activities from face painting to information about services and health issues. In addition, a display from the League of Friends was in place to track their 50 year history.

PS went on to discuss the meetings with strategic partners which have included Hertfordshire Community NHS Trust, Derby Teaching Hospitals Partnership Board, North Derbyshire 21C Programme Delivery Group, Southern Derbyshire Leadership Group and informed the Board that Helen Phillips, Chair of Chesterfield Royal Hospital NHS Foundation Trust will be visiting some of our services as part of her induction.

PS attended the second Access to Healthcare Forum with TA at which there was commitment from all to foster a culture of inclusion. The aim is to ensure that the voices of service users who have protected characteristics are heard and reiterated that we need to build on this work.

During the month PS has attended the Quality People Committee at which the Extra Mile Awards were discussed. He also attended a follow up meeting with members of Board and other leads regarding Equality and Diversity, which features on the agenda today.

At a national level PS attended the NHS Confederation Annual Conference and the NHS providers Chairs and Chief Executives Forum.

PS reported on the good news stories that DCHS have been listed in the HSJ best Places to Work top 100; our work on Vanguard has received




national recognition with TA being interviewed by the HSJ; DCHS being able to halve our agency spending in the last two years which links to the HSJ Value in Healthcare Awards: our responsive workforce approach being highlighted in the Nursing Times; we now have 14 active volunteers working across Derbyshire on the Home from Hospital initiative; Dementia Awareness Week during which our OPMH team at Walton helped launch the Chesterfield Dementia Action Alliance and also on the subject of Dementia, the patients’ art is part of a summer exhibition in Matlock.

Finally, PS thanked TO for his contribution to the Trust as a Non Executive Director and Deputy Chairman of the Board. TO is moving to a new Non Executive Director post in Liverpool.

The Board received the Chairman’s Report

169/15 QUALITY AND GOVERNANCE

170/15 Quality Service Committee (QSC) Summary Report CB presented the Summary Report of the meeting held on 16 June 2015 and highlighted the patient story, which was presented to QSC and illustrated the value of involving family members in the care of a person with Dementia.

QSC had a discussion on whether any of the new forms of service such as Primary Care, 21st Century and Strategic Shift be recognised as strategic risks on the BAF.

CB explained that the Insight Visits are being relaunched and the documentation associated with these has been reviewed and will be piloted from July 2015.

CB reported that QSC had received a positive report from PEEG which demonstrated that work is underway to improve the effectiveness of the Learning the Lessons Group to ensure messages are disseminated effectively. A paper on the Learning the Lessons strategic approach will be presented to QSC in September.

QSC took limited assurance from the Healthcare for All Report and requested further work on this. CS expressed concern regarding the limited assurance since the RAG scoring forms part of the Monitor Self Certification. CB explained that we had met the target scores and it was issues relating to the action plan that led to the assurance level being given.

The Board discussed concerns regarding the roll out of TPP and the support being provided to clinicians regarding this IT system. WJ explained that this will form part of the Due Diligence process when taking on new services and TA added that it is being discussed through the IM&T processes.CB stated that the number of risks in the Risk Management Report had




fallen however, the number of Top X risks had increased. PS questioned if these were all clinical risks and CW responded to say that the highest risks were clinical but the Top X included commissioning, estates and IT risks.

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

171/15 Quality People Committee (QPC) Summary reportBAW presented the Summary Report of the meeting held on 15 June 2015 and referred to a staff story, which highlighted the value of the appraisal process.

Reference was made to the Strategic Workforce Report and BAW was pleased to report the reduction on agency spending. Poor response rates in some areas relating to pulse checks was noted and DCHS are looking at new ways to invigorate these. In contrast to this, BAW stated that QPC had reflected on the number of awards given to the Trust recently.

BAW stated that assurance had been taken from the 360 Assurance Report into expenditure on pay but had requested a deeper review of staff absence.

BAW explained that a long discussion had taken place regarding the recommendation to revert to 3 yearly Disclosure and Barring Service (DBS) checks. DCHs will continue with current DBS policy until further guidance is received.

QPC took limited assurance from the Equalities Report and Learning and Education Report especially with regard to DOLs training. CS challenged the timeframe for completing this training and MC explained that Level 2 training was ongoing for the 1,000 staff that require it, the workbooks are being obtained from a Trust in Bournemouth, Audit & Assurance Committee were monitoring the situation and an action plan is in place.

The Board discussed the lessons learned from the 2014 Flu Vaccination Campaign and TA explained that she had approved changes for the future with CW as DCHS is falling behind other NHS organisations regarding vaccination levels.

BAW reported on the lessons learned from the Extra Mile Awards (EMA) and the changes being considered for next year. PS explained that RM is looking into the development of DCHS as a Research and Development Trust which links to the EMA process.


172/15 Audit and Assurance Committee (AAC) Summary ReportNS presented the Summary Report from the meeting held on 28 May 2015 and highlighted that this provided a clean opinion on the accounts




and our overall position was good.


173/15 Mental Health Act Committee (MHAC) Summary ReportBAW presented the Summary Report from the meeting held on 1 June 2015.

BAW provided an update on the Dementia Services Strategy (DSS) Development and explained that it is a challenging piece of work as numerous organisations are involved.

Limited assurance was taken by the Committee on the NHS Code of Practice however, actions are being progressed. CS asked if we were undertaking any sharing with other organisations and if consideration had been given to the 360 assurance process. BAW to consider the 360 approach and MC added that sharing with Lincolnshire was taking place.

BAW reported that the Committee had approved the MHA Training Matrix but as there were financial and time implications this would need further discussion at QPC.


174/15 Quality ReportCW presented the report and stated that the Safety Thermometer score was below target for May and further work is taking place within teams to understand the variations.

CW commented on Medication Incidents and reported that the trend is coming down.

CW reiterated the changes made to the Insight Visits, previously referred to under item 170/15 and stated that the new documentation was being trialled at visits in July 2015.

CW confirmed that the GP practices at Cresswell and Langwith have been registered with the CQC.

A discussion took place on the Pressure Ulcer section of the report, the graphical trends and common themes, particularly regarding documentation. CW responded that IT was not yet aligned to our policies in relation to timescales for assessments but this would improve. NS suggested that we include a patient story relating to an avoidable pressure ulcer and CW will discuss this within the Quality Directorate.PS highlighted the number of pressure ulcers deteriorated in our care had increased and CW stated we do not fully understand all the reasons for this, however early indications from investigations suggest we are seeing patients with much more complex needs. She added that we still

CW




have issues with non-compliance from some patients and a project is ongoing within the Bolsover area to promote pressure ulcers and influence patient choice before they become DCHS patients.

TA questioned whether further work looking at skill mix against number of patients would be useful when considering key patient safety risks. CW to action.

The Board received the Quality Report for information and assurance.

CW

175/15 Nurse RevalidationCW presented the report and explained the challenges faced by the Trust regarding the timetable since revalidation comes into operation in the Spring of 2016.

A discussion took place on the inclusion of bank and agency staff, the difficulty in prediction of numbers this affects and the need to work innovatively to implement this initiate. PS commented that he was pleased to see the process being linked to appraisals.

The Board noted the progress made to date, agreed that the reporting mechanism should be through QPC and exception reports would be provided to Board.

176/15 Annual Monitor Self-certificationMC presented the report explaining the three components:

Part 1 – the Board were asked to consider any risks regarding the Corporate Governance Statement and none were identified.

Part 2 – this is not applicable to DCHS. Part 3 – training has been provided to Governors.

PS requested Section 5, E of Appendix 1 be strengthened to include other levels of assurance for example, patient stories and CS requested Fit and Proper Persons be added. MC to action for the next quarterly report.

The Board confirmed they had met the requirements of General Condition 6 of the Licence and were assured by the report.

MC

177/15 STRATEGY

178/15 Chief Executives Report TA presented the reported and highlighted:

Following the General Election things are settling down in relation to priority areas in the NHS and it is clear that providers will need to focus on the delivery of technical efficiency opportunities.

Transformation Updates – in the North (21st Century Joined Up care) the timetable for agreeing the preferred options has been delayed as a result of the need to engage with relevant stakeholders and increase GP involvement. In the South (Joined




Up Care) the Board is asked to endorse the documents, which was agreed, and to note the progress made.

The strategic shift in service proposals between DCHS NHS FT and Derby Teaching Hospitals NHS FT.

The Big 9. TO expressed concern that 4 of the 9 are still under development three months into the year. CW reported that these would be confirmed for the July meeting.

CB requested that the risk section of the report be completed. TA to action.

TA

179/15 Equality and DiversityAR presented the report and Focus Area plan for 2015/16, which was discussed. CS requested to see outcome measures and AR will ensure these are added for the future.

The Board agreed to approve the progress report and to receive regular updates.

AR

180/15 PERFORMANCE

181/15 Performance ReportCS presented the report and stated that we have met all the Monitor compliance indicators in May.

AR presented the Quality People section of the report and highlighted that there has been significant improvement in resuscitation and safeguarding training however, performance in other areas remains static.

IL provided positive comments on the report format but there were a number of measures with no target and some of those within the exception reports, shown as red, had no timescales or actions linked in and so some deep dive work was required. The Board discussed and it was noted that we need to improve the reporting in some areas of the report and this will be discussed at QBC.

NS challenged the Board on the number of people exceeding the waiting time for respiratory services and WJ responded that this is being looked into. NS also questioned the poor smoking cessation figures and WY explained that there had been issues with the specification and allocated resources however, this was being addressed with the Council and when resources are released from elsewhere, progress will be made.

The Board received the report and the assurance it provided.

182/15 Financial Performance Report CS presented the report and highlighted that income and expenditure was to plan. He added that Monitor have introduced new financial metrics and taking this into consideration, a planned surplus of £0.35m is expected and will be actioned from Month 3.




CS explained that a report regarding the sexual health contract to look at issues driving under performance will be presented to July QBC, and Board will be updated in the same month.

The Board discussed the CIP position and CS reported that QBC will be providing a holistic view of these.

The Board received the report and the assurance it provided.

CS

183/15 Any Other Urgent BusinessThere were no items of any other urgent business.

184/15 Review of the Meeting and OutcomesPS requested feedback on the meeting and received positive comments from the Board members.

185/15 Questions from the public relating to today's board businessThere were no members of the public present at the end of the meeting.

186/15 Date of Next MeetingThursday 30 July 2015 at Belper Town Football Club, Christchurch Meadow, Bridge Street, Belper, DE56 1BA. The Public Session will commence at 9.00am and following completion of business on the public agenda the Board will move to a Private Session



P

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

Date/Item No:

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

Progress: Responsible Person:

Deadline: Outcome:

April 2015104/15

June 2015167/15

Chairman’s Report

TB to investigate whether the pilot at Babington using Co- Wheels cars to transport patients can be rolled out to other services.

Mark Armstrong-Read, Strategy and Planning Manager to meet with Erewash CCG and GEM to discuss the possibility of a 6-month trial at a number of our hospitals to match the Babington trial on supporting discharges. Mark also in discussion with Sue Ryan, General Manager, Learning Disabilities about the possibility of having pool cars at LD Core Units.

CS to pick up with TB to ensure the Board is informed of the conclusion.

July update:The pilot at Babington has been successful and we are currently planning the extension for a 6-month trial at 8 locations: Babington, Clay Cross, Cavendish, Whitworth, St Oswald’s, Ripley, Ilkeston and Newholme. A meeting is planned with Erewash CCG and NSL on 14 July 2015 to look at details of funding

Tim Broadley

Chris Sands/ Tim Broadley

July 2015

July 2015

Complete

Complete

197�Actions�Matrix.docxOverall�Page�18�of�211Page�1�of�5


Date/Item No:



Deadline: Outcome:

May 2015133/15

Carer’s Story TB to discuss the story at the planning meetings in the North to highlight the gaps between services

PS to discuss at the Health and Wellbeing Board.

WJ to discuss with Jayne Needham who manages the 0-19 Children’s Services

It was agreed this would be discussed at the 21st Century Joined Up Care Programme workstreams

Tim Broadley

Prem Singh

William Jones

July 2015

July 2015

July 2015

Complete

Complete

April 2015 110/15

Quality Always TA to raise the question of future proofing Quality Always at the appropriate Commissioner Governance Workstream meeting

Raised at meeting on 8th June. This will be addressed through the Governance workstream of 21C#Joined Up Care – Jo Hunter is project manager and the Medical Director and Chief Nurse are on the Clinical Professional Reference Group to ensure cohesive development

Tracy Allen July 2015 Complete



Date/Item No:



Deadline: Outcome:

May 2015139/15

Quality Service Committee (QSC) Summary Report

PS asked whether it would be better to have a further report on the service directory back to QSC earlier date than the agreed date of November as there had been limited assurance agreed. CW will review and consider.

Service directory has been updated and will continue to be reviewed in light of service changes. A further report will not provide any additional assurance as the action is with Care Quality Commission (CQC) to register new acquisitions, and this can take many months. As services are confirmed by CQC, QSC will be advised

Carolyn White July 2015 Complete

June 2015174/15

Quality Report Skill mix against number of patients to be considered in relation to key patient safety risks.

Skill mix is included within clinical dashboard key performance indicators (KPIs). When this is fully implemented we will be able to report regularly

Carolyn White July 2015 Complete

June 2015176/15

Monitor Self-Certification

Section 5, E of Appendix 1 to be strengthened to include other levels of assurance.

Fit and Proper Persons to be added

Melanie Curd

Melanie Curd

July 2015

July 2015

Complete

Complete

June 2015179/15

Equality and Diversity

Outcome measures to be included in future reports

Amanda Rawlings

July 2015 Complete

June 2015182/15

Financial Performance Report

Report regarding Sexual Health Contract to go to QBC and Board in July

Chris Sands July 2015 To be reported to Private Session via QBC Summary Report



Date/Item No:



Deadline: Outcome:

April 2015116/15

Chief Executives Report

Future Board Development Session to be held on Public Health

Kirsteen Farrar Sept 2015

May 2015133/15

Carer’s Story TB to discuss the story at the planning meetings in the North to highlight the gaps between services

Tim Broadley Sept 2015

*changed from July 2015

June 2015178/15

Chief Executive’s Report

Risk section to be completed

July’s Chief Executive’s Report is a verbal report. This will be completed for the next Board meeting.

Tracy Allen Sept 2015

*changed from July 2015

Mar 201580/15

Quality Report Three month trial for Mediquip out of hours orders to be approved by the member of staff

A phased approach has been undertaken during June to release staff from the requirement to secure on call manager approval for equipment ordered out of hours. A full review will be made available to the September Board

William Jones Sept 2015*changed from July 2015



Date/Item No:



Deadline: Outcome:

May 2015143/15

Quality Report A deep dive into Falls will be presented to the Board meeting in June

Locality Statistical Process Control (SPC) charts for pressure ulcers to include trends and future trajectory

July Update:SPC charts have been extended to include different grades of pressure ulcers. Work is ongoing on locality SPC charts which will take until September to develop.

Carolyn White

Carolyn White

Sept 2015*changed from June 2015

Sept 2015*changed from June 2015

Agenda Item September Board Meeting

May 2015139/15

Quality Service Committee (QSC) Summary Report

Following stopping the use of Information Governance workbooks a Quality Impact Assessment to be completed for to ensure staff who cannot access IT are not disadvantaged.

In progress Chris Sands Sept 2015*changed from July 2015

April 2015 103/15

Matters arising - Carer’s Story

Postponed from January 2015 due to bad weather, to be rearranged for a future meeting

Kirsteen Farrar Oct 2015 Agenda Item - October Board

June 2015174/15

Quality Report CW to discuss including a patient story relating to an avoidable pressure ulcer this within the Quality Directorate

July Update:To be included with the patient story plan and aligned with locality of the Board meeting

Carolyn White Oct 2015



Summary Report from Quality Service Committee

Report To: Board

Date: 30 July 2015

Name of Reporting Committee / Group: Quality Service Committee

Date of Meeting: 21 July 2015

Presenter: Chris Bentley

Author: David Boddy

This paper is for Assurance

Key Issues discussed at meeting:

Board Assurance Framework Reference and Level of Assurance Agreed

213/15 Patient Story - The story from Children’s Community Services demonstrated the skills and support offered to a young person by the School Nurse in partnership with other professionals. 217/15 Board Assurance Framework Update – Executives had agreed that there should be two new risks on the BAF - one regarding the overarching risk about acquisition and one to particularly address Primary Care. The new risks will be in place for Quarter 2. The Committee discussed whether there should be a third new BAF risk regarding overall capacity with regard to the impact of acquisition. It was considered that because this is an overarching risk Audit Committee would be the most appropriate committee to consider it under the Governance Section of the BAF. This will be raised with the Board for discussion and agreement. 218/15 Quality Assurance and Compliance Report Strategic Shift update – a key action has been to review the CQC compliance actions currently in place following the CQC visit to Derby Hospital (DHFT) in December 2014.The action plan is currently indicating a ‘red’ status for the majority of actions pending further clarification. DHFT currently have 3 compliance actions. It had been clarified by CQC that the formal status of outstanding actions with them would not be automatically transferred to DCHS if the service transfers. However, it seems likely that the underlying issues may still need to be resolved. Work is underway in readiness should DCHS acquire these compliance actions following the CQC inspection in 2016. Deep Dive Report on Gaining Consent – SB reported assurance

Paper for Information 4.2.2.Significant Assurance 1.2.1. 1.2.4. 4.2.1 Significant Assurance 1.2.1. 1.2.4. 4.2.1 Limited

200�QSC�Summary�Report�and�PEEOverall�Page�23�of�211Page�1�of�15


on Consent regarding clinical records, staff knowledge and patient feedback that are being measured and evidenced through existing processes. The Committee took assurance from the work to date but this was limited pending completion of the work to close current gaps which will be reported to PEEG on a quarterly basis. 219/15 Quality Dashboard Project - The Quality Dashboard is live with some Key Performance Indicators (KPIs) in place. The KPIs will be refreshed and information from the TPP system will be included from Quarter 2 and 3. The Committee discussed in detail the progress towards having clinical systems in place in community hospitals. RM said that the timelines related to work to properly ensure that the clinical systems are linked up and workable. The Committee noted that staff training was not on the project GANTT chart. To address staff IT training adequately it was agreed that further investment was required. It was agreed that:

• IT training should be added to the GANTT chart • A referral should be made to QPC to request that

Workforce Planning and Development Group ensure a training exercise is planned to catch up with the rollout of IT

The Committee took assurance from the progression of the work plan however this was limited by the requirements for engagement with the workforce, and the scope of the plan itself. The Committee acknowledged that the scope of the project had expanded in the last two years owing to strategic changes such as Primary Care and Strategic Shift. The Committee agreed that this was an informatics issue. A referral was made to QBC to review the impact of the changes on the scope of the project. 221/15 Quality Report - The Committee took limited assurance from the information regarding Pressure Ulcers.

• The trend over the past year has been a large reduction in verified avoidable Pressure Ulcers. There was an 83% reduction in avoidable grade 3 or 4 pressure ulcers from the same period last year.

• The Committee requested a review to check on the progress of actions which have been in place for some time and to be done in conjunction with the NICE report on Pressure Ulcers scheduled in August

• A review to understand what further capacity in the Tissue Viability team might be required. As this is a priority outcome for the Trust, it would be inappropriate if progress was being held back by lack of resources.

The recent focus of resource diverted to Bolsover has been

Assurance 1.2.4. Limited Assurance 1.1.1. 1.3.1. Limited Assurance



challenging for the directorate in its achievement of all its other goals, illustrating the limitations of its capacity. It is important to have the right balance of resources going forward. 360 Assurance Clinical Supervision Follow Up Report A follow-up review has recently been completed and found that all agreed action points have now been implemented. The original report was issued with Significant Assurance in relation to the control frameworks established. 360 Assurance Medicines Management Audit - A referral had been made from Audit Committee regarding the 360 Assurance audit that showed that some transfers from Acute trusts did not consistently provide appropriate documentation to DCHS, and there are gaps in the documentation used by DCHS to confirm medicines are present and reconciled on admission. They also found that several medicine-related transfer incidents had been incorrectly coded on Datix. The Committee were updated regarding actions to address the issue. The Committee took limited assurance from the 360 Assurance audit. The current DCHS process will be reviewed and revised. JH and RM will provide a report to Audit Committee. 222/15 Risk Management Report – There were no breaches in deadlines reported and a number of new and emerging risks will be reviewed at Operations Senior Management Meeting. QSC quarterly risk review meeting will review all risks in detail in early August. 223/15 Falls Strategy - The Committee discussed the difficulties over accurately recording and benchmarking community falls. The Committee asked for some significant modifications to the current version of the Falls Strategy before approval. A revised paper will be presented to the September meeting which will:

• Reflect the strategic changes taking place such as the change from community hospitals to care at home and multi-agency and Integrated teams

• Include more content, including milestones, so that it provides assurance about how goals will be achieved.

224/15 Clinical Safety Group Summary Report – The paper was reviewed for assurance. 225/15 Safeguarding Governance Safeguarding Governance Group Summary Report The report highlighted a number of issues where further work is to be done and reports were therefore taken for limited assurance.

1.1.1. Significant Assurance 1.1.1. Limited Assurance 4.2.2 Significant Assurance This paper was received for a Decision 1.1.1. Significant Assurance 1.1.1 Limited Assurance



The committee discussed the Changes to Child Health Services North Derbyshire and recommended that the group take into account a multi-agency approach. The Committee took limited assurance from the Summary Report owing to the number of papers that provided limited assurance. The assurances reflected the maturing management of the meetings and the raised expectations regarding the information now required by the group. The action includes improving the quality of the papers to the group. Safeguarding Children Annual Report - the Committee commended the comprehensive report. The Safeguarding team, during a time of depleted staff, had worked very hard to successfully deliver Safeguarding training to 1,700 staff across the organisation. The Chair of QSC will send a letter of thanks to the staff. The Committee discussed the capacity of this small team in light of increased workload from acquisitions. A bid for an increase in baseline resource has been made. Further resource will also be added from the services transferred in. The Committee approved the submission of the report to North Derbyshire Clinical Commissioning Group via the Quality Assurance Group. 227/15 Patient Experience and Engagement Group (PEEG) Summary Report - The Committee took assurance from the activity of the group. Volunteer Strategy 2015-2018 - The Committee approved the strategy. Patient Experience Annual Report (2014-2015) - The Committee took assurance from the annual report as a demonstration of how we acquire and respond to good intelligence about patients’ individual experiences. The Committee asked that:

• The paper is presented to the Board for information • It is then presented to the governors

228/15 Patient Experience Quarterly Report – 5,594 Friends and Family Test surveys were returned, with 98.2% of people saying they would recommend our services. The percentage is above the national average. The Bronze/Silver/Gold Dignity in Care Awards have now been amalgamated into a single award called the ‘Derbyshire Dignity Award’. Work is underway to support teams to get their award.

1.1.1 Significant Assurance 1.3.1 Significant Assurance Paper for Decision 1.3.1 Significant Assurance 1.3.1 Significant Assurance



The Committee took assurance from the report. 229/15 Legal Issues Report – The Committee reviewed the report on the effective arrangements in place for managing Claims and Coroner’s inquests and investigations. 230/15 Healthcare for All and Monitor Risk Assessment Framework - The Committee discussed the baseline assessment and agreed that there was insufficient detail to make a decision regarding compliance and assurance. The Committee asked that the Board receive the paper along with the detailed evidence of compliance. 232/15 Clinical Effectiveness Group (CEG) Summary Report: Quality Always - 11 wards are amber rated, with two currently green rated. 360 Tracker Update -

• The Clinical Supervision report was ratified by 360 Assurance who acknowledged that good progress had been made

• Progress has been made against: actions in the Consent Report. 360 Assurance are currently validating the Report

• The PGD report has all actions completed and is awaiting validation by 360 Assurance.

Clinical Audit - Support has been obtained to assess actual costs of participating in national audits and the challenges in terms of resourcing them. Improvements to SystmOne could assist with the audits which need to be undertaken. The Committee discussed the resource requirements to complete the national audits, the nature of the obligation to participate, and the benefits that are taken from the results of the publications. NICE Update - The Committee welcomed the progress that has been made. The Committee asked that the process is discussed with the Clinical Commissioning Groups at the Quality Assurance Group to enquire how they wish to be involved in the process. 237/15 Divisional Monthly Quality Report – the Committee reviewed the report.

1.1.1. 1.2.1. 1.2.3. 1.3.1. Significant Assurance Paper received for Information 1.2.1. 1.2.2. 2.1.1. 2.1.2. Significant Assurance 1.2.1. 2.1.1. 2.1.2. Significant Assurance 1.1 Safety 1.2 Clinical Effectiveness 1.3. Patient Experience Significant Assurance. BAF Reference Key: 1.1.1 Exposure to unsafe care resulting in harm 1.2.1 Failure to provide services that are clinically effective and of high quality 1.2.2 Priority Clinical Audit



Programme not being appropriately focused and effective 1.2.3 Clinical records not meeting national standards 1.2.4 Implementation of changes to our Quality Assurance processes 1.3.1 Failure to learn lessons from patients feedback and experiences 2.1.1 Staff not being appropriately trained to provide high quality care 2.1.2 Staff performance not being monitored and improved 4.2.1 Not meeting regulatory, contractual or legal obligations resulting in sanctions 4.2.2 Not having strong risk management controls in place resulting in failure to put effective mitigation plans in place promptly

Policies Approved 234/15 Mental Health Act Policy 235/15 Policy for the Management of External Agency Visits, Inspections and Accreditations – extension request approved Issues to be escalated to Board or a Committee To Board: 217/15 Board Assurance Framework (BAF) Update – overall leadership and management capacity with regard to the impact of acquisition to be discussed by the Board with respect to it being a new risk under Audit Committee 227/15 Patient Experience Annual Report (2014-2015) to be presented to the Board. To Committees: 219/15 Quality Dashboard Project – to QPC, to request that Workforce Planning and Development Group ensure a training exercise is planned to catch up with the rollout of IT and for QPC to report back to QSC regarding progress. 219/15 Quality Dashboard Project – to QBC, to review the impact of the changes on the scope of the IT project. The Committee acknowledged that the scope of the project had expanded in the last two years owing to strategic changes such as Primary Care and Strategic Shift



1

Patient Experience and Engagement Group (PEEG)

Document Title: Patient Experience Annual Report (2014-2015)

Presenter/Title: Lana-Lee Jackson – Head of Patient and Family Centred Care Contents of Paper were previously discussed by:

Author/Title: Lana-Lee Jackson – Head of Patient and Family Centred Care Contact Email and Telephone Number: [email protected]

Date of Meeting: 21 July 2015 Agenda Item No: 227/15

No of pages inc. this one: 9

Document is for: (more than one box can be ticked) Information Decision Assurance x

Purpose of Paper

The following report is intended to provide an overview of Patient Experience and Engagement activity at Derbyshire Community Health Services NHS Foundation Trust (DCHS) from 1 April 2014- 31 March 2015, including a summary of: Complaints and general feedback Friends and Family Test survey (patients and staff results are provided which describes

how likely people are to recommend our services) Overall patient experiences

The DCHS is committed to acquiring and responding to good intelligence about patients’ individual experiences so that we always put our patients at the heart of every decision we make.

Recommendations

For QSC to take assurance from the annual Patient Experience and Engagement Annual Report


1.3.1

Financial Impact

None



mailto:[email protected]


2



Governors play a key role in quality governance, including patient experience, through their input into PEEG and Council of Governors.


The monitoring questions on the FFT now allow us to understand how the experience of our patients with an identified protected characteristic differs from the experience of other patients. Some patients may find that the FFT is not a suitable way to provide feedback – because of a disability – physical, cognitive or sensory. For them it is important that a range of feedback methods are provided as alternatives.


DCHS welcomes all feedback from patients. Complaints are used to make service improvements and are one way for patients to be involved. The FFT is one way in which we invite every patient to be involved in the work of the Trust.

Risk Register

Is the issue on the current Risk Register? No If yes, what is the Risk Number? n/a




3

Patient Experience Annual Report (1 April 2014- 31 March 2015)

97% of people would recommend our services

15 patient groups

established

25221 contacts and

patient feedback

69 comments

from Healthwatch

118 complaints

investigated & 6 PHSO requests

64 posts on NHS Choices & Patient Opinion

89% of staff would recommend our services



4

Complaints and Concerns Complaints are just one of the many ways we capture the views of our patients and service users to ensure we are detecting shortfalls in service early, acting to put things right and learning to prevent similar events recurring in the future. During 2014-15 we received a total of 118 complaints which were investigated under the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. An additional 177 contacts were resolved (Level 1) within 72 hours. Overall complaints have reduced by 61% compared to the previous year. Outcomes *complaint status is subject to change Outcomes 2013-14 2014-15 Not upheld 54 43 Partially upheld 65 37 Upheld 73 30 Ongoing - 8 Total 192 118

Investigation Timescales Acknowledged within 72 hours 100% Responses sent within 25 working days or under 17% Responses sent 25-40 working days 34% Responses sent over 40 working days 49%

During the year we responded to all complaints within the 72 hour acknowledgement target. 51% of responses to complaints were provided in under 40 working days. We are committed to ensuring complainants receive timely responses and we continue to improve response timescales. KO41a Department of Health annual return: Complaints by subject Complaints by Subject- K041a 2013/14 2014/15 Admissions, discharge and transfer arrangements 4 0 Aids and appliances, equipment, premises (incl. access) 6 8 Appointments, delays/cancellation (out-patient) 23 13 Attitude of staff 20 12 All aspects of clinical treatment 101 67 Communication/information to patients (written & oral) 25 16 Consent to treatment 1 0 Patients’ privacy and dignity 1 0 Patients’ property and expenses 4 0 Personal records (including medical and/or complaints) 3 0 Failure to follow agreed procedure 2 1 Policy and commercial decisions of trusts 2 1 Totals 192 118



5

Learning and putting things right: The following examples demonstrate how we have learned from the shortfalls identified in patient experiences when a complaint has been investigated including actions of service improvement.

Service Complaint Description

Complaint Outcome

Improvement Identified

Minor Injuries Unit

Patient was not seen by a Dr in MIU, only a nurse. Unhappy with care.

Not Upheld Wall signage installed stating that MIU is 'Nurse Led' so patients are aware prior to treatment. Statement added to NHS internet web page advertising MIU that MIU services are 'Nurse Led'

Outpatients Department

Lack of post-operative care. Patient suffered pain and other symptoms. Did not receive guidance or treatment.

Not Upheld Discharge Booklet given to patients reviewed. The team will work with the Ophthalmology nurse to improve Team knowledge/review the leaflet so additional information and advice is provided.

Health Visiting

Patient received 'no access communication' that HV had called at her home. Patient unsure why HV needed to visit due to pregnancy loss.

Upheld Appointments to be cancelled/deleted on SystemOne and paper diaries after pregnancy loss. Antenatal appointments not to be created by letter or electronic appointment until after pregnancy reaches 28 weeks and pregnancy re-confirmed

Community Nursing

District Nurse did not have stitch cutting equipment required and asked patient to attend Practice.

Partially Upheld

All new staff to be provided with a basic stock of dressings, stitch cutter, forceps, sharps box as part of their induction into the team

Minor Injuries Unit

Social Services Referral as 2 nurses documented conflicting accounts of child's fall causing head injury. Not clarified with parent before leaving MIU

Upheld All triage information to be reviewed before assessment. Clarification of discrepancies whilst child was on MIU. Peer review of documentation. Clinical Supervision of Safeguarding cases.

Outpatients Department

Repeated appointment changes/cancellations to appointment with consultant (Cardiac)

Partially Upheld

Patient Access Policy revised advising of the number of times an appointment can be changed by the patient and hospital.



6

“Despite the incident being very stressful and upsetting, the way the complaint was managed from start to finish was very positive. A number of staff took the time to come and meet with us which we greatly appreciated. The complaint was dealt with very sensitively. We are reassured that practices have changed and lessons have been learnt as a result of our complaint and these have been very clearly explained to us. We would like to thank the complaints team and the other staff involved for turning our experience into a much more positive one.”

Wheelchair Service

Wheelchair unsuitable despite service measuring and discussion. Wheelchair dangerous, uncomfortable and causing posture problems with severe pain and deterioration of condition.

Not Upheld Allow patients to consent to unwise decisions if they have capacity. This does not impact upon staff ability as a clinician. To consider using Case conference on difficult cases - integrated approach.

Sexual Health Services

Photograph taken 10 years ago used on a Sexual Health Poster in GP surgeries and schools, without permission.

Partially Upheld

Consent had been given but Trust wide policy for the capture and storage of all images/recording of patients, clients and members of the public reviewed and updated. Consent forms updated.

Community Nursing

Community Nursing request for catheter care. Patient told they could not visit without GP referral. GP did not visit as not an emergency. Out of Hours Community Nurse visited and requested follow-up from Community Nurse

Partially Upheld

Arranged specialist training by the continence nurse at the Community Nursing Divisional meeting to outline the remit of the Community Nursing Team. To discuss the best practise of catheter care upon referral with the continence nurse and other Community Nurse Teams.

Community Nursing

Community Nurses care and support lacking. Clinical needs not met. Did not provide prescribed care and products. Did not follow up information after discharge. Patient not treated with dignity and respect.

Upheld Robust message system introduced including named person to take responsibility for actions. Standards set for passing on information and handover and will be recorded on planner. Link nurse established with Residential Home as point of liaison. Training on bowel management set up for whole team.

Hospital Nursing (Rehab)

Patient fell prior to discharge. Complained of pain. Dr examined; no x-ray deemed necessary. Patient discharged advising of pain. Community Nurse suggested x-ray needed. Patient's pain increased and ambulance called. Patient had two fractures.

Upheld Review of guidance of x-ray following a fall, which now states that the doctor should have a low threshold of requirement to send patients for x-ray. Falls wrist band pilot: Patients given coloured wrist bands following assessment. Green = patient can walk independently; Amber = patient requires supervision. Red = requires physical assistance. Ward team aware so alerted if a patient with a red or amber band is walking without a staff member therefore at risk of falls.

We have provided additional

staff training and support

We have acted on patient’s

suggestions to improve our

processes and systems

Introduced new systems

to improve integrated models of working



7

Parliamentary and Health Service Ombudsman (PHSO) All complainants have the option to contact the PHSO to review their complaint and the way in which it has been handled should they remain unhappy with our investigation findings and response to their concerns. The PHSO will assess complaints to determine if further investigation is required. If the PHSO accept a complaint for investigation, we receive a full report detailing their findings and recommendations. The following table provides a summary of PHSO referrals, investigations and outcomes: Ombudsman

Request Reference Service Report

Received Ombudsman

Outcome Action

2013/14 23-Sep-13 P1904JE Outpatients,

Ilkeston 18-Nov-13 Not upheld No action recommended

4-Mar-14

P2423JE UHL & Rutland Outpatients

21-Jan-15 Upheld Recommended letter of apology to complainant and £2000 Financial Redress

2014/15 11-Aug-14 P2140JE Outpatients,

Ilkeston 16-Jan-15 Not upheld No action recommended

21-Jan-15 P2063JE Imaging, Hinckley

21-Jan-15 Not upheld Ombudsman to pursue with Global Diagnostics

08-Jan-15

P2224JK Hospital Nursing, Heanor

Outstanding

2-Mar-15 P1971JK Community Matron

Outstanding

Friends and Family Test (FFT) Example of the FFT Children and Young People’s card:

200�QSC�Summary�Report�and�PEE

Overall�Page�35�of�211Page�13�of�15


8

24809 Friends and Family Test responses were received during 2014-15. The graph below provides a summary of the % recommended results by service

28 services achieved

100% recommendation 66 services achieved

above 91%

In 2014-15

97% of people said they

would recommend our services

One of the top community trusts

for % recommended

nationally

In 2014-15

89% of staff said they

would recommend our services



9

Patient Involvement We have established and supported 15 patient groups during 2014-15 and are committed to working with more groups in the next year. In addition to this we have worked with NESTA to launch the home from hospital service and have launched the Access to Healthcare Forum. “Attending the Living Well with Dementia Group and talking about my husband’s

diagnosis has made me feel like I am not alone in this”

“It’s great staying here, we get to choose and make our favourite food”

“I could relate to how my diagnosis was described. It was explained in a way I could fully

understand”

In summary It is clear from the feedback we have received during 2014-15 that on the whole patients, relatives and/or carers have a very positive experience when accessing DCHS services. They describe staff as being professional, friendly, kind, caring and compassionate with services being of a high quality. However, regrettably we sometimes fall short of our expectations. When such shortfalls are identified we ensure action is taken to learn from poor patient experiences and that similar events are prevented wherever possible. During 2015-16 DCHS will be committed to continuing to improve patient experiences of service and some of our priorities include: Improving response timescales to complaints Increasing the number of Friends and Family Test returns Working with our partners to ensure online options for feedback are maximised Working with our service users to ensure we learn from their experiences and identify

meaningful actions to achieve real and sustainable change Improving the options available for all service users (including seldom heard groups) to

provide feedback and for their voices to be heard



Summary Report from Audit and Assurance CommitteeReport To: Board

Date: 30 July 2015

Name of Reporting Committee / Group: Audit and Assurance Committee


Presenter: Nigel Smith, Non-Executive Director

Author: David Boddy, Corporate Governance Manager


Key Issues discussed at meeting: Board Assurance Framework Reference and Level of Assurance Agreed

91/15 Board Assurance Framework (BAF): Quality People Committee Presentation - the Committee discussed BAF red risk 2.2.1 (not attracting, recruiting and retaining staff), the number of vacancies and where they were. It was identified that there are hotspots in certain services and teams. However, other vacancies present a more general risk that is better managed through the risk register.

The committee agreed the following actions: BAF reference 2.1.3 (health and safety) – the Committee

asked that QPC review the Key Performance Indicators (KPI’s) in order to give AAC assurance that we are sufficiently assured that the Health and Safety risks of the organisation are being tracked and managed.

QPC to consider a new risk regarding whether we have appropriate workforce planning in place to support the changes anticipated with strategic change

BAF reference 2.3.3 (embedding equalities) – the KPI’s should compare DCHS against the Derbyshire ethnic profile to allow Board to reflect how we compare to the people we serve

92/15 Counter Fraud Annual Report – the Committee reviewed the annual report and highlighted:

The Overtime Payments Review including record keeping was discussed. A number of recommendations are under review with the People and Organisational Effectiveness (POE) division.

The Committee also discussed the Employment Agency Pre-Employment Screening investigation. The Committee requested that they receive an update of the outcome of the

4.1.1. Significant Assurance


201�AAC�Summary�Report�inc�AnnOverall�Page�38�of�211Page�1�of�14


risk assessment from QPC.

93/15 Counter Fraud Progress Report – the Committee received an update on progress against the counter fraud annual plan.

94/15 Procurement Report (Data Mining) – as a proactive exercise, LCFS tested data from April to September 2014 and reported that no fraudulent activity had been identified.

The Committee also considered if there were other potential risks from procurement. Although internal audit had found no significant issues, it was agreed to schedule further proactive work in this area.

96/15 Board Assurance Framework (BAF) Quarterly Review - the Committee considered the risks and discussed the progress being made. The Committee recommended the report to the Board.

It was agreed to recommend to the Board that in October/November the Board will review the BAF in light of strategic risks to inform the 2016/17 planning process.

97/15 Attendance at Board and Subcommittee Meetings - attendance at Board and subcommittee meetings from April 2014 to March 2015 was reviewed.

98/15 Data Quality Update - the Committee were updated regarding the current status of data quality for DCHS, the strategic roadmap for data quality and the enablers that will facilitate ongoing improvements in data quality and completeness across the Trust.

The data quality improvement action plan was reviewed. Internal audit will review the kitemark work towards improving scores.

100/15 Report on Level of Bad Debt in Comparison to Previous Year – the meeting reviewed detailed analysis of the movement in the Trust’s level of Bad Debt Provision over the last financial year and information regarding the key issues behind the level of provision made.

Arrangements were discussed for future provisioning and, taking into consideration the low level of write offs, the Committee agreed to leave the accounting policy as it is.

101/15 Compliance with Governance Arrangements - internal assurance was reviewed that the Trust is complying with its governance requirements and arrangements for Quarter 1.

103/15 Internal Audit Annual Report - the report provided further



4.2.2 Significant Assurance

4.1.1. Significant Assurance.






detail to support the Interim Head of Internal Audit Opinion along with a summary of the delivery of the internal audit service for the 2014/15 financial year.

The Committee reviewed the KPIs for internal audit, and confirmed that the performance was adequate

104/15 Internal Audit Progress Report - reviews in the last quarter reported to Audit Committee:Quality Account Indicator Testing360 Assurance provided:

- Significant Assurance regarding quality of data underpinning the indicators ‘Delayed Transfers of Care’ and ‘A/E 4 hour waits’

- Limited Assurance over the quality of data relating to the 18 week wait data for dental services for 2014/15

Medicines Management Limited Assurance was given owing to a limited set of documents received when patients are transferred in from other services. The Committee asked QSC to undertake a deep dive review

105/15 Consent, Capacity and Mental Capacity Act Audit Update – actions are underway to improve staff training, particularly for patient facing staff who do not receive Safeguarding training.The Committee took assurance from the work underway but this was limited because the training has yet to be completed. Action - the Committee asked for clear timeframes for completion of the work. The issue will be raised with Board and also discussed by the Executives to ensure prioritisation of the work.

107/15 Annual Audit Letter - the letter summarised the key issues arising from the 2014/15 audit by KPMG. KPMG issued:

- An unqualified opinion on the Trust’s seven month NHS Trust financial statements

- An unqualified opinion on the Trust’s five month Foundation Trust financial statements

The Committee reviewed the KPIs for external audit, and confirmed that performance was adequate

108/15 Audit Progress Report - the Committee received an update on the work of KPMG against the annual plan.

110/15 Self-Certification Report Q1 - the Committee considered the self-certification, discussed the issues and recommended that the Board approve the Quarter 1 return.



2.1.1, 4.2.1 Limited Assurance






112/15 Audit Committee Annual Review - the Committee approved the Annual Review to demonstrate that the Committee had fulfilled its Terms of Reference and significantly contributed to improving internal control within the Trust. The Annual Report is attached to this Summary Report for presentation to the Board.

113/15 Review of Committee Training Requirements - the Committee agreed that the training had been good and no further specific training was required.



Key to BAF References:2.1.1 risk due to Staff not being appropriately trained to provide high quality care

3.2.3 risk due to inability to meet financial targets, specifically cost improvement plans

3.2.6 - risk due to poor decisions being made due to poor data quality resulting in poor outcomes and financial loss

4.1.1 risk due to not having strong corporate governance systems in place

4.2.1 risk due to not meeting regulatory, contractual or legal obligations

4.2.2 - risk due to not having strong risk management controls in place

Policies Approved95/15 Counter Fraud, Corruption and Bribery Policy

Issues to be escalated to Board or a CommitteeNone.



AUDIT & ASSURANCE COMMITTEEDocument Title: Audit and Assurance Committee Annual Report 2014/15

Presenter/Title: Nigel Smith, Non-Executive Director; Chairman, Audit and Assurance Committee

Contents of Paper were previously discussed by:

Author/Title: Chris Sands, Director of Finance, Performance and InformationDavid Boddy, Corporate Governance Manager

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



Document is for:(more than one box can be ticked) Information Decision X Assurance X

Purpose of Paper

This is the Annual Report of the Audit and Assurance Committee covering the work of the Committee for the financial year 2014/15.

The report demonstrates that the Committee has fulfilled its Terms of Reference and has significantly contributed to improving internal control within the Trust.

Recommendations

The Committee is asked to approve the Annual Report. Once approved, the Annual Report will be presented to the Board.


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

Financial Impact

None.


AUDIT AND ASSURANCE COMMITTEE ANNUAL REPORT FOR THE AUDIT YEAR 2014/15

1. SCOPE

This is the Annual Report of the Audit and Assurance Committee. This report covers the work of the Committee for the period July 2014 to June 2015. The report was not completed until June 2015 to allow the financial year to be completed.

2. INTRODUCTION

The Board remains committed to the continued development of good governance principles that



reflect the changing needs of the NHS, recognise the developments in broader corporate governance and ensure that the organisation remains relevant and responsive in this changing environment.

3. ROLE OF THE AUDIT AND ASSURANCE COMMITTEE

As the senior Board committee, the role of the Committee is central to the governance of the Trust. The role has continued to develop to incorporate a wider responsibility for scrutinising the risks and controls which affect all aspects of the organisation’s business whilst continuing to retain a critical financial focus.

The Committee met on a quarterly basis and reported directly to the Board. The membership of the Committee is confined to Non-Executive Directors, not including the Chairman of the Foundation Trust, and consists of three Non-Executive Directors appointed by the Board, including the Chair of the Committee. A quorum is not less than two Non-Executive Directors.

Membership (Period July 2014 to June 2015):

Name Title Membership Period

Nigel Smith Non-Executive Director - Chair July 2014 to June 2015

Barbara-Anne Walker Non-Executive Director July 2014 to June 2015

Barry Steans Non-Executive Director July 2014 to December 2014

Tony Okotie Non-Executive Director January 2015

Ian Lichfield Non-Executive Director April 2015 to June 2015

Attendance at Audit Committee meetings



All meetings were quorate.

The attendees, including members and regular attendees at the meetings are listed below.

Audit and Assurance Committee Attendance Record:

Key: = Attended

X = Did Not Attend

Jul-14

Oct-14

Jan-15

Apr-15

May-15

Nigel Smith Chair, Non-Executive Director

Barbara-Anne Walker

Non-Executive Director

Barry Steans Non-Executive Director

Tony Okotie Non-Executive Director

Ian Lichfield Non-Executive Director

Regular Audit Committee Attendees:

John CornettDirector, KPMG

Simon Gascgoine or deputy

Associate Director, 360 Assurance X

Penny Gee Local Counter Fraud Specialist, 360 Assurance X X X

Kirsteen Farrar Trust Secretary X

Chris Sands Director of Finance, Performance and Information

Rick Meredith Medical Director

X X XCarolyn White Chief Nurse/Director of Quality

X

Cath Benfield Head of Finance X X

Alisdair Colston External Audit Assistant Manager, KPMG X X X

In general, Executive Directors were invited to attend when the Committee discussed areas or risk relating to the Director’s responsibilities and at the Committee’s discretion.

4. REVIEW OF BUSINESS 2014/15



4.1 Internal Control and Risk Management

4.1.1 Review of Audit Committee Handbook Action PlanIn January 2015 the Committee reviewed the Trust’s position against the NHS Audit Committee Handbook Self-Assessment Checklist.

The Committee took assurance from the report.

4.1.2 Board Assurance Framework The Committee reviewed the Board Assurance Framework (BAF) quarterly and was satisfied that it was fit for purpose, that risks are appropriately identified and that it allowed the Board to understand the appropriate management of those risks. Areas of limited or negative assurance were presented in the report and were reviewed in detail by the Committee.

The Committee made progress in developing and improving its assurance framework during 2014/15.

The Assurance Framework was the key assurance document for the Committee. This document underpins self-certifications made by the Trust to external bodies.

During the year the Committee also received presentations from lead Directors regarding the strategic risks for Quality People, Quality Business and Quality Governance 4.1.3 Corporate Governance ManualIn January 2015 the Committee reviewed and recommended to the February Board that the updated Corporate Governance Manual be implemented.

4.1.4 Statutory SubmissionsThe Committee received a number of reports regarding governance arrangements and statutory submissions, particularly in preparation for Foundation Trust status in November 2014. The reports included:

Statutory Submissions Learning the Lessons Audit Code for NHS Foundation Trusts Preparation for Foundation Trust Status Part Year NHS Trust Accounts Planning for Year End Statutory Submissions Draft Response to Consultation on Risk Assessment Framework Fit and Proper Persons Requirement Governance over audit, assurance and accountability: Guidance for FTs

4.1.5 Self-certificate DeclarationsThe Committee has a role to review the assurances supporting the self-certification to Monitor, and to provide assurance to the Board as to the accuracy of any declarations made. The Committee reviewed and recommended to the Board reports on quarterly self-certificate declarations.

The Committee reviewed declarations to the Trust Development Authority during the part year as a NHS Trust. From 1 November 2014, as a Foundation trust, the Committee reviewed submissions to Monitor



The Committee was informed that in future this report will be merged with the Finance Self-Certification report, owing to the overlap of a number of matters reported.

4.1.6 Governance ArrangementsThe Committee took assurance from quarterly reports that the Trust is complying with its governance requirements/arrangements and any instances where this is not the case. The quarterly review included: Coroners Inquests, Claims, Central Alert System, Losses and Compensations, Declarations of Receipt of Gifts, Hospitality and Donations, Declarations of Interest, Use of Powers, Legal Documents and Sponsorship.

The Committee was updated regarding the work to review our Whistleblowing arrangements and policies which enable staff and patients to raise concerns.

4.1.7 Data QualityThe Committee reviewed and challenged progress during the year regarding data quality developments. These included the roll out of TPP SystmOne, Data Quality Kite Mark and work planned regarding harmonising the suite of Key Performance Indicators. 360 Assurance were invited to review the development of a new control system to collect Key Performance Information.

4.1.8 NHS Counter Fraud Service The Trust is required to monitor and ensure compliance with the Directions of the Secretary of State regarding its arrangements for counter fraud and corruption work. A key role for the Committee is to provide assurance to the Board that these arrangements are robust. During the year, the Committee:

Approved the Annual Counter Fraud Plan for 2015/16 (95 days) Monitored progress against the plan quarterly Took positive assurance from the Annual Report on Counter Fraud 2014/15

4.2 Clinical AuditThe Committee monitored the work of the revised team managing the Clinical Audit Programme. The Committee reviewed the Clinical Audit Programme for 2015/16. The Clinical Audit Programme sits alongside the Internal Audit Programme to give assurance.

The Committee discussed: The focus of the programme around patient care priorities, CQUIN and Quality Schedule

items and National Audits appropriate for a Community Trust. The audit work in partnership with clinicians with focus on their preferred outcomes for

patients. A move away from an administrative process towards a more meaningful cycle of

improvement.

The detail of the Clinical Audit Programme was reported through to the Quality Service Committee.

4.3 Internal AuditThe Committee approved the Internal Audit Plan for 2015/16 to cover mandatory areas as required by NHS Internal Audit Standards, and to meet the statutory responsibility to provide a Head of Internal Audit Statement. The plan provided for 300 audit days.



4.3.1 Internal Audit Plan 2014/15:The Committee approved the Internal Audit Plan for 2014/15 to cover mandatory areas as required by NHS Internal Audit Standards, and to meet the statutory responsibility to provide a Head of Internal Audit Statement. The plan provided for 350 audit days.

The following audits were completed during the period: Risk Management Compliance – Significant Assurance Falls: Data Quality and Strategy – Limited Assurance Data Quality Kitemark – Significant Assurance Consent, Capacity and the MCA – Limited Assurance Clinical Supervision – Significant Assurance Working Capital Management – Significant Assurance Equality and Diversity - Significant Assurance Mobile Working Benefits Realisation – Limited Assurance Complaints – Significant Assurance Healthcare Records - Significant Assurance Expenses – Significant Assurance Patient Experience - Significant Assurance Disciplinary Grievances and Dignity at Work Case Review – Limited Assurance Key Financial Systems – Significant Assurance Procurement - Significant Assurance. e-rostering – Significant Assurance Pay Expenditure – Significant Assurance Review IG Toolkit Self-Assessment – Significant Assurance Clinical Audit – Limited Assurance

Where weaknesses in control were identified the Trust agreed action plans to address the identified shortfalls and these were followed up by Internal Audit with progress reported to the Committee.

In the areas where limited assurance was provided, the Committee received further assurance from management that actions had been implemented.

4.3.2 Head of Internal Audit OpinionThe following opinion was provided by the Head of Internal Audit for the period 1st April 2014 to 31st March 2015:

“Significant assurance can be provided that there is a generally sound system of internal control, designed to meet the Trust’s objectives, and that controls are generally being applied consistently”.

The Head of Internal Audit opinion is additional external assurance which supports the Accountable Officer in signing off the Annual Governance Statement (AGS) on behalf of the Board.

4.4 External AuditThe Trust’s external auditor for 2014/15 was the KPMG.

4.4.1 External Audit Plan



The Audit Plan set out the work to be undertaken in relation to the 2014/15 accounts and was developed on the basis of a risk-based approach to audit planning. The Committee reviewed the progress of work against the plan through the course of the year.

The external auditors presented their Auditors Report on Annual Accounts to the Committee prior to the Committee’s review of the Annual Accounts in May 2015.

The auditors provided clean opinions for the period April 2014 to October 2014 and for November 2014 to March 2015 (when the Trust was authorised as a Foundation Trust) that:

The Trust has adequate arrangements to secure economy, efficiency and effectiveness in its use of resources.

The audit of the Trust financial statements in accordance with the requirements of the Code found no issues that would cause KPMG to delay the issue of their certificate of completion of the audit.

DS discussed with the Committee three areas of significant risk this year (valuation of tangible assets, income recognition and associated fraud risk, management override of controls) that KPMG reviewed. KPMG did not find any issues relating to these risks.

4.5 Reporting

4.5.1 Quality AccountThe external auditors reviewed the Quality Report and subject to minor amendments provided a clean opinion.

4.5.2 Financial AccountsThe Committee reviewed the Trust plans for preparation of the Trust’s fully audited Accounts. Due to the Trust’s authorisation with effect from 1st November 2014, the first set of accounts covered the final period as an NHS Trust, 1st April 2014 to 31st October 2014 and the second set covered the first period in operation as an NHS Foundation Trust, 1st November 2014 to 31st March 2015.

The Committee then reviewed the 2014/15 Financial Accounts and recommended to the Board that both sets of the 2014/15 accounts were adopted.

4.5.3 Annual ReportThe Committee reviewed the Annual Report prior to submission to the Board, and made a recommendation to Board to adopt the annual report.

4.5.4 Going ConcernThe Committee, following review of the financial projections for 2015/16, satisfied itself that the Trust’s Annual Accounts for 2014/15 should be prepared on a “Going Concern” basis.

The Committee considered whether it is necessary for the Trust to continue to hold a working capital facility given the level of cash headroom reported. The Committee agreed that owing to the small level of risk, that negotiations took place for the working capital facility to be removed.

4.5.5 Annual Governance Statement (AGS)In April 2015 the Committee reviewed and approved the draft Annual Governance Statements for 2014/15.



As DCHS was authorised as a Foundation Trust from 1 November 2014, the Trust submitted an AGS to the Trust Development Authority for the first 7 months of the financial year, and an AGS to Monitor for the remaining 5 months of the year.

During the year, there were 2 significant control issues:

A high risk was identified in an internal audit review of Consent, Capacity and the Mental Health Act. This related to the knowledge and understanding of staff about when and how to document the lawful authority utilised to provide care and treatment. The Trust has taken action to develop the controls in this area, but there is still a need to roll out revised processes and gain sufficient evidence of the impact of these controls on outcomes to reduce the severity of the risk. The outcomes from the training will be monitored through the Quality People Committee, and the Audit and Assurance Committee.

The Trust has not included its dental general anaesthetic pathways in its Referral to Treatment indicator, nor has it routinely reported on them throughout the year. The assurance framework surrounding the collection and validation of this information is not as robust as for the medical pathways. The Trust will work with its internal auditors to develop the data collection and validation processes. The work will be monitored through the Audit and Assurance Committee.

4.6 Other Matters

4.6.1 Individual ReportsThe Committee reviewed a number of issues that were presented during the year. These included:

Core Essential Learning Business and Attendance of the Board and its Subcommittees CQC License Safeguarding Group

4.6.2 Terms of ReferenceThe revised Terms of Reference were approved at the May 2015 Board meeting.

4.6.3 Recommendation TrackingThe Committee have a system of recommendation tracking to monitor the implementation of actions identified in audit reports. This is included in the internal audit progress report.

4.6.4 Annual Report of the CommitteeThis Annual Report summarises the work of the Committee for financial year 2014/15. This report will be presented to the Board.

4.6.5 Training for Committee MembersThe Committee reviewed training for committee members as set out as best practice in the Audit Committee Handbook.

The members agreed that the training they had received was sufficient.

4.6.6 Referrals to other CommitteesThere were a number of referrals made to other Quality Committees and Council of Governors regarding:

Board Assurance Framework risk reviews (QSC and QBC)



Board Assurance Framework assurance review (QSC) Recruitment agency issue (QPC) Monitor the delivery of DoLS training (QPC) Preparation for Foundation Trust Status (Council of Governors)

The Committee also received one referral from QSC regarding: Tracking and receiving assurance regarding progress of actions from 360 Assurance

reports

5. COSTS OF THE COMMITTEE

There are costs incurred for running the Committee. These are the costs of attendance, costs of producing and circulating the papers, costs of audit attending, and cost of ensuring Committee members are up to date with the latest developments in governance. The Committee has its functions set out in its Terms of Reference.

The membership of the Committee is confined to Non-Executive Directors, but attendance of management to support the Committee is reviewed regularly to ensure best use of management time. The Committee also reviews how regularly it meets to ensure meetings are effective. The Committee currently meets on a quarterly basis with extraordinary meetings when required.

Through the Annual Report, it can be demonstrated the added value that the Committee brings to the governance of the organisation. It is the Committee’s view that this added value is delivered in an efficient manner

6. CONCLUSION

In summary, the Trust has continued to strengthen internal control within the organisation.

The Committee has an important wide ranging set of responsibilities. To fulfil these responsibilities, the Committee is constantly reviewing how it undertakes its work, and its forward agenda. It has worked closely with the Quality Service, Quality Business and Quality People Committees to ensure a smooth transition of responsibilities, and to ensure that all Committees fulfil their roles effectively and efficiently.

This report demonstrates that the Committee has fulfilled its Terms of Reference and significantly contributed to improving internal control and assurance processes within the Trust.





The Committee considers if any matters should be referred to the Council of Governors for their consideration.


Equality and Diversity issues are considered by the Quality Service Committee and the Quality People Committee and are considered during the review of strategic risks in the board Assurance framework and also presentations by lead Directors.


There were no Patient, Public, Staff, Member and Stakeholder involvement implications.

Risk Register


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



Summary Report from Council of Governors

Report To: Board

Date: 30 July 2015

Name of Reporting Committee / Group: Council of Governors


Presenter: Prem Singh

Author: David Boddy


Key Issues discussed at meeting Board Assurance Framework Reference and Level of Assurance Agreed

53/15 Carer’s Story - the Council discussed the story of Katy, a young person who was growing up while providing care for her family.

The Council were updated regarding the work going on to identify and meet the needs of this vulnerable group of young people.It was agreed that the story would be taken to the 21st Century overarching Board for discussion with Derbyshire County Council.

55/15 Quality and Performance ReportQuality – Highlights included:• Performance against the NHS Safety Thermometer • An update regarding the management of issues at Bolsover Hospital. • The reinstatement of Insight VisitsThe governors discussed the performance against 6 week and 18 week Referral to Treatment (RTT) measurements.

Regulatory Performance – DCHS has met all its regulatory reporting targets and a green RAG rating was expected from Monitor.

Finance - although early in the financial year, DCHS are on plan and the Trust is forecasting that it will achieve all its statutory financial duties. A lot of work is underway to deliver our new services and achieve our financial goals.

The Council were updated about the national focus on the financial position of health providers. The focus on cost improvements has included bank, agency and consultancy spending. DCHS’s own position regarding this area is that Agency and Flexible Workforce

The story was received for information.

The report was received for information.

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costs have continued to reduce with a reduction in spending in May of £0.03m compared to April.

The Council discussed the Strategic Shift programme and Ilkeston in particular, A concern was raised about the transfer of management of operating theatres to Derby Royal Hospital (DRH). The case for change made by the commissioners is that DHFT will be able to make more efficient use of the theatre capacity, thus helping with the 18 week RTT.

56/15 Clinical Effectiveness Group Annual Review - the annual review demonstrated the progress that has been made in building up clinical services to deliver effective care.

The report had been written with the intention of making the information accessible to all staff and a wider audience. The governors provided feedback on the content and style for future improvements.

The Council were updated regarding the Quality Always work and how it has developed significantly in the past year. There have been big improvements in RAG ratings for teams involved in the process. Linacre Ward has become the first ward to receive a green RAG rating. The Council were told about the plans to roll out the programme into community and mental health settings.

57/15 Quality Service Committee (QSC) – the Council received a presentation about the work of QSC.

The tone of the QSC meetings was described as ‘high challenge, high support’. The meetings have full and challenging agendas with open and inclusive discussions that get into levels of detail about service quality and delivery which would not be possible at the Board.

The Council were informed of the structure of the meetings and key governance work such as:

Risk management Driving consistent standards – Quality Always Maintaining quality during acquisition and integration Pressure ulcers and falls in the community IT issues and clinical documentation Equity standards including Healthcare for All

The Council discussed the impact of staff levels on the delivery of quality service. The links and measurements that bring service and staff together were discussed.

The Council were also informed about how QSC have focused on the issues and risks relating to the acquisition of services. This includes the capacity of corporate functions to manage increased business levels and services along with the added complexity of some of the new





services.

DCHS were commended for their work with North Derbyshire Clinical Commissioning Group (CCG). DCHS manage issues openly and work closely with the CCG’s to resolve them. To support the open relationship, North Derbyshire CCG have a representative who now attends every QSC meeting.

59/15 Chief Executive’s Report – the report discussed key national and local strategic issues affecting DCHS.

The excellent work in reducing agency spending was again highlighted.

The Council were updated about: The work under the 21st Century Joined Up Care Programme

relating to providing community bedded care and emergency care.

The positive feedback from the Clinical Senate regarding how the 21st Century programme is joining up the services

The strategic ambitions and vision around the Southern Derbyshire Joined Up Care Programme (previously called STAR) that are being considered for adoption by health and social care partners within the programme during June and July.

The proposal to transact a strategic shift in service portfolios between DCHS NHSFT and Derby Teaching Hospitals NHS FT

The Council discussed the reasons why patients are not always referred by GP’s to DCHS.

The Council also agreed that the Governance Group would be the best forum to discuss changes to the makeup of the Council such as to reflect the changes brought about by the Strategic Shift. This is in keeping with DCHS’s strategic plans to deliver comprehensive community services across Derbyshire.

61/15 Nominations and Remuneration Committee Summary Report - the Group had discussed the appraisals of the Chair and Non-Executive Directors.

The Council approved the recommendations of the Committee that the tenure should be extended for Non-Executive Directors Chris Bentley, Barbara-Anne Walker and Nigel Smith.

In the autumn a decision will be made on the recruitment process and timeline for a replacement Non-Executive Director for Tony Okotie.

The Council discussed the recruitment process for a replacement governor and how we might better recruit from a diverse background. It was also important to seek a diversity of skills.

The paper was received for information.

The Council approved the proposals.



62/15 Trust Secretary’s Report – the Council were updated regarding:

Arrangements for the first meetings of the governor groups Lead Governor and Deputy Lead Governor elections Declaration of Interests Update on Nominations Committee

63/15 Amendment to Constitution – the Governance Group had discussed options following the resignation of Healthwatch. The group discussed having an additional commissioning representative and acknowledged that a representative from the south of the county would be valued because the planning landscapes in the north and the south of the county are different.

The Council approved: The group’s recommendation to offer the vacant seat to the

commissioners in the south of the county A further proposal from the group that Appointed Governors

only, be allowed to send a named deputy in their place.

The paper was received for information.

The Council approved the amendments to the Constitution.

Policies ApprovedNone.Issues to be escalated to Board or a CommitteeNone.



TRUST BOARDDocument Title: Quality Report

Presenter/Title: Jo Hunter, Deputy Chief NurseContents of Paper were previously discussed by: Quality Service Committee (QSC)

Author/Title:Jo Hunter, Deputy Chief NurseMichelle O’Connor, Senior Matron Clinical Quality & Professional StandardsContributions from Subject Specialists form the body of the report

Contact Email and Telephone Number:

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



Document is for:(more than one box can be ticked) Information Decision Assurance

Purpose of Paper

The paper is presented to Board to provide an assurance report against a range of quality indicators and work streams in place across DCHS. The format of the report has been reviewed and future reporting will be under the five domains developed by the Care Quality Commission (CQC) as part of its new health inspections regime. (These sections continue to represent the Trusts focus on quality i.e. patient safety, clinical effectiveness and patient experience):

1. Safe Care2. Effective Care3. Responsive4. Well led 5. Caring6. Staffing for Quality

Recommendations

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


1.1.1 - there is a risk to patients due to exposure to unsafe care resulting in harm (Risk Reg ID - 2357)1.3.1 - There is a risk to patients due to the failure to learn lessons from patients feedback and experiences resulting in negative effect on patient care (Risk Reg ID - 2361)

Financial Impact

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

203�Quality�Report.docxOverall�Page�56�of�211Page�1�of�39



Key Messages Comparison of data (avoidable grade 3 and 4 pressure ulcers) in April 2015 against the same

data set from April 2014 confirms an 83% reduction in these grades of avoidable pressure ulcers

Analysis of all grades of pressure ulcers demonstrates a 62.5% reduction in incidence of avoidable pressure ulcers during quarter 1 2015

There has been a decrease of 10.8% in the number of pressure ulcer incidents reported (DATIX) in June; the data continues to demonstrate early recognition of pressure damage at superficial grades

There are no C difficile infections to report for June 2015

1.0 Harm Free Care

1.1 Safety Thermometer (ST) - Prevalence data

The internally set DCHS Harm Free Care target for 2015/16 is 94%. The June 2015 Harm Free Care (HFC) Score across all Services was 93.09% an improvement from 91.93% in May. The combined 2015/16 Harm Free Care (HFC) Score across all Services (Year to Date) – 92.64%

Pressure UlcersThe prevalence for June is 5.96% (May 7.53%). ‘New PU’ prevalence for June is 1.25% (May 1.26%).

FallsThe Falls with Harm rate for June has increased to 0.54% from May’s performance of 0.42%

CAUTI’sThe CAUTI rate for June has increased to 0.42% from 0.18% in May

VTEThe New VTE rate for June has decreased to 0% from 0.06% in May

New Harm RateThe proportion of patients with ‘No New Harms’ for June is 98.03% which is a decrease from 98.19% in May.Action to be taken – work is underway to drill down into the ST data at a ward and team level across the Community Hospitals and Community nursing teams to understand the variations in reporting and data quality and to put additional support and local targets into those areas with the poorest harm free care scores.

1.2Harm Free Care – Graph 1 incident data (from Datix)It should be noted that there is no benchmarking data available from April 2015 at present.



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DCHS All Injurious InpatientFalls

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Rate of Injurious Falls per 1,000 Occupied Bed DaysApril 2013 to June 2015

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1.2.1 FallsFalls continue to be a serious cause for concern and as can be seen from the graphs below when comparing 3 monthly rolling averages the incidence of falls overall seems to be increasing where the incidence of falls resulting in harm is static at approximately 40 per month.

Table 1 Total number of falls 3 monthly Cumulative Average 2015/16

Jan 15 –Mch 16 Jan Feb Mch Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarTotal number of falls

105 79 90 101 105 96

CUMALATIVE 3 MONTHLY AVERAGE

91 90 97 101

Graph 2 illustrates the total number of falls per month compared with 3 month rolling average

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100120

Total number of falls3 month rolling average



Table 2 presents the data relating to falls resulting in harm to the patient

Jan 15 –Mch 16 Jan Feb Mch Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarMinor harm/injury

46 26 38 43 33 37Significant harm/injury

2 3 2 1 3 2Major harm/injury including permanent disability

0 0 0 0 0 0CUMALATIVE 3 MONTHLY AVERAGE of all falls resulting in harm

Graph 3 illustrates the numbers of falls resulting in harm by category and the three month rolling average.

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Action to be taken July QSC received the draft Falls Strategy 2015 -2018 which was discussed at length and a revised version will be presented to September QSC and then Board for final approval. September Board reporting will include a ‘deep dive’ into falls). The revision will ensure that the Strategy supports the move to a reduction in inpatient beds, increasing care in the community and the integration agenda.

There are a number of initiatives currently in place, working towards the delivery of the strategy A new post has been created to lead on falls prevention within DCHS. There are significant

variations in service provision across Derbyshire. One key role of the Falls Prevention Lead is to identify and address inequalities, as well as providing a coherent and consistent framework for falls and fracture prevention work.

Clinical records audit to support the monitoring and measurement of the use of risk assessment tools

A falls Root Cause Analysis will be carried out for multiple fallers, and patients sustaining any



injury following a fall to identify causes and contributing factors in order to learn, and work towards preventing future falls

Safe care Champions will be introduced within the trust aiming to provide a local resource within clinical areas for maintaining quality, improvement and innovation. They will also support developments and changes in practice which is evidence based

A robust Falls Performance Framework is being developed to cover the strategic objectives, reducing the number of falls and in particular injurious falls, achieving improvements in quality of services and cost savings



1.1.2 Pressure Ulcers The range of SPC charts for monitoring pressure ulcers has been increased and are provided for board members information as previously requested. It is not intended to present these monthly to board but to include them in the detailed quality report to QSC.

GRAPHICAL DATA

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TOTAL ACTIVITY TOTAL PUs Mean No. of PUs UCL LCL Warning UCL Warning LCL

Graph 4 - Total number of Pressure Ulcers reported vs Activity for: DCHS



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Graph 5 - Pressure Ulcers Developed and Deteriorated under DCHS care

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TOTAL ACTIVITY No. of Avoidable Pressure Ulcers Mean No. of Avoidable PUs UCL LCL Warning UCL Warning LCL

Graph 6 - Verified Avoidable Pressure Ulcers by Incident Date for DCHSPlease



Please note that graph 6 reflects data that was verified up to April, there continue to be ongoing RCA investigations to verify avoidable/ unavoidable status within time standards.

Please note there is one incident identified which was originally reported and investigated in 2014, due to an administration error this was not verified until 2015/16. The Tissue Viability Matron has reviewed the internal processes to ensure that there is no repetition.

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Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

May-14

Jun-14Jul-1

4

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-150

2

4

6

TOTAL ACTIVITY No. of D&D Pressure Ulcers Mean No. of D&D PUs UCL LCL Warning UCLWarning LCL

Graph 10 - Pressure Ulcers Developed and Deteriorated Grade 4

One of the grade 4 ulcers was identified 5/3/15 where a patient had a grade 3 which progressed to a grade 4 following a fall and being on the floor for a number of hours whilst awaiting ambulance service.



Current PositionThere has been a decrease of 10.8% in the number of incidents reported in June; the data continues to demonstrate early recognition of pressure damage at superficial grades.

Drilling down into the locality level data, North East & Bolsover was showing variation above the SPC upper warning limits in May, but this has significantly reduced by 30% during June, of which 88.4% of the incidents were grade 1 and 2. Amber Valley were also above the SPC upper warning limit in May but shows a reduction of 10.8%.in pressure ulcer incidents in June, of which 88% were grade 1 and 2 pressure ulcers. High Peak also demonstrates a 6% reduction in pressure ulcer incidents but remains above the SPC upper control limits, however 94% of these incidents were grade 1 and 2. Further analysis of the subsets by grades of pressure can be seen in graphs 9,10,11,12.

There has been a sustained reduction in avoidable pressure ulcers, confirming that clinical teams are demonstrating a more consistent approach to delivering preventative care standards. Analysis of all grades of pressure ulcers demonstrates a 62.5% reduction in incidence of avoidable pressure ulcers during quarter 1 2015. Comparison of the data for avoidable grade 3 and 4 pressure ulcers in April 2015 against data from April 2014 confirms an 83% reduction from our position last year. Zero tolerance to avoidable pressure ulcers remains a priority and there needs to be sustained focus on reduction in all pressure ulcer development and deterioration.

The most common reoccurring themes identified through the RCAs relates to patient long term and complex conditions as well as poor documentation, evidence of skin checks and recognising changing conditions and updating documentation to reflect this.

Focused Actions Being Taken An awareness campaign on the effects of hot weather on skin integrity launched during June

2015, this will encourage staff to proactively identify patients on their case load who are at risk of adverse effects from hot weather. Conditions such as dehydration, heatstroke, falls, infection, pressure ulcers or skin fungal infections, moisture lesions can occur as a result of prolonged warm weather periods. Staff will provide patients and carers with simple advice on what to do during warm spells to protect themselves so that adverse effects can be minimised. The campaign which will continue during predicted and unexpected warm weather spells.

The East Midlands Tissue Viability Teams will be holding a webinar “Stop the Pressure Ulcer Conference” on the 17th November 2015 which aims to deliver the same key messages on prevention and will provide practical SSKIN Care workshops to unregistered carers throughout the Region so that increased awareness will help reduce the overall number of pressure ulcer incidents. Representatives from primary and secondary care including Derbyshire, Derby, Leicestershire, Leister, Nottingham, Nottinghamshire, Northampton, Kettering, Lincoln and Lincolnshire. This will be open to all un-registered carers including social services as well as private carers and or individuals who care for family members at home.

A communication campaign led by the CCGs is currently being finalised and due to be launched in August. The campaign is aimed at patients and their family /friend carers to raise awareness on their role in prevention and seeking help in a timely manner.



A meeting has been held with the Patient Safety Collaborative to discuss DCHS current challenges in reducing the incidence of pressure ulcers and the following work streams are being progressed

o Resource support to the Leading Across Organisational Boundaries projecto Working with industry to de-medicalise the look of pressure ulcer equipment in a patient’s

home. o Sharing from other organisations nationally who have reduced the grade 2 incidenceo National and local work on understanding patient non-concordance as well as how to

identify those at risk who are not active on an NHS provider case load, seen regularly by a GP or at an outpatients

Pressure Ulcer Prevention Tool agreed with Audit Team regarding monitoring of compliance to the implementation of the SSKIN Bundle in more detail. Discussions are ongoing between the Quality Directorate Audit Team and Operational Leads regarding the identification of resources to undertake the audit.

Pressure Ulcer training is included in the Clinical Essential Programme- This involves group work working through a patient scenario which includes, risk assessment, care planning and pressure ulcer grading. Additional training is being given to areas who have repeated avoidable incidents

Areas of Concern/ Priority A review of documentation and care standards as well as frequency of reassessments is

currently being undertaken by TV Team to reduce duplication and ensure that documentation is essential, meaningful and most importantly patient focused. This will include rationalisation as to the frequency of reviewing care plans so that updates are timely and easily made through the skin bund documentation so that records are meaningful and patient focused.

Pressure Ulcer Policy is currently under review and being amended to include more recent changes to standards from NICE 2015 as well as pending changes to the reporting of pressure ulcers as “Serious Incidents”. This has not yet been finalised and the East Midlands Tissue Viability group have been tasked with developing and agreeing a robust criteria of reporting based on significant harm. .

All of the above are significant pieces of work and there is limited capacity within the Team to move this work forward as quickly as it needs to. Efforts are being made to try to free up time in order to prioritise this work by the introduction of a new RCA tool which will need to be supported by a training programme to support managers in its completion.



1.1.3 Catheter Acquired Urinary Infections (CAUTI)

June 2015

Safety Thermometer Overall DCHS

Catheter and New UTI Catheter and UTI

3 = 0.21%7 = 0.42%

Community Hospital Catheter and UTI 1District Nursing Catheter and UTI 6

Catheter in situ 9.93 %DATIX for CAUTI Overall DCHS

CAUTI 8All of which were unavoidable

Hospital 4Community own homeCommunity Resi Home

40

1.1.4 VTE There have been no reported VTEs in June 2015.

1.1.4 Infection Prevention & ControlThere are no MRSA infections to report for June 2015

ESBL infection Patient One – Rowsley Ward, Newholme Hospital (22.06.2015)This patient was transferred from Chesterfield Royal Hospital Foundation Trust following a fall resulting in a fractured femur. On admission to Rowsley Ward, the patient was immobile and their continence needs were met using continence pads. Due to the patient’s reduced mobility and the use of continence pads, this patient was at risk of urinary tract infection. It is not clear what the trigger was for this episode of infection, the patient was effectively treated with antibiotics.

Clostridium difficile infectionsThere are no C difficile infections to report for June 2015

Norovirus OutbreaksThere were no outbreaks during June 2015.

1.1.5 Medicines Management

Medication IncidentsDuring June 2015 there were 20 Medication incidents, 4 of which resulted in minor harm and 16 of which resulted in no harm. This number accounts for incidents which have been given final quality checks by the Patient Safety Team and uploaded to NRLS during this period. These incidents will be discussed in detail at the next Medication Safety Group (MOST).



E prescribingRoll out of e-prescribing has been delayed to allow the population of the software with advised doses from the Derbyshire formulary and to ensure that appropriate safety alerts are embedded within the system. A locum pharmacy technician has been employed to complete this work and to minimise the delay in implementation.

2.0 Effective CareCQC updates and registration The Sexual Health registration process continues to progress with leads in each of the associated areas in Chesterfield and Derby. The Compliance Facilitator within DCHSFT is co-ordinating these contacts to ensure that DCHSFT are assured that registration is in place. The registration of the GP practices at Cresswell and Langwith is now complete and all key stakeholders are aware.

360 Assurance is providing a forum for a review of the complexities of registration that faces organisations with regard to the acquisition of diverse services; as previously referenced in the June Report. It is the intention of 360 Assurance to invite a member of CQC Registration to engage and respond to these regional challenges.

The Statement of Purpose will be reviewed quarterly to ensure that this continues to match Service development as tendering processes gain momentum.

3.0 Responsive

3.1 Friends and Family Test (FFT) ResultsA total of 5594 FFT responses were received during Q1 (1 April – 30 June 2015). There has been an increase in the total number of FFT returns in June by 48% which brings us back on target to achieve the average monthly return rate.

The graph above shows the total FFT returns by month: 1 April to June 2015.



3.2 Friends and Family Test (FFT) Results: Children and Young People The FFT Children & Young People’s card was developed in accordance with NHS England’s guidance for making the FFT inclusive and has been trialed with services during Q4 & Q1. A total of 22 FFT Children & Young People’s cards were received in June 2015. Below are examples of children and young people using their cards to express their feedback through drawings:

3.3 Patient FeedbackPatient feedback received on patient opinion and NHS choices remains low with 15 comments being received during Q1. Service user involvement with patient opinion remains significantly poor with zero comments being received during June 2015. To address this, the Patient Experience Team have identified five operational teams to focus resources and support staff to monitor feedback and respond online during Q2 and Q3. The Patient Experience Team will continue to monitor engagement.



4.0 Well Led

4.1 Clinical SupervisionA detailed paper is being taken to Quality People Committee in August reporting uptake and the output of a qualitative audit. The clinical supervision policy, paperwork and training is currently under review in light of the NMC launching Nurse Revalidation from April 2016. Clinical Supervision will be an essential mechanism to support nursing colleagues through the process. 360 Assurance follow up report A follow-up review has recently been completed to examine the extent to which actions agreed as a result of our 2014/15 Clinical Supervision review (report reference 1415/DCHS/05, issued October 2014) have been implemented. For information, the original report was issued with Significant Assurance in relation to the control frameworks established. The current status of the 6 originally agreed action points is summarised in the table below.

Risk Level Total Implemented Ongoing Outstanding Superseded High 0 0 0 0 0Medium 2 2 0 0 0Low 4 4 0 0 0

4.3 Update on progress to comply with the East Midland Cervical Screening Quality Assessment at Ilkeston and Buxton HospitalsNew national cervical standards were introduced in April 2015. The aim is to:

reduce the waiting time for Colposcopy appointments for women with abnormal results ensure that women who need treatment after a biopsy will be offered treatment within 4

weeks.

The East Midland Cervical Screening Quality Assessment Centre Team visited Buxton Hospital on the 24th June 2014, and DCHS received their final report on 22nd August 2014. The visit to Ilkeston Hospital, took place on 16th July 2014 and we received their final report on 11th September 2014. Following receipt of these reports, action plans were developed to ensure that recommendations were implemented. Good progress has been made against the areas identified for improvement. The areas which remain outstanding are:

The services in DCHS are not yet able to use the Cervical Screening QA Regional Colposcopy Audit system. Lack of access is not preventing the service from completing the required audit programme but is resulting in a less efficient process. The service will continue to work towards access to this system. This issue has been escalated to the Head of Informatics at DCHS

The Ilkeston service is still unable to access the system at Nottingham University Hospitals to view histology results. An update has been requested and the issue escalated to the Head of Informatics at DCHS.

Organisational Learning Outcomes: In addition to the specific recommendations, DCHS has noted the following learning outcomes:

A review of all medical staff treating patients within DCHS has been undertaken to ensure they have appropriate contractual and governance arrangements in place, which are available for regular audit.

A Trust wide coordinated service has been developed to ensure that formal mechanisms exist within DCHS, to receive and implement changes in National good practice guidelines



relating to Colposcopy.

4.4 Professional Guidance to Nurses and Doctors When things go wrong patients should expect a face to face explanation and apology from nurses, midwives and doctors according to new guidance developed by the Nursing and Midwifery Council (NMC) and the General Medical Council (GMC). The Duty of candour guidance also makes clear that professionals need to have the support of an open and honest working environment where they are able to learn from mistakes and feel comfortable reporting incidents that have led to harm.

4.5 Compassion in PracticeDCHS has been selected as a contributor organisation to an evaluation of the Compassion in Practice national strategy (https://www.engage.england.nhs.uk/survey/abb5eccc). Whilst this was initially directed at nurses, DCHS encouraged allied health professional colleagues to engage in this important agenda and they embraced this challenge enthusiastically. The Director of Quality / Chief Nurse has written to all clinical staff to encourage as many colleagues as possible to respond to the questionnaire and remind them of the specific work we have done towards this strategy as sometimes the language we have used is a little different:

Safer staffing within our community hospitals Safer staffing project in community hospitals Safer staffing contribution to national work on LD and MH staffing Implementation of electronic acuity tool as part of e-rostering Caring Always initiative and our promises to our patients about what they can always expect

when receiving our services. Recruitment of Care Makers including nurses, therapists, and support staff Work led in caring and particularly the 6C s through front line care council Extra mile award for care and compassion Focus on clinical supervision and improvements in numbers of staff undergoing supervision Work on dementia friendly wards Making every contact count all staff trained and also work on MECC for staff Use of pulse check (cultural barometer) Raising concerns and development of raising concerns app Development of two week induction programme for all healthcare support workers (talent for

care)

5.0 Caring

5.1 Derbyshire Dignity AwardsFrom the 1 April 2015 the Bronze/Silver/Gold Dignity in Care Awards have now been amalgamated into a single award called the ‘Derbyshire Dignity Award’. Work is underway to support teams to achieve the award. The wards and teams highlighted in red in the table below are those who have had the process delayed due to this external change. The table below shows the current status for June 2015:


https://www.engage.england.nhs.uk/survey/abb5eccc


6.0 Staffing for QualityPlease see Appendix 1 for the ward by ward breakdown of information and exception reports.

APPENDIX 1

Due to the high levels of acuity with 3 of the 4 patients staff from valley view are working on Hillside daily to make best use of staffing. The complexities of the patient mix means bank and agency have been used.There are current RN vacancies which are open to recruitment and a band 3 vacancy



Ash Green – Valley View

There are some vacancies on the ward for band 5 which is open to recruitment and a band 3 vacancyDue to the acuity of patients on Hillside staff are working across the site to meet patient need



Ash Green Site

Babington Hospital - Baron Ward

Due to the acuity of patients on Hillside staff are working across the site to meet patient need



Additional HCA shifts have been used due to some supernumerary shifts required during this period



Bolsover Hospital - Sherwood Ward

The ward manager is covering from Hopewell ward. There has been some unavailabilityPreviously there were two wards that merged together



Cavendish Hospital - Fenton Ward

There have been some staffing variations due to patient acuity during this period



Cavendish – Spencer ward

Staffing levels are dependent on patient acuity. There has been some unavailability due to sickness



Cavendish Hospital Site

Due to variations in specialism on the wards at Cavendish hospital staff do not work across the wards but this graph shows staffing on site for emergency planning only



Clay Cross Hospital - Alton WardThere has been some staff unavailability due to sickness



Ilkeston Hospital - Hopewell Ward

The ward manager is covering at Sherwood ward Staffing levels have been influenced by acuity of patientsStaff work across site to provide cover



Ilkeston Hospital Site

Where necessary staff work across site to provide cover across all the shifts



Newholme Hospital - Riverside WardThere is often shifts with 1 HCA on duty, previously some posts were transferred to housekeeper and activity co-ordinator roles to meet patient need but these are now not counted in the numbers but these staff are available to support patients recruitment has taken place to HCA posts

Riverside has RMN vacancies open to recruitment



Newholme Hospital - Rowsley Ward

There is a current vacancy that is open to recruitment and bank has been used to fill shifts where required for this vacancy



Newholme Hospital site

Due to variations in specialism on the wards at Cavendish hospital staff do not work across the wards but this graph shows staffing on site for emergency planning only



Ripley Hospital – Butterley Ward

Butterley ward had a patient that required 1-1 support in June. There was additional HCA’s for escorts and to support training. With regard to RN the ward manager has done some clinical shifts again to support training. Due to increased patient acuity extra staffing was required for a short period



St Oswald’s Hospital – Okeover Ward

There has been some unavailability due to sickness and to fill some of these shifts bank staff have been utilised



Walton Hospital Linacre Ward

There are currently some vacancies on the ward Fluctuations in patient acuity will determine staffing levels on occasions there needs to be extra staffing to support 1-1 observations



Walton Hospital – Melbourne Ward

There is some unavailability due to sickness and maternity leave. Patient acuity needs to be taken into consideration when staffing the ward as this can fluctuate on a regular basis



Walton Hospital Site

All Grades of Staff flex across both wards to maintain Staffing levels. Bank is used due to patient acuity to allow for flexibility to meet patient need

All Grades of Staff flex across both wards to maintain Staffing levels. Bank is used due to patient acuity to allow for flexibility to meet patient need



Whitworth Hospital – Oker Ward

Bed numbers have reduced during the month of June but were higher at the start of the month and staffing levels are reflective of this





The Chief Nurse presents a paper covering the Quality Agenda reflected in this report to the Council of Governors. Governors are involved in some of the pieces of work reported in this paper.


Individual items within this report will have implications for Equality and Diversity. It is always possible to present the information in more accessible formats should this be required.


The report covers Clinical Quality which impacts on Patients, Public, staff and in many cases will have stakeholder implications.

Risk Register

Is the issue on the current Risk Register?

Yes(Delete as appropriate)

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


No



TRUST BOARDDocument Title: Healthcare for All and Monitor Risk Assessment Framework

Presenter/Title: Amanda Rawlings, Director of People and Organisational EffectivenessContents of Paper were previously discussed by: QSC, June and July 2015

Author/Title:Sally Edwards, Head of Equality, Diversity and InclusionMary Heritage, Assistant Director of QualityCarolyn White Chief Nurse/Director of Quality

Contact Email and Telephone Number: [email protected] Tel: 07766 282951



Document is for:(more than one box can be ticked) Information X Decision Assurance X

Purpose of Paper

Trust Board has requested a statement of compliance against Monitor’s Risk Assessment Framework in relation to its 6 criteria (MRAF Appendix A Access targets and Outcomes objectives, section Q) that relate to people with learning disabilities who use any of our services.

Previously DCHS has declared overall compliance with the standards whilst demonstrating that further improvements and developments were possible and in plan.

The action plan has been monitored regularly by QSC and shows the planned work streams that DCHS will deliver to ensure that people with learning disabilities have the best experience and best outcomes that we can offer where ever they access our services. Organisational focus has been on those services where patients with a learning disability regularly access services and include podiatry, minor injuries units and dental services as well as our core learning disability services. The trust now needs to focus more generically on other services and ensure that wherever a patient or carer with a learning disability accesses our services they receive an equitable service. Responsibility for HealthCare for All has recently moved from operational services to the Head of Equality Diversity and Inclusion and this provided an opportunity to reassess our current compliance and progress against our developmental plan. This review has been undertaken in conjunction with the Assistant Director of Quality and lead for Patient Engagement and Experience. The trusts self-assessment has moved from a ‘RAG’ rating to an assessment of full, partial or non-compliance and information supporting the trusts current position and planned developmental work is provided to the Board in order that the Board can assure itself that the trust meets the appropriate standard to declare compliance overall

Recommendations

Currently the self-assessment demonstrates full compliance against four standards and partial compliance in the remaining two, with evidence of current and future planned work which will improve the trusts ability to assess full compliance in the near future.

A recommendation of compliance overall is made.


204�Healthcare�for�All�and�MonOverall�Page�95�of�211Page�1�of�5


4.2.1 There is a risk to the organisation due to note meeting regulatory, contractual or legal obligations resulting in sanctions. Risk Reg ID 2384

Financial Impact

None identified in this paper. Funding for two new work streams (Inclusive Communication and Carers) has been identified.


Monitor’s Risk Assessment Framework (MRAF) Appendix A section Q on Learning Disability access outlines six criteria for meeting the needs of people with a learning disability, based on recommendations set out in Healthcare for All (DH, 2008):

Does the NHS foundation trust have a mechanism in place to identify and flag patients with learning disabilities and protocols that ensure that pathways of care are reasonably adjusted to meet the health needs of these patients?Current compliance: DCHS has mechanisms in place to identify people with learning disabilities.

We have an equality monitoring questionnaire on TPP and PAS which should be completed at each patient admission or visit. This informs the organisation on the protected characteristics of patients using our services.

We have recently undertaken an Equality Delivery System 2 (EDS2) audit trust-wide and preliminary results suggest that service areas feel that they are meeting the needs of Disabled service users 88.6% of the time.

There are areas of excellent practice which should be highlighted for their work in supporting patients with a learning disability. These include: Podiatry, Minor Injuries Units and Dental Services, and of course our specialist LD services.

Areas for Development: Currently we do not have protocols for deciding reasonable adjustments of care for patients

with a learning disability in all general care settings; however, we are confident that clinicians are able to identify individual patient needs, seek advice from specialist services and are able to ensure equity of care for patients where needed.

Following analysis of the EDS2 audit, the trust will be in a better position to identify specifically where further work is needed to support the care of patients with a learning disability. The trust has demonstrated its commitment to improve services for all patients with protected characteristics through the recruitment of a new Equalities Officer post, recent Board Development Session and the creation of a Board Equalities Action Plan. The trust has also recently established the Access to Healthcare Forum for our service users from all protected characteristic groups.

A key priority for the trust this year is to improve our equality monitoring of patients. Current completion rates are 28.6% (target 30% in July 2015) of services are completing the equality monitoring questionnaire. Year end trajectory target is 100% of services. This features as one of our Big 3 quality targets. A communication strategy for both staff and patients has been developed to achieve this.

Compliant



Does the NHS foundation trust provide readily available and comprehensible information to patients with learning disabilities about the following criteria:o treatment options;o complaints procedures; ando appointments?

Current compliance: There are examples of good practice which include LD Services, Podiatry, MIU and Dental Services where there are significant numbers of patients with a learning disability; however this remains inconsistent across the wider trust.

Through our contract with Pearl Linguistics, any document can be converted into an Easy Read alternative version.

The Friends and Family Test (FFT) card has been adapted into an easy read format and is currently being used in LD services.

Areas for Development:

An Inclusive Communication project has been proposed through Patient Experience and Engagement Group (June 2015) that will equip employees to make adjustments to the way information is provided, face to face communication is conducted and how best to support involvement for any person with a communication barrier.

FFT easy read card to be made available in all service areas.

Partial compliance

Does the NHS foundation trust have protocols in place to provide suitable support for family carers who support patients with learning disabilities?Current Compliance: Carers of people with learning disabilities should be signposted to Derbyshire County Council’s First Contact service, in order to have their own needs assessed and met.

Training has been provided to enable staff on hospital wards to signpost carers to First Contact. Through the Carers’ project (Family Centred Care) this will be effectively shared with all DCHS’ employees.

The trust has supported resources through charitable funds for a Carers’ strategy project officer to lead this work.


Development and implementation of the Carers strategy and project group. Monitoring of training and numbers of referrals through the First Contact Service.

Compliant

Does the NHS foundation trust have protocols in place to routinely include training on providing health care to patients with learning disabilities for all staff? There is training on the Trust Induction programme which covers how to identify people’s individual needs. This is under review and could be strengthened. On Essential Learning, a video covers the need to identify people’s individual needs and the importance of personalising care (content covers bias, stereotypes and discrimination). The content does not focus specifically on the needs of people with learning disabilities Specialist training and support is provided for staff working within Learning disability specialist



areas and teams working with high numbers of patients with an LD. There is now an on-line Equalities Essentials e-learning package which all staff will be

required to complete.


The trust needs to develop a more robust approach to the training and development of staff with regards to meeting the specific needs of patients with a learning disability.

Specifically the trust has developed an Equalities Forum Theatre Group which provides an excellent participative training resource for staff around all protected characteristics and will develop a scenario specifically around Learning Disability in the form of a training video and/r live performance. This will be in place by October 2015.

The trust have employed a specific temporary member of staff one day per week to attend and teach on the trust Induction Programme on all aspects of equality; this will commence in August 2015.

Roll out of e-learning equalities package.

Partial compliance

Does the NHS foundation trust have protocols in place to encourage representation of people with learning disabilities and their family carers?Current Compliance: The Healthcare for All stakeholder group is now part of the Access to Healthcare Forum. Representatives with learning disabilities have attended and participated in both Forum

meetings in 2015. The trust has appointed an equalities officer three days per week at band 6 on a fixed term

contract for 9 months to lead this work.

Compliant.

Does the NHS foundation trust have protocols in place to regularly audit its practices for patients with learning disabilities and to demonstrate the findingCurrent Compliance: The quarterly clinical records audit checks that the flag for learning disability is used. The monthly equalities monitoring audit measures compliance of all services against our standards for identification and monitoring of people with a protected characteristic. From July 2015, this is reported as a 2015/16 Big 9 target.

Compliant

The Healthcare for All Action Plan that has been presented regularly to QSC, will deliver compliance on all of these gaps in assurance over the next 12 months.





Governors need to be assured of the ability of the Trust to meet the individual needs of people with learning disabilities who use our services. Governors also need to take assurance that we are compliant with the Risk assessment Framework set out by Monitor. Two public governors sit on the Equalities, Diversity & Inclusion Leadership Forum and take an active part in discussions and decision making. Governors have attended the Access to Healthcare Forum.


Disability is a protected characteristic. DCHS needs to ensure that their outcomes and experience is as good as other people who use our services. We need to take additional steps to ensure this. Progressing Healthcare for all within DCHS will have a positive impact on the Trust’s aspirations in relation to the broader equality, diversity and inclusion and Human Rights agenda. It will enable the Trust to identify and tackle the health inequalities experience by people with learning disabilities and will result in more positive outcomes for those who use our services.


People who use our services should be enabled to participate in decisions about DCHS services and how we improve them. Additional steps are needed to ensure that people with learning disabilities are enabled to participate fully. The active engagement and involvement of people with learning disabilities is a key action within the Trust’s Healthcare for All Assurance Framework and Equalities action plan.

Risk Register


Yes If yes, what is the Risk Number? Risk Reg ID 2384


No



TRUST BOARD Document Title: Board Assurance Framework 2015 – Quarter 1

Presenter/Title: Kirsteen Farrar – Trust Secretary

Contents of Paper were previously discussed by: Audit and Assurance Committee – 17 July 2015

Author/Title: Melanie Curd – Deputy Trust Secretary

Contact Email and Telephone Number: 01773 525065



Document is for: (more than one box can be ticked) Information x Decision x Assurance x

Purpose of Paper

The 2015-16 Board Assurance Framework (BAF) is split into four distinct sections aligned to the DCHS Way:

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

The BAF will document the assurances received by the Board and the Sub-Committees of the Board specific to the management of the strategic risks aligned to the corporate objectives. The BAF allows the Board to be assured that the principal risks to achieving the organisations’ strategic objectives are being systematically managed. The BAF demonstrates the management (internal) and independent assurances (external) that have been considered at the Board or at one the Board Sub-Committees and any gaps in control or assurance. This paper provides the Quarter 1 position following review by the Audit and Assurance (AAC) Committee on 17 July 2015.

Recommendations

The Board is asked to approve the Board Assurance Framework.


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

Financial Impact

There is no financial impact linked to this BAF report.

205�Board�Assurance�Framework�Overall�Page�100�of�211Page�1�of�25



Quality People, Quality Business and Quality Governance sections of the BAF have all been reviewed and refreshed for the new financial year. The Quality Service section is currently going through this process and will be in place from Quarter 2. During this process it was agreed it was more appropriate for the risk regarding maintaining a representative and involved membership to move from section 3.0 to section 2.0 of the BAF and so this is now 2.3.5 and will be reviewed by the Quality People Committee. There are four high risks on the BAF for the Quarter 1, that have previously been reported to Board: 1.1.3 - There is a risk to patients due to non-implementation of pressure ulcer prevention strategies within a community setting resulting in patient harm 2.2.1 - There is a risk to the organisation in not attracting, recruiting and retaining the right number of high quality, effective and compassionate employees with the appropriate level of skill and experience 3.1.3 - There is a risk to the delivery of the Integrated Business Plan (IBP) due to changing commissioner priorities 3.2.3 - There is a risk to the organisation due to the inability to meet financial targets, specifically Cost Improvement Programmes, as set out in the annual plan and IBP resulting in financial risk and reputational damage In addition, at Quality Business Committee it was agreed that, 3.1.4 - There is a risk to the effective and efficient provision of DCHS services due to the impact of funding cuts in social services resulting in greater activity being directed towards health should be moved to a high risk due to the context of political and economic change. The mitigation for this risk will be DCHS planning processes, monitoring of triggers and the actions in response to the impact on services. The Quality Service Committee discussed new risks for the BAF linked to the acquisition of new services, including Primary Care and the capacity of the senior management team. The new risks, scores, controls and KPIs will be developed and included in the BAF from Quarter 2. The ‘Summary View’ of the BAF allows the Board to see the various component parts that help determine the level of risk and highlights any papers that have been presented during Quarter 1 through all “Q Committees” that received ‘limited’ or ‘negative’ assurance Assurance is formally recorded on the BAF using the colour scheme below:

• Green – Positive Assurance • Amber – Limited Assurance with clear action to resolve, • Red – negative assurance

The Board is asked to approve the BAF for Quarter 1.





The Governors receive the BAF with the Board papers for their information.


There are risks relating to non-compliance with the Equality Act on the BAF.


There are risks relating to engagement on the BAF.

Risk Register

Is the issue on the current Risk Register? N/A If yes, what is the Risk Number?

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

All operational risks on the Risk Register are linked to a BAF risk.



DCHS NHS Foundation Trust Board Assurance Framework QUALITY SERVICE - Quarter 1 2015-16

Objective: To deliver high quality and sustainable services that echo the

values and aspirations of the communities that we serve Lead Committee: Quality Service Committee, chaired by Chris Bentley, Non-Executive Director Lead Executive Director: Carolyn White, Director of Quality/ Chief Nurse Summary of Quality Service BAF Risks by Lead Executive Director: Patient safety and specifically the management of pressure ulcers continued to be the organisations biggest clinical risk during Q1. Progress has been made with the number of avoidable pressure ulcers but the overall burden of tissue damage continues to rise. Strategies for management have been regularly reported to QSC and the board. Good progress was been made within the clinical effectiveness and audit team and there is now clear evidence of constructive progress and reaudit which is influencing clinical practice, of particular note is the progress on end of life care. The new quality assurance model Quality Always is progressing well and is evidencing clinical areas for development and support in association with this work the clinical governance team are putting in place a model for self-assessment of CQC fundamental standards. During Q4 second audits of all inpatient areas were undertaken by the peer review team and action plans have now been developed and implemented Patient feedback during quarter 1 continued to be positive.



1.1 - Safety BAF ID Risk Description Operational risk

profile Current

Risk Score Previous Quarters

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

Month 1 Month 12

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

High – 4 Medium – 12

Low - 0

L2 x C 5 = 10

(medium)

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

Harm Free Care Score % 92.9% 92.22% Avoidable PUs (no.) 8 4

Medicines incidents resulting in serious harm 0 0

Falls (Major Harm/Death) 1 4 All papers presented for Assurance in Quarter 1 were received positively with the exception of: Clinical Quality Report Chlamydia Update: Final Rapid Response Report Chlamydia Screening Update Report Establishing Assurance Frameworks with Partner Organisations Safeguarding Governance Group Summary Report

Identified Gaps in Control (c) /Assurance (a): Pressure Ulcer performance (a) Falls and Harm Free Care Score (c) Pending completion of the action plan and also the findings of the 360 Assurance Audit (a) Pending completion of the action plan and also the findings of the 360 Assurance Audit (a) Paper is the start of a work in progress (a)

MCA Audit Results (a) DOLS - length of time to process DOLS applications (a)

Action planned to address (and timescales): Improvement Plan in place An update to be brought to September QSC An update to be brought to September QSC Further update to be brought to November QSC

Action Plan being developed Escalation process in place



BAF ID Risk Description Operational

risk profile

Current Risk

Score

Previous Quarters


Month 1 Month 12

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


Low - 0

C4 x L2 = 8

(medium)

14/15 Q4 - 8 14/15 Q3 - 8

Harm Free Care Target 93% 93% Grade 2 (actual from Datix) 194 179

Grade 3 (actual from Datix) 73 69


All papers presented for Assurance in Quarter 1 were received positively with the exception of: Clinical Quality Report

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

Action planned to address (and timescales): Improvements to be delivered through Improvement plan

BAF ID Risk Description Operational

risk profile

Current Risk

Score

Previous Quarters


Month 1 Month 12

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


Low - 0

C4 x L4 = 16

(high)

14/15 Q4 -16 14/15 Q3 - 16

Harm Free Care Target 93% 93% Grade 2 (actual from Datix) 194 179




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


205�Board�Assurance�Framework�



1.2 Clinical Effectiveness

BAF ID Risk Description Operational risk

profile

Current Risk

Score

Previous Quarters KPI Q4 Q3

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


Low - 2

L2 x C5 =

10 (medium)

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

Expected Deaths 2014-15 35 41

Deaths on the End of Life (EoL) Care Pathway

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

All papers presented for Assurance in Quarter 1 were received positively with the exception of: Clinical Quality Report Quality Assurance and Compliance Report Chlamydia Update: Final Rapid Response Report Establishing Assurance Frameworks with Partner Organisations

Identified Gaps in Control (c) /Assurance (a): Pressure ulcer performance (a) Falls and Harm Free Care Score (c) Need to improve DCHS Service Directory (c) Pending completion of the action plan and also the findings of the 360 Assurance Audit (a) Paper is the start of a work in progress (a)

Action planned to address (and timescales): Improvements to be delivered through Improvement plan An update to be presented to QSC Nov 2015 An update to be brought to September QSC Further update to be brought to November QSC



BAF ID Risk Description Operational risk profile

Current Risk Score


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


Low - 0

L3 X C4 = 12

(medium)

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

% of patients with a preferred place of Death community

56% 70%

% of patients with a preferred place of Death hospital

93% 93%


Identified Gaps in Control (c) /Assurance(a): Pressure ulcer performance (a) Falls and Harm Free Care Score (c)



Current Risk Score

Previous Quarters KPI Qtr 1 Qtr 4

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


Low - 0

L4 x C3 = 12

(medium)

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

CRA Participation rate 99% 96%

CRA completion rate 74% 79%

All papers presented for Assurance in Quarter 1 were received positively.

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

Action planned to address (and timescales):




Current Risk

Score


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


Low - 0

L3 x C4 = 12

medium

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

Delivery of CQUIN

Delivery of Quality Schedule (Contract)

All papers presented for Assurance in Quarter 1 were received positively with the exception of: Clinical Quality Report Quality Assurance and Compliance Report Establishing Assurance Frameworks with Partner Organisations

Identified Gaps in Control (c) /Assurance (a): Pressure ulcer performance (a) Falls and Harm Free Care Score (c) Need to improve DCHS Service Directory (c) Paper is the start of a work in progress (a)

Action planned to address (and timescales): Improvements to be delivered through Improvement plan An update to be presented to QSC Nov 2015 Further update to be brought to November QSC


Current Risk

Score

Previous Quarters KPI Month

12

1.2.6 This was a QBC risk (Q3)

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


Low - 3

L2 x C4 =

8 (medium)

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

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

All papers presented for Assurance in Quarter 1

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

Action planned to address (and timescales):




1.3 Patient Experience BAF ID Risk Description Operational risk

profile

Current Risk

Score

Previous Quarters KPI Month 1 Month

12 1.3.1 There is a risk to patients due to the

failure to learn lessons from patients feedback and experiences resulting in negative effect on patient care (Risk Reg ID - 2361)


Low - 0

L2 x C4 =

8 (medium)

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

Friends & Family Test 98.3% 98.2%

Complaints received 11 10

All papers presented for Assurance in Quarter 1 were received positively with the exception of: Clinical Quality Report Establishing Assurance Frameworks with Partner Organisations

Identified Gaps in Control (c) /Assurance (a): Pressure ulcer performance (a) Falls and Harm Free Care Score (c) Paper is the start of a work in progress (a)

Action planned to address (and timescales): Improvements to be delivered through Improvement plan Further update to be brought to November QSC

BAF ID Risk Description Operational risk

profile

Current Risk

Score

Previous Quarters KPI Month 1 Month

12

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


Low - 0

L2 x C4 =

8 (medium)

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

Services with a PPI lead (no.) These measures

are being developed

Service with a PPI group (no.)


Identified Gaps in Control (c) /Assurance (a): Pressure ulcer performance (a) Falls and Harm Free Care Score (c)




DCHS NHS Foundation Trust Board Assurance Framework QUALITY PEOPLE - Quarter 1 2015-16

Objective: To build a high performance work environment that engages, involves and supports staff to reach their full potential Lead Committee: Quality People Committee, chaired by Barbara-Anne Walker, Non-Executive Director Lead Executive Director: Amanda Rawlings, Director of People and Organisational Effectiveness

Summary of Quality People BAF Risks by Lead Executive Director: The risks within the QPC BAF remained unchanged during Q1 after a review and some changes at the end of quarter 4. However, a thorough review of the risks and their associated controls and KPIs has been completed by the Deputy Director of POE in order to ensure the Trust can take assurance that these risks are being managed robustly. The Trust has one red 15 Quality People risk section on the BAF relating to attracting and retaining staff with the right behaviours to the right locations to deliver high quality care (Risk Reg ID - 2366). DCHS has had success in attracting qualified staff to community roles but this is more challenging for inpatient wards. There is an on-going recruitment campaign, making use of innovative attraction methods such as social media. Close monitoring is also in place to link staffing levels with bank/agency usage with risks and mitigations managed and escalated to QPC/QSC where appropriate. There is one 12 point amber risk regarding the ownership and management of Health and Safety and compliance with legislation - (Risk ID – 2604). Following the appointment of a qualified Health and Safety Manager the progression of an action plan relating to this risk is on-going. There is an on-going challenge relating to the recording and escalation of operational risks and the correlation with the data presented in the monthly Quality People Performance Report.

Where there is slippage against key People metrics associated with the BAF, clear action plans are in place to recover the Trust’s position.




2.1 Risk Description Risk

Score Previous Quarters

Operational Risk Profile Lead KPIs Quarter 1

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

L2 x C5 = 10

Medium

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

High = 0 Med = 5 Low = 1

Measure April May June Essential Learning Attendance 92% 92% 91% Clinical Essential Learning Attendance Fire Training 92% 92% 89% IG Training 93% 92% 90% Staff Attending Corporate Induction within 3 months of start date 100% 100% 86%

Appraisal Completion 93% 91% 89% All papers presented for Assurance in Quarter 1 were received positively with the exception of: Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Quality People Performance Report Review of ICBS North and South re staff absences (a) Action Plan to drawn up and report presented to QPC in June Learning and Education Update Mental Capacity Act/Deprivation of Liberty Safeguard training (c)

Withdrawal of IG workbooks (a)

Working group set up to improve and oversee implementation of new training. Update to August QPC Review of workbooks to be undertaken

Workforce Equalities Data and Analysis Process in place but no evidence of outcomes (a) Work underway with Health Education England re how workforce is trained

Risk Description Risk Score Previous Quarters


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

L2 x C5 = 10 Medium

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


Measure April May June

Staff Attendance 95.59% 95.55% 96.12%

Appraisal Completion 93% 91% 89%

All papers presented for Assurance in Quarter 1 were received positively with the exception of: Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Quality People Performance Report Review of ICBS North and South re staff absences (a) Action Plan to drawn up and report presented to QPC in June



Risk Description Risk Score

Previous Quarters


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

L3 x C4 = 12

Medium

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



Total incident reports entered on to Datix 60 56 77

Percentage of staff receiving Health and Safety training No of staff completed in month 146 195 181 % of DCHS workforce 5% 4% 4% DCHS compliance 94% 94% 94%

Riddor reported injuries 1 1 1


2.2


Previous Quarters


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

L3 x C5 = 15

High

14/15 Q4 - 15 14/15 Q3 - 15 14/15 Q2 - 15 14/15 Q1 - 15



Staff Turnover 10.27% 10.21% 10.47%

Health Visitor FTE 141.1 142.4 142.2

Vacancies as a % of total workforce 6.1% 6.3% 5.9% Bank and Agency spend (clinical) as a % of total workforce cost 1.1% 0.7%

Time to Recruit' (Target 60 days) 47.8 days 46.6 days 46.6 days

All papers presented for Assurance in Quarter 1 were received positively with the exception of: Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Quality People Performance Report Review of ICBS North and South re staff absences (a) Action Plan to drawn up and report presented to QPC in June



2.3


Previous Quarters

Operational Risk Profile Lead KPIs Quarter

1 2.3.1 There is a risk to organisation due to the loss of staff engagement resulting in poor patient outcomes (Risk Reg ID - 2367 )

L2 x C5 = 10

Medium

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


Measure

Improvement in Staff Engagement Score (%) 75%

Pulse Check - Recommend DCHS to Friends and Family If They Needed Care or Treatment (%) 89%

Pulse Check - Recommend DCHS to Friends and Family as a Place to Work (%) 69%

Pulse Check - Participation Rate (%) 35%

All papers presented for Assurance in Quarter 1 were received positively with the exception of:

Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales):

Quality People Performance Report Review of ICBS North and South re staff absences (a) Action Plan to drawn up and report presented to QPC in June


Previous Quarters


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

L3 x C3 = 9

Medium

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



Number of Grievances (regarding Organisation Change) 0 0

Number of Appeals against Redundancy 0 0

Percentage of staff successfully redeployed following risk of redundancy

No redundancies

No redundancies 33%

Pulse Checks Engagement Score 75%


Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales):

Quality People Performance Report Review of ICBS North and South re staff absences (a) Action Plan to drawn up and report presented to QPC in June




Operational Risk Profile Lead KPIs Quarter One

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

L2 x C5 = 10

Medium

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


Measure

EDS2 grading outcome Currently being developed

EIA completion rates 73%

Equalities Action Plan (% completion rate) 2014/15 - 75%

All papers presented for Assurance in Quarter 1 were received positively with the exception of: Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Quality People Performance Report Review of ICBS North and South re staff absences (a) Action Plan to drawn up and report presented to QPC in June Workforce Equalities Data and Analysis Process in place but no evidence of outcomes (a) Work underway with Health Education England re how workforce is trained



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

L2 x C5 = 10 Medium

14/15 Q4 - 14/15 Q3 - 14/15 Q2 - 14/15 Q1 -



Workforce equality profile (overall)

BME: 130 Not Stated: 81 White: 3904



Equality profile of recruits




Equality profile of leavers








Previous Quarters


2.3.5 There is a risk to the organisation due to ineffective governance as a result of not maintaining a representative involved membership resulting in poor engagement with the local community (Risk Reg ID - 2381)

L2 x C3 = 6 Medium

14/15 Q4 - 6 14/15 Q3 - 6 14/15 Q2 - 6 14/15 Q1 - 6



FT membership (no.) 12514 12505 12523 Representative Membership Pulse Check - Recommend DCHS to Friends and Family as a place to work 71% Pulse Check - Recommend DCHS to Friends and Family if they needed care or treatment

89%




DCHS NHS Foundation Trust Board Assurance Framework QUALITY BUSINESS - Quarter 1 2015-16

Objective: To ensure an effective, efficient and economical organisation which

promotes productive working and which offers good value to its community and commissioners

Lead Committee: Quality Business Committee, chaired by Ian Lichfield, Non-Executive Director Lead Executive Director: Chris Sands, Director of Finance, Information and Strategy

Summary of Quality Business BAF Risks by Lead Executive Director: The Trust has two red risks on the Quality Business section of the BAF. There is the risk to delivery of the IBP due to a change in commissioner priorities. In both the North and South of the county, commissioners have engaged consultants to support the development of integrated 5 year plans. These plans are developing in line with our IBP. However, there remains uncertainty due to the recent publication of the 5 Year Forward View and Dalton Review which could impact on commissioner strategies. In addition, we are planning to go to consultation on service changes in the North Unit of Planning, and any delays in this process, or changes as a result of consultation could impact on our ability to deliver the IBP. Due to this continued uncertainty, the strategic risk remains a 15. The month 2 financial position is on plan. The delivery of cost improvement plans, and the pressures on activity in block contracts continues to be a risk. The financial climate in which the Trust is operating continues to be challenging. In both healthcare and social care, there are significant pressures on budgets, and many provider organisations are forecasting a deficit for 2015/16. It is possible that there will be indirect financial impacts of these pressures impacting upon the Trust’s financial position. The BAF risk has been maintained at a 15 to reflect the level of financial risk. The Committee is asked to consider whether the financial risk needs amending to reflect the financial risk within the wider health and social care system.



3.1 Risk Description Risk Score Previous

Quarters Operational Risk Profile Lead KPIs Quarter 1

3.1.1

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

L2 x C5 = 10

Medium

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

High = 1 Med =

Low = 0


All papers presented for Assurance in Quarter 1 were received positively



3.1.2

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

L2 x C4 = 8 Medium

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



Number of Tenders Won (no) 0 0 0

Number of Tenders Lost (no) 0 0 0

Value of Tenders Won (£,000) 0 0 0

Value of Tenders Lost (£,000) 0 0 0




3.1.3 There is a risk to delivery of the IBP due to change in commissioner priorities and national policy (Risk Reg ID - 2441)

L3 x C5 = 15

High

14/15 Q4 - 15 14/15 Q3 - 15 14/15 Q2 - 15 14/15 Q1 - 15








3.1.4

There is a risk to the effective and efficient provision of DCHS services due to the impact of funding cuts in social services resulting in greater activity being directed towards health services (Risk Reg ID - 2729)

L4 x C4 = 16 High

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



Delayed Transfer of Care-Total (%) 9.8% 7.8% 7.5%

Delayed Transfer of Care for Inpatient (Rehab & Urgent Care) - contract calculation (%)

11.5% 8.1% 8.3%

Delayed Transfer of Care for OPMH - contract calculation (%) 2.6% 6.7% 5.2%


3.2



3.2.1

There is a risk to the organisation due to poor estate impacting upon patient care resulting in poor outcomes (Risk Reg ID - 2372)

L3 x C4 = 8 Medium

14/15 Q4 - 8 14/15 Q3 - 12 14/15 Q2 - 12 14/15 Q1 - 12




Risk Risk Description Risk Score Previous Quarters


3.2.2

There is a risk to the organisation due to poor asset utilisation impacting upon the efficient use of resources (Risk Reg ID - 2373)

L3 x C3 = 9 Medium

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



Facilities Unused Space % Under review






3.2.3

There is a risk to the organisation due to the inability to meet financial targets, specifically cost improvement plans, as set out in Annual Plan and IBP resulting in financial risk and reputational damage. (Risk Reg ID - 2374)

L3 x C5 = 15 High

14/15 Q4 - 15 14/15 Q3 - 15 14/15 Q2 - 15 14/15 Q1 - 15



CIP Planned (£,000) 428 768

CIP Actual (£,000) 319 657

CIP Planed (%) 7.0% 12.6%

CIP Actual (%) 5.2% 10.8%

Cash Position (£m) 11.3 All papers presented for Assurance in Quarter 1 were received positively



3.2.4

There is a risk to the organisation due to the inability to meet contractual activity targets, resulting in financial risk (Risk Reg ID - 2375)

L2 x C5 = 8 Medium

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



Income - Planned (£,000) -13,948 -27,689

Income - Actual (£,000) -13,984 -27,299




3.2.5

There is a risk to the delivery of the organisation's plans through non-delivery or slippage in the enabling IMT plans, resulting in objectives not being achieved. (Risk Reg ID - 2377)

L3 x C4 = 12

Medium

14/15 Q4 - 12 14/15 Q3 - 8 14/15 Q2 - 8 14/15 Q1 - 12



Progress Against IM&T Plan (%) 0 0 0

Proportion of Services on an Electronic System (%) 77% 77% 77%

All papers presented for Assurance in Quarter 1 were received positively with the exception of: Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): IM&T Plan Benefits Realisation Clearer justification for the benefits realised needed (a) Forward plan and 6 monthly outputs





3.2.6

There is a risk to the organisation due to poor decisions being made due to poor data quality resulting in poor outcomes and financial loss (Risk Reg ID - 2378)

L3 x C4 = 12

Medium

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



CIDS-Services Under Kitemark (%) 100% 100% 100%

SUS-Patient Records With NHS Number (%) 100% 100% 100%

All papers presented for Assurance in Quarter 1 were received positively with the exception of Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): IM&T Plan Benefits Realisation Clearer justification for the benefits realised needed (a) Forward plan and 6 monthly outputs



3.2.7

There is a risk to the Trust’s activities, due to an emergency or severe disruption, resulting in an impact on patient care, inability to meet targets, loss of revenue. (Risk Reg ID - 2484)

L2 x C5 = 10 Medium

14/15 Q4 - 14/15 Q3 - 14/15 Q2 - 14/15 Q1 -


Measure April May June Gold Training -Number Compliant (no) 6 6 Gold Training -Number Available (no) 7 7 Gold Training (%) 86% 86% Silver Training -Number Compliant (no) 7 7 Silver Training -Number Available (no) 9 9 Silver Training (%) 78% 78% Core Standards Training (%) 97% 97% Compliance Against Core Standards Within National Guidance (%) 100% 100%

No papers presented for Assurance in Quarter 1





3.3.1

There is a risk to the organisation due to failure to maintain a positive reputation, resulting in impact upon future demand for services (Risk Reg 2380)

L2 x C5 = 10

Medium

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



No papers presented for Assurance in Quarter 1



3.3.3

There is a risk to the organisation due to delivering integrated care through poor relationships with partners resulting in poor outcomes for patients (Risk Reg 2382)

L2 x C4 = 8

Medium

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






DCHS NHS Foundation Trust Board Assurance Framework QUALITY GOVERNANCE - Quarter 1 2015-16

Objective: To manage and develop a successful organisation Lead Committee: Audit and Assurance Committee, chaired by Nigel Smith, Non-Executive Director Lead Executive Director: Kirsteen Farrar, Trust Secretary

Summary of Quality Governance BAF Risks by Lead Executive Director: There are currently no high risks within the Quality Governance section of the BAF. All of the risks are currently scoring between 10 and 8.

There was one paper which received limited assurance during Quarter 1; The Mental Health Act Code of Practice. Work has been ongoing which allowed the Mental Health Act Committee to take limited assurance on this item, as it was reported as negative assurance in Quarter 4.

The committee took assurance about the processes in place to form the action plan, the immediate actions being undertaken and the CQC suggested view regarding work in progress. A report has been provided to Board in June 2015 updating them on the work undertaken in this important area.

All other papers presented during the quarter received positive assurance.





4.1.1

There is a risk to the organisation due to not having strong corporate governance systems in place resulting in Trust vision not being delivered (Risk Reg ID - 2383)

L2 x C5 = 10

Medium

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



Governance Rating




4.2.1

There is a risk to the organisation due to not meeting regulatory, contractual or legal obligations resulting in sanctions (Risk Reg ID - 2384)

L2 x C5 = 10

Medium

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


Measure April May June CQC Non-Compliance with Essential Standards resulting in Enforcement Action (no) 0 0

CQC Compliance Action Outstanding (no) 0 0

Governance Risk Rating

Continuity of Service Rating 3 3

All papers presented for Assurance in Quarter 1 were received positively Risk Description Risk Score Previous


4.2.2

There is a risk to the organisation due to not having strong risk management controls in place resulting in failure to put effective mitigation plans in place promptly (Risk Reg ID - 2385)

L2 x C4 = 8 Medium

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



Number of top X risks 23 29 33

Number of overdue risks 7 2 0





Quarters Operational Risk

Profile Lead KPIs

4.3.1

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

L3 x C4 = 12

Medium

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


Measure 2014/15 2015/16 Completion of 2 AMHAM Audits per year on OPMH and LD inpatient services

100%

All papers presented for Assurance in Quarter 1 were received positively with the exception of Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales):

Mental Health Act Code of Practice

Policies and procedures to be reviewed against new Code (c) Lack of timescales on Action Plan (c)

Action plan to be developed and monitored by MHOG, TME and QSC Action Plan to be formally overseen by MHOG and high level timescales to be developed



TRUST BOARDDocument Title: Amendment to Constitution

Presenter/Title: Kirsteen Farrar – Trust Secretary

Contents of Paper were previously discussed by: Council of Governors Meeting - 1 July 2015

Author/Title: Melanie Curd, Deputy Trust Secretary Kirsteen Farrar, Trust Secretary

Contact Email and Telephone Number:

[email protected] 525065



Document is for:(more than one box can be ticked) Information Decision x Assurance

Purpose of Paper

The purpose of this paper is to ask the Board to approve the amendment to our Constitution. Any amendment to the Constitution requires the approval of both the Council of Governors and the Board of Directors; the amendment was approved by the Council of Governors on 1 July 2015.

Recommendations

The Board is asked to approve the amendment to the Constitution


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

Financial Impact

Nil


The Council of Governors is made up of three constituent areas, namely; Public, Staff and Appointed Governors. In October 2014, Healthwatch formally resigned from their position as an Appointed Governor and the seat has been left vacant.

The Governance Grouping of Governors were asked to consider and make a recommendation to the Council on which organisation could fill this vacant seat.

The group looked at what other Foundation Trusts have on their Council of Governors and also discussed the option of only having two Appointed Governors. The group specifically considered the pros and cons of an Appointed Governor from a University and from the Voluntary Sector.

206�Amendment�to�Constitution.Overall�Page�125�of�211Page�1�of�2



The voluntary sector was a popular option however the Group acknowledged the difficulty in having just one seat to represent the sector. It was agreed this option would be discussed further at the Governance Grouping of Governors for future consideration for our Council of Governors. The group discussed having an additional commissioning representative and acknowledged the value this could add to have a representative from the south of the county as the planning landscapes in the north and the south of the county are different.

The recommendation the group made to the Council was to offer the vacant seat to the Commissioners in the south of the county – Annex 3 of the Constitution is attached which reflects this change.

In addition, the group acknowledged the difficulty in any Appointed Governor being able to commit the time to attend all the meetings and proposed that Appointed Governors only, be allowed to send a deputy in their place. The proposal was supported by the Council of Governors in July 2015 and there is no statutory restriction that prevents us from putting this in place however further work is required to agree the powers and scope of the deputy and to reflect this appropriately within the Constitution. This work will be undertaken by the Governance Grouping of Governors at their next meeting and will be presented to a future Council of Governors and Board.

The Board is asked to discuss and agree the amendment to the Appointed Governor.



The Council of Governors has to formally approve amendments to the Constitution.


The Council of Governors and the Board of Directors have a duty to consider equality and diversity implications as part of the business of the meetings.


The Constitution is a publicly available document and is on our website.

Risk Register

Is the issue on the current Risk Register? No If yes, what is the Risk Number? N/A

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

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Summary Report from Quality Business CommitteeReport To: Board

Date: 30 July 2015

Name of Reporting Committee / Group: Quality Business Committee


Presenter: Ian Lichfield

Author: David Boddy


Key Issues discussed at meeting: Board Assurance Framework Reference and Level of Assurance Agreed

135/15 Board Assurance Framework Quarterly Review - The Committee considered the level of risk assigned to each strategic risk and any further ‘Gaps in Assurance or Control’.The Committee reviewed referrals from QSC:

3.1.4 - to review what assurance could be evidenced. The Committee considered that the risk should be refreshed in the context of political and economic change and should be amended from amber to red RAG rating. The mitigation for this risk (and also 3.1.3) will be DCHS planning processes, monitoring triggers and the actions in response to the impact on services

3.2.5 - with respect to the roll out of TPP. It was agreed that there is a specific risk on the risk register that addresses this issue.

The Committee discussed how the BAF could be further improved regarding measures used to track risks. Where the risk is generic and there are no directly related Key Performance Indicators (KPIs) then this should be recorded on the BAF and the methodology for deriving the risk RAG status. The Committee also agreed that the KPIs should be RAG rated.

138/15 Capital & Estate Programme Group Summary Report The group supported Phase 1 option for 63 car parking

spaces at Ilkeston Hospital. The Committee approved the option with £8,554 additional funding

A full business case for the Heanor Site Development is being prepared. The final case will be presented to the September QBC meeting. The Mechanical and Engineering Design Consultant’s Agreement Contract will be forwarded to the Chief Executive’s Department for signing and sealing

Planning applications for the Walton site have been secured

4.2.2. Significant Assurance.

3.2.1. 3.2.2. Significant Assurance

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Capital & Estate Programme Group Annual Review – the Committee took significant assurance from the work of the group over the past year against its KPIs.

360 Assurance Estates Strategy and Capital Planning – the Committee took significant assurance from the external assurance.

139/15 Emergency Preparedness, Resilience & Response (EPRR) Report – The report supported the Trust’s compliance with NHS England’s Core Standards for EPRR and the requirements of the Civil Contingencies Act 2004.

The Committee reviewed the self-assessment and accepted it as a current picture of the Trust’s position against NHS England’s Core Standards for EPRR. The Committee took assurance from the work undertaken but that this was limited pending completion of further actions that are currently amber RAG rated.

The Board will be made aware via the QBC Summary Report of our current position against the core standards.

140/15 Security Group Summary Report - The Committee took limited assurance from the report owing to the number of reports that provided the group with limited assurance. These will be addressed by completion of work for each of the reports.

Terms of Reference (ToR) - The Committee approved the ToR.

141/15 Information Management & Technology (IMT)IMT Group Summary Report - The Committee reviewed the summary report.

Strategy Quarterly UpdateThe project to replace the PAS system with TPP’s Community Hospital electronic patient record system went live in July.

A decision has been made to include more clinical functionality in electronic clinical recording. The costs are being scoped and it is estimated that the enhancement will delay project delivery by four months. The benefits of this work will be that:

The system will be more efficient because it will provide prompts and prescribing safeguards for clinicians

Clinicians will build confidence and engage with the electronic system

The Committee discussed the reasons for why early engagement with the Clinicians was delayed.

The Committee also discussed the change in licensing arrangements. Work is underway to redeploy devices.



3.2.7. Limited Assurance

3.2.1. 3.2.2. Limited Assurance





142/15 Transformation Group - The Committee reviewed progress against health and social care economy transformation priorities. The Committee also considered the next steps of the Agile strategy implementation and requested that:

A business case demonstrates the financial benefits of the initiative including the contribution to the Cost Improvement Programme (CIP) as this is the critical measure to justify the investment

That there are KPIs against the objectives Investment Objective 10 is reworded to say “Reduction of

duplication of administration roles” The results of benchmarking are seen by the Committee

Terms of Reference (ToR) - the Committee approved the ToR.

144/15 Performance Report - The Committee reviewed the key exceptions in the report. The Committee requested that measurements are put in place for each of the targets.

146/15 Finance Report - The Committee discussed the current surplus position and potential financial challenges such as capacity in certain teams in the year ahead. This will be debated by the Board.

147/15 Financial Bridge and Investment Report - The paper provided the Committee with an understanding of the components of the financial plan for 2015/16. The analysis bridged the 2014/15 outturn at summary level to the final 2015/16 plan.

It was requested that a report be developed to identify the profitability of services so that the QBC can better understand the performance of the portfolio of services and it will help to shape investment decisions in the future.

148/15 Project Management Office (PMO) Escalation ReportThe Committee discussed the reasons for slippage to projects regarding reductions in beds, medical support and mobile phone savings and requested:

Consider what projects might be brought forward in order to achieve the goals.

PMO makes this a continuous process so where there are shortfalls reported planned mitigations are also presented

Prioritise the overheads projects first because these will not impact on patients

149/15 Cost Improvement Programme Planning 2016/17 - The Committee took limited assurance from the work in progress which needs further development. The Committee asked that the work is developed further to form the main PMO CIP reporting tool. The report should show the project pipeline include estimated timings


3.1.2. 3.2.3. 3.2.4. 3.2.6. Significant Assurance



4.1.1. 4.2.2. 4.3 Significant Assurance

3.2.3 Limited Assurance



for when CIPs will be delivered.

151/15 Business Development Report – The report updated the Committee regarding the external business environment, business opportunities (including accredited providers – Derbyshire Smoking) and contracts.The Committee were also updated regarding the work regarding quality governance and due diligence to better assure the services coming into our organisation.

152/15 Tender Oversight Group (TOG) – The Committee took assurance from the Summary Report and approved the Terms of Reference.

3.1.1. 3.1.2. 3.1.3. 3.2.3. 3.3.1. 3.3.3. Significant Assurance

3.1.1. 3.2.3. 3.3.1. 3.3.3. Significant Assurance

Key to BAF Risks:3.1.1 Lack of integrated planning3.1.2 Loss of business 3.1.3 Delivery of the IBP due to change in commissioner priorities3.1.4 Impact of funding cuts3.2.1 Poor estate impacting on patient care3.2.2 Variable site utilisation3.2.3 Inability to meet financial targets3.2.4 Inability to meet contractual activity targets3.2.5 Non-delivery or slippage in IMT plans3.2.6 Poor decisions due to poor data quality3.2.7 Emergency or severe disruption3.3.1 Failure to maintain a positive reputation3.3.3 Delivering integrated care through poor relationships with partners4.1.1 Not having strong corporate governance systems in place4.2.2. Not having strong risk mgt. controls in place.4.3 Failure to meet Monitor requirements

Policies ApprovedNone.Issues to be escalated to Board or a CommitteeNone.



TRUST BOARD Document Title: Performance Report – July 2015

Presenter/Title: Chris Sands, Director of Finance, Information and Strategy


Author/Title: David Caddy, Management Accountant - Performance and Costing Kate Davis – Head of Costing and Performance

Contact Email and Telephone Number: [email protected] 01246 253042




Purpose of Paper

The Board Performance Report sets out a summary of DCHS’ performance against the three DCHS Way focus areas of Quality People, Quality Service and Quality Business. The Balanced Scorecard has been reviewed to incorporate the contractual and other performance regime changes in 2015/16. There are 85 green, 15 amber, 18 red, and 37 unrated indicators this month. The Overview of Measures at page 12 gives further details. The table below summarises the red rated year to date KPI’s. These are the key issues for the Quality Business Committee to focus on from a performance perspective. The benchmarking KPIs aren’t listed due to these not being specific DCHS performance measures.

211�Performance�Report.pdfOverall�Page�131�of�211Page�1�of�44



Recommendations

Note and comment


3.1.2 There is a risk to the organisation due to loss of business as a result of not actively managing the more competitive environment resulting in financial loss (Risk Reg ID - 2371) 3.2.3 There is a risk to the organisation due to the inability to meet financial targets, specifically cost improvement plans, as set out in Annual Plan and IBP resulting in financial risk and reputational damage. (Risk Reg ID - 2374) 3.2.4 There is a risk to the organisation due to the inability to meet contractual activity targets, resulting in financial risk (Risk Reg ID - 2375)



3.2.6 There is a risk to the organisation due to poor decisions being made due to poor data quality resulting in poor outcomes and financial loss (Risk Reg ID - 2378)

Financial Impact

The report contains a number of issues and risks that have a financial impact on the organisation. These are detailed within the report including, where appropriate, any mitigation plans and strategies that are in place.



What are the Governor involvement implications? The Council of Governors receive performance reports


Equality and Diversity measurements are recorded in the report


The report includes measurements of service experienced by patients

Risk Register


Yes

If yes, what is the Risk Number?

Smoking Cessation – 2417 Breastfeeding Sustainment-2549 Chlamydia-2706 Pressure Ulcers-2225


No



Board Performance Report – July 2015 Background The Board Performance Report sets out a summary of DCHS’ performance against the three DCHS Way focus areas of Quality People, Quality Service and Quality Business. Section Index Document Page No’s Summary Document-Overview 1 – 3 Risk Assurance Framework Scorecard 4 Monitor Organisational Health Card 5 Summary Document-DCHS Balanced Scorecard 6 - 10 Overview of Measures 12 DCHS Balanced Scorecard 13 – 17 HCAI Scorecard 18 CQUIN Scorecard 19 RTT Waiting Times Scorecard 20 - 21 Exception Reports 23 – 37 Glossary 38 – 40 Key for RAG, arrows and Data Quality Kitemark 41



OVERVIEW Summary Overview

This month there are 85 green, 15 amber, 18 red, and 37 unrated indicators. The Overview of Measures at page 12 gives further details.

2015/2016 targets were reviewed by the Quality Business Committee at its April 2015 meeting. Contributors have been given the opportunity to propose changes to internal measures and we will continue to review and confirm all targets.

Key Issues The key issues for the Board to discuss are: Risk Assurance Framework We are currently meeting all our Risk Assurance Framework targets and are

forecasting to maintain our green rating for the year. This will be updated following the Board decision. The Risk Assurance Framework Scorecard is presented at page 4.

There is a paper on the Board agenda to consider compliance against healthcare for all. This is currently rated as green on the basis of the previous self assessment

Quality People This month Fire Training is red rated at 89% against a target of 95%. Staff

Appraisal is red rated at 89% against a target of 100% and attendance is amber rated at 96.12% against a target of 97%. An exception report for Fire Training and Staff Appraisal are presented at pages 24 and 27.

Quality Service



Health and Wellbeing are red rated for Specialist Stop Smoking , Community Weight Management, Community Smoking Cessation and Diabetes exception reports are presented at pages 31 to 35.

Total Harm Free Care measures are green rated at 93.1% for the month and

amber rated at 92.6% for the year to date against a target of 93%. This has been discussed in the Quality Report

Quality Business The monthly financial position at month 3 shows a favourable variance

against plan of £130,000. The trust is forecasting to achieve a year end surplus of £1.6 million and a continuity of services rating of 4.

Activity plans are generally on plan, with the exception of Healthy Lifestyles and Sexual health services. Discussions are taking place with commissioners to improve performance in these areas.



Monitor Risk Assurance Framework Indicators 2015 -16

Measure Measure-Sub GroupRAF

Appendix A Area

RAF Target 2015/16

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Narrative

RTT Waits - admitted patients seen within 18 weeks - 90% (target) (%)

See note 1 1 90% 95.3% 96.5% 95.7%


2 95% 98.1% 98.4% 97.0%


3 92% 97.9% 99.2% 97.9%

A&E 4 Hour Wait for A&E Attendances (%) 4 95.0% 100% 100.0% 99.9%

Healthcare Care Associated Infections - Clostridium difficile lapses (no.)

14Not applicable - DCHS does not have

a target

Delayed Transfer of Care for OPMH - Monitor compliance framework calculation (%)

16 7.5% 2.6% 6.7% 5.2% Monitor quarterly calculation.

Mental Health data completeness: identifiers 17 97% 100% 100% 100%

Certification against compliance with requirements regarding access to healthcare for people with a

learning disability19 Yes Yes Yes Yes

To be reported to EDS & quarterly to QSC

Data completeness: community services , comprising:referral to treatment

information %20 50% 83.1% 83.1% 91.9%

Data completeness: community services , comprising: referral information % 20 50% 69.0% 69.0% 84.7%

Data completeness: community services , comprising:treatment activity

information %20 50% 74.7% 74.7% 84.7%

Risk Score Rating 0 0 0



Monitor - Organisational Health Indicators 2015-16

MeasureMeasure-Sub

GroupTarget

2015/16Q1 Q2 Q3 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Narrative

Patient Revolution Friends & Family Test Recommended Score (%)

Patient 95% 98.0% 98.3% 98.3% 98.0% Replaces Friends and Family score

Staff Metrics-Executive Turnover Staff2 or less in 6 months

0 1 0 0 Quarterly scores are quarter ending scores. Board turnover figure

Staff Metrics-Staff Satisfaction-Engagement Rates

Staff 75% 75.0% 77.0% 75.0% 75.0% Quarterly scores are quarter ending scores

Staff Metrics - Pulse Check - Recommend DCHS to Friends and

Family as a Place to WorkStaff 71% Quarterly scores are quarter ending

scores

Staff Metrics-Sickness Absence Rate Staff 3% 3.88% 4.4% 4.45% 3.88% Quarterly scores are quarter ending scores

Staff Metrics-Proportion of Temporary Staff (Agency & Bank) as a % of total

workforce costsStaff 5% 2.4% 2.7% 2.4% 2.4% Quarterly scores are quarter ending

scores

Overal Score Rating 1 1 1



Board Performance Report – July 2015

Details – DCHS Balanced Scorecard QUALITY PEOPLE HEADLINES: (pages 13 -14) Key Issues

Total Workforce Costs (£,000) – The year to date costs for our workforce are £28,260k against our target of £28,248k and is amber rated.

Health Visitor WTE (no) – The Trust has a target of 140.5 Health Visitors for the year. We had a total of 142.2 Health Visitors in post. Family Nurse Partnership staff are now commissioned directly by CCGs. This measure has been green rated.

Staff Attendance (%) – Attendance in June has increased to 96.12%. The rolling 12 month attendance is 95.89%. The June absence rate is 3.88%. Long term sickness is 2.55% and short term is 1.33% (long term is those absences over 30 days). Anxiety, Musculoskeletal and Gastrointestinal problems were the main issues this month. The Attendance Management Group meets on a monthly basis to address attendance issues.

Staff Turnover (%) – This measures the movement of employees joining and leaving DCHS and can be an indication that DCHS is viewed as a good place to work. Staff turnover was 10.47% which is green rated against a plan of 14%.

Vacancies - Average Length of Time (days) – The Average Length of Time to Recruit is 46.6 days and is green rated against a target of 60 days. The Average Length of Time from Offer to 1st Working Day is 39.9 days against a target of 40 days and in green rated. The average Length of Time for Pre Appointment checks is 15.0 days against a target of 21 days and is green rated. In June, 10.01 wte posts were not filled first time due to candidates not being suitable or a limited amount of candidates being available for interview.

Essential Learning (% Compliance) – The Essential Learning day covers

the key areas of Core Mandatory Learning identified by DCHS and supports compliance with the NHS Litigation Authority and CQC requirements. All staff are required to complete the Essential Learning Course every two years. 91% of staff have completed their Essential Learning within the past 2 years, as at the end of June. This remains amber rated. Alternative methods of delivering the training including e-learning are being developed to help improve this level of performance.



Information Governance Training (% Compliance) – Information Governance Training needs to be completed annually by all staff. This training can be undertaken by attending the Essential Learning day, completing a workbook or via e-learning. The Trust has a target that at least 95% of staff complete this training annually. As at the end of June the Trust’s performance is 90% of staff being compliant with this training requirement and is red rated. An exception report is presented at page 23.

Fire Training (% Compliance) – DCHS staff are required to complete annual Fire Training. There are a number of delivery methods for this training including e-learning. The Trust has a target that at least 95% of staff receive this training annually. However, this still remains a challenging target with a compliance of 89% in June. This target is red rated. An exception report is presented at page 24.

Training - Resuscitation & Safeguarding (% Compliance) – Resuscitation and Safeguarding compliance have now been reported under separate headings. Analysis of compliance shows that: • 89% of clinical staff have completed Resuscitation Training. • 91% have completed Safeguarding Children Level 2 • 96% have completed level 3, where this is required for their role. • 81% have completed Safeguarding Adults level 2. The Level 1 element for both Adults and Children’s safeguarding is included within the Essential Learning programme that all staff (clinical and non-clinical) undertake every 2 years. The Resuscitation exception report is presented at page 25.

New Starters Attending Induction (% Compliance) – New starters are required to attend induction training. This training can be undertaken by attending the Essential Learning day. The Trust has a target that at least 95% of staff complete this training within one month of starting. As at the end of June the Trust’s performance is 86% of new starters were compliant. This has been red rated. An exception report is presented at page 26.

Staff with Appraisal Completed (% Compliance) – 100% of our staff are

expected to receive an annual appraisal. The aim of appraisals is to provide a comprehensive review of the performance of individual staff, identify any training and development needs and to record their overall contribution to the organisational goals of DCHS. Performance in June remained below this target, with 89% of staff having received an appraisal in the last year. This measure has again been red rated. An exception report is presented at page 27. Directorates are being reminded that they should have a robust process in place to ensure all out of date appraisals are chased and put back on track.



Given the current performance, this remains a key area of focus for DCHS. Further details regarding current performance and improvement plans will presented in an exception report to the Board. QUALITY SERVICE HEADLINES: (pages 14 - 16) Key Issues The HCAI summary is presented at page 18. To date there have been 0 positive Clostridium Difficile results reported for DCHS. Clostridium Difficile figures now include an agreed lapse count, following agreement with our Commissioners. This is discussed in the Quality Report.

The CQUIN summary is presented at page 19. Three Dementia and Delirium measures for Appropriate Assessment, Specialist Referral and Written Care Plans are amber rated for June.

The RTT Waiting Times scorecard is presented at pages 20 & 21. An exception report for the Leicestershire Dental Service is presented at page 28. Nothing has been received back from the Leicestershire Dental service to assess the impact. This will be followed up with the management team at their monthly performance meeting on 28th July 2015.

Patient Revolution – Friends and Family Test (%) – As from January 2015 we report, to NHS England, the percentage of respondents who would recommend our services together with the total number of FFT returns. The June figure for this measure was that 98.0% would recommend our services. This has been green rated against our target of 95%.

Complaints (no) – The number of complaints received in June was 9. This information has been reconciled to DATIX and confirmed by the Patient Support Team.

A&E Targets (rating) – The longest wait is 214 minutes against a target of 360 minutes. This has been green rated. All other A&E targets are also green rated.

Delayed Transfer of Care - OPMH (%) – DCHS have a target to reduce the

time patients stay in an OPMH bed as a result of transfer delays. In June this was 5.2%. This is below the target of 7.5% and is therefore green rated. The year to date score is 4.9%. The Monitor compliance score for quarter 1 is also 4.9% and is also green rated.



Inpatients Average Length of Stay (no) – DCHS have a target to reduce the

average time patients stay in an inpatient bed by increasing the amount of care provided in the community. The average length of stay in June was 21.3 days and the 3 month year to date performance decreased to 21.3 days. This is above the aspirational target of 20 days and is red rated. The service continues to work on reducing the average length of stay. An exception report is presented at page 29.

Total Harm Free Care, In Accordance With Safety Express (%) – The elimination of the four “harms” of Pressure Ulcers, Falls, Urinary Tract Infections and New Venous Thromboembolism fell to a green rated score of 93.1% for June, against the Trust target of 93%. Our year to date target is amber rated at 92.6%. Further information will be presented in the Quality report.

Avoidable grade 2, 3 & 4 Pressure Ulcers (no) – In June 3 instances were recorded. This target is red rated and is discussed in the Quality Report.

Falls Resulting In Severe Injury or Death (no.) – There was 1 fall reported on STEIS in June. This measure remains red rated. Further information will go to the Quality Service Committee (QSC). Falls prevention strategies continue to be developed to reduce the risk of an event. An exception report is presented at page 30.

Integrated Wellbeing-Smoking Quitter & Weight Management Indicators - The new integrated Wellbeing Service contract began in December 2014, replacing the previous smoking measures. This service has been given an overall red rating. Exception reports are presented at pages 31 to 35. QUALITY BUSINESS HEADLINES: (pages 16 - 17) Key Issues

Continuity of Services Risk Rating & Capital Servicing Capacity (%) –The Continuity of Services Risk Rating is 4 & the Capital Servicing Capacity Risk Rating is 4. The will be further discussed in the Finance Report.

Activity Performance (no.) – The majority of service lines are either overperforming against their year to date profiled activity plans, or have very low and therefore recoverable levels of underperformance. Activity in June has been maintained for most specialties. An exception report for Vasectomies is presented at page 36.



FT Membership (no.) – Our Foundation Trust Membership has increased to

12,523 members against our aspiration of 12,500 members and is green rated.

Health Visiting (All Measures ) – We screened 94.5% of babies within 10-14 days in June, against a target of 100% giving a year to date figure of 94.3% which is red rated. In June 94.9% of babies were screened at the 2 to 2.5 year stage, giving a year to date figure of 96.5% which is amber rated. The percentage of mothers who received an antenatal contact in June was 86.5% against a target of 100%. This has been red rated. The year to date measure is also 86.5%, which is also red rated. An exception report is presented at page 37.



.DCHS Board Performance Management Reports July 2015



Month

Measure

Monitor Risk Assurance Framework Scorecard

Scorecards-Monitor Risk Assurance Framework 11 (11) 10 (10) 0 (0) 0 (0) 1 (1)

Scorecards-Monitor Organisational Health Indicators 6 (6) 4 (4) 1 (1) 0 (0) 1 (1)

Totals 17 (17) 14 (14) 1 (1) 0 (0) 2 (2)

DCHS Balanced Scorecard

Quality People 27 (27) 9 (12) 6 (6) 5 (2) 7 (7)

Quality Service - Service User Experience 22 (22) 11 (10) 3 (2) 2 (1) 6 (9)

Quality Service - Service User Safety 20 (20) 13 (13) 1 (1) 2 (2) 4 (4)

Quality Service - Clinical Effectiveness & Planning 4 (4) 1 (1) 1 (1) 1 (1) 1 (1)

Quality Business - Finance 1 (1) 0 (0) 0 (0) 1 (1) 0 (0)

Quality Business - Business & Marketing 16 (16) 8 (8) 2 (3) 2 (1) 4 (4)

Quality Business - IM&T 5 (5) 4 (4) 0 (0) 0 (0) 1 (1)

Quality Business - FT Regime 5 (5) 4 (2) 1 (3) 0 (0) 0 (0)

Totals 100 (100) 50 (50) 14 (16) 13 (8) 23 (26)

Other Scorecards

Scorecards-Healthcare Associated Infections 18 (18) 18 (17) 0 (1) 0 (0) 0 (0)

Scorecards-CQUIN 11 (11) 0 (0) 0 (0) 0 (0) 11 (11)

Integrated Wellbeing 9 (8) 3 (3) 0 (0) 5 (4) 1 (1)

Totals 38 (37) 21 (20) 0 (1) 5 (4) 12 (12)

Grand Total 155 (154) 85 (84) 15 (18) 18 (12) 37 (40)

Percentages Allocated 100% 99% 55% 54% 10% 12% 12% 8% 24% 26%

The previous month totals are shown in bracketsMeasures included:Integrated Wellbeing-Chlamydia

Measures removed:

Derbyshire Community Health Services Board Performance Overview of MeasuresJune-15

Total Number of YTD

Measures Rated Green

Total Number of YTD

Measures Rated Amber

Total Number of YTD Measures

Rated Red

Total Number of YTD

Unrated Measures

Total Number of Measures



Measure Type Frequency Director 2014 / 15 Outturn

2015 / 16 Full Year Target

Year to Date Target

Apr-15 May-15 Jun-15 Trend Year to Date Narrative

Total Workforce Cost (£000s) 12 Internal Monthly DoHR 111,809 114,500 28,248 9,347 9,406 9,507 28,260 Includes Agency & Bank. Plan is from QBC Finance report.

Temporary Staffing Costs - Agency (£000's) 12 External Monthly DoHR 2,192 No target No target 132 78 161 371 Funded by vacancies budget.

Temporary Staffing Costs - Bank (£000's) 12 External Monthly DoHR 1,803 No target No target 171 196 147 514 Funded by vacancies budget.

Agency & Bank Spend (Clinical) as a % of total workforce costs (%) 12 External Monthly DoHR 2.9% 5.0% 5.0% 2.7% 2.4% 2.4% 2.5%

Total Headcount (no) 18 Internal Monthly DoHR 4,128 No target No target 4,115 4,126 4,132 4,132

Health Visitor WTE (no.) 18 External Monthly DoHR 140.3 140.5 140.5 141.1 142.4 142.2 142.2 Family Nurse Partnership Specialist Nurses now contract direct to Commissioners.

Staff Attendance (%) 18 Internal Monthly DoHR 95.82% 97% 97% 95.59% 95.55% 96.12% 95.89% Year to Date is rolling 12 month average. YTD absence rate is 4.25%. NHS absence rate is 4.25% (4.35% East Midlands).

Staff Turnover (%) 18 Internal Monthly DoHR 9.78% <14% <14% 10.27% 10.21% 10.47% 9.97% Year to Date is rolling 12 month average.

Board Turnover (no.) 12 Internal Monthly DoHR 0 2 or less in 6 months

2 or less in 6 months

1 0 0 1

Redundancy (no.) 18 External Monthly DoHR 17 No target No target 0 0 1 1 All posts were sent to RATS for authorisation.

Vacancies - Average Length of Time To Recruit (days) External Monthly DoHR 60 60 47.8 46.6 46.6 46.6 The average length of time from approved vacancy being advertised on NHS Jobs to agreed start date of employment being confirmed including pre-employment checks.

Vacancies - Average Length of Time From Offer to 1st Working Day (days) External Monthly DoHR 40 40 39.9 39.9 39.9 39.9 The average length of time from an agreed offer of employment being made to the applicant commencing employment with DCHS.

Vacancies - Average Length of Time For Pre Appointment Checks (days) External Monthly DoHR 21 21 15.0 15.0 15.0 15.0 The average length of time for pre-employment checks to be completed.

Vacancies - Externally Filled (no.) Internal Monthly DoHR No target No target 50 45 50 50

Vacancies - Internally Filled (no.) Internal Monthly DoHR No target No target 11 14 28 28

Advertised Vacancies (no.) 18 Internal Monthly DoHR 50 No target No target 33 54 34 34

Essential Learning completed (% compliance) 18 Internal Monthly DoHR 93% 95% 95% 92% 92% 91% 91% Year to Date is rolling 12month average-shows compliance at renewal date.

Information Governance Training (% compliance) 18 External Monthly DoHR 95% 95% 95% 93% 92% 90% 90% Year to Date is rolling 12month average-shows compliance at renewal date. Exception report at page 23.

Fire Training (% compliance) 18 External Monthly DoHR 92% 95% 95% 92% 91% 89% 89% Year to Date is rolling 12month average-shows compliance at renewal date. Exception report at page 24.

Training - Resuscitation (% compliance) External Monthly DoHR 88% 95% 95% 87% 88% 89% 89% Year to Date is rolling 12month average-shows compliance at renewal date. Exception report at page 25.

New starters attending induction (compliance %) 18 Internal Monthly DoHR 90% 95% 95% 100% 100% 86% 86% Year to Date is rolling 12month average-shows compliance at renewal date. Exception report at page 26.

Staff with appraisal completed (% compliance) 18 Internal Monthly DoHR 93% 100% 100% 93% 91% 89% 89% Year to Date is rolling 12month average-shows compliance at renewal date. Exception report at page 27.

DCHS BOARD PERFORMANCE REPORT BALANCED SCORECARD 2015-16

Data Quality Score

Focus Area

QU

ALIT

Y PE

OPL

E

WO

RKFO

RCE

MET

RICS

TRAI

NIN

G





Year to Date Target



Data Quality Score

Focus Area

Improvement in Staff Engagement Score (%) Internal Monthly DoHR 77% 75% 75% 75% 75% 75% 75%

Staff Survey - Recommend DCHS to Friends and Family If They Needed Care or Treatment (%) External Monthly DoHR 89% 90% 90% 89% Annual Target - Survey is for November and is available February

Staff Survey- recommend DCHS to friends and family as a place to work (%) External Monthly DoHR 71% 71% 71% 71% Annual Target - Survey is for November and is available February

Pulse Check - Recommend DCHS to Friends and Family If They Needed Care or Treatment (%) External Quarterly DoHR 89% 90% 90% 89% 89% 89% 89% Quarterly- May, Aug, Feb (November score is calculated via the staff survey)

Pulse Check - Recommend DCHS to Friends and Family as a Place to Work (%) External Quarterly DoHR 71% 71% 71% 69% 69% 69% 69% Quarterly- May, Aug, Feb (November score is calculated via the staff survey)

Patient Revolution Friends & Family Test Recommended Score (%) External Monthly DoNQ 98.2% 95% 95% 98.3% 98.3% 98.0% 98.0%

Complaints Received (no.) External Monthly DoNQ 118 No target No target 11 9 9 29 There were 11 complaints in June. 2 complaints have been removed for April & May.

PLACE (score) External Quarterly DoSD 99% 95% 95% 91.0% 91.0%Q1-Looks at the environment in which care is provided and the quality of non-clinical services - food and privacy and dignity. Q2-Looks at cleanliness. Q3-external verification.Q4=Q1. Additional category of dementia has lowered the overall score.

Certification against compliance with requirements regarding access to healthcare for people with a learning disability

External Monthly DoNQ Yes Yes Yes Yes Yes Yes Yes

A&E

RTT Targets (rating) 18 External Monthly DoSD

RTT Waiting Times (Scorecard) 18 External Monthly DoSD Leicestershire Dental Exception Report at page 28.

Choose and Book Targets (rating) Internal Monthly DoSD

Diagnostics - Patients exceeding 6 weeks wait (%) External Monthly DoSD 0.0% <1% <1% 0.1% 0.3% 0.0% 0.0%

Patients who have operations cancelled for non clinical reasons on the day (%) External Monthly DoSD 0.5% <0.8% <0.8% 0.0% 0.0% 0.0% 0.0%

Patients who have operations cancelled for non clinical reasons receiving treatment within 28 days (%)

External Monthly DoSD 100% 100% 100% 100.0% 100.0% 100.0% 100.0%

Mixed Sex Accommodation Breach Rate (No) External Monthly DoSD 0 0 0 0 0 0 0

Delayed Transfer of Care (%) External Monthly DoSD 8.3% <7.5% <7.5% 9.8% 7.8% 7.5% 8.4% Percentage of patients whose discharge is delayed for non clinical reasons (DTOC). Contract calculation for Inpatients & OPMH. Data now taken from BI.

Delayed Transfer of Care for Inpatient (Rehab & Urgent Care) - contract calculation (%) External Monthly DoSD 8.6% No target No target 11.5% 8.1% 8.3% 9.4%

Delayed Transfer of Care for OPMH - contract calculation (%) External Monthly DoSD 6.1% <7.5% <7.5% 2.6% 6.7% 5.2% 4.9%

Delayed Transfer of Care for OPMH - Monitor compliance framework calculation (%) External Monthly DoSD 3.1% <7.5% <7.5% 2.6% 4.7% 4.9% 4.9% Year to date is the Quarterly monitor calculation.

Inpatient (Rehab & Urgent care) Average Length of Stay (days) 18 Internal Monthly DoSD 22.3 20.0 20.0 21.6 21.4 21.3 21.3 Linked to achievement of IBP. Year to Date is 3 month rolling average. Exception report at page 29.

Older Peoples Mental Health Average Length of Stay (days) Internal Monthly DoSD 82.9 No target No target 58.8 39.1 60.5 52.3

FEED

BACK

INPA

TIEN

T SE

RVIC

ESPA

TIEN

T SA

TISF

ACTI

ON

REFE

RRAL

TO

TRE

ATM

ENT





Year to Date Target



Data Quality Score

Focus Area

Inpatient (RUC) Occupancy (%) External Monthly DoSD 80.3% No target No target 75.1% 71.4% 66.3% 66.3%

Older Peoples Mental Health Occupancy (%) External Monthly DoSD 89.3% No target No target 85.4% 86.4% 95.6% 95.6%

LD Occupancy (%) External Monthly DoSD 72.6% No target No target 73.0% 71.0% 67.3% 67.3%

Achievement of consultation /involvement/engagement inclusion priorities (%) Internal Monthly DoHR 100% 100% 100% 100% 100% 100% 100%

New or revised policies/procedures/strategies supported by EIAs (%) Internal Monthly DoHR 85% 87% 87% 85% 73% 84% 84% Percentage of Equality Impact Assessments carried out on approved policies. 4 reports in May failed the requirements.

CQC Registration - Overal (rating) External Monthly DoNQ Pilot still under development, registration with new partners being developed.

CQC Warning Notices currently in effect (no) External Monthly DoNQ 0 0 0 0 0 0 0

CQC Compliance Action Outstanding (no) External Monthly DoNQ 0 0 0 0 0 0 0

CQC Non-Compliance with Essential Standards resulting in Enforcement Action (no) External Monthly DoNQ 0 0 0 0 0 0 0

CQC - Moderate concerns or impacts regarding the safety of healthcare provision (as at time of submission) (no)

External Monthly DoNQ 0 0 0 0 0 0 0

CQC Financial Penalties (no) External Monthly DoNQ 0 0 0 0 0 0 0

CQC Enforcement action within last 12 months (no) External Monthly DoNQ 0 0 0 0 0 0

CQC - Major concerns or impacts regarding the safety of healthcare provision (as at time of submission) (no)

External Monthly DoNQ 0 0 0 0 0 0

CQC Enforcement action (including notices) currently in effect (no) External Monthly DoNQ 0 0 0 0 0 0 0

Total Harm Free Care, in accordance with Safety Express (%) External Monthly DoNQ 92.2% 93% 93% 92.9% 91.9% 93.1% 92.6%

Avoidable Grade 2, 3 & 4 Pressure Ulcers developed or deteriorated in DCHS care (no.) 16 External Monthly DoNQ 63 0 0 8 4 3 15 To be discussed in the quality report.

Total Grade 3 & 4 Pressure Ulcers developed or deteriorated in DCHS care (no.) 16 External Monthly DoNQ 191 No target No target 14 9 16 39

Incidence of Newly Acquired Pressure Ulcers (no.) 16 External Monthly DoNQ 248 No target No target 14 14 21 49

EQU

ALIT

Y

QU

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RVIC

E

SERV

ICE

USE

R SA

FETY

CQC

HAR

M F

REE

CARE

OCC

UPA

NCY





Year to Date Target



Data Quality Score

Focus Area

Medication Errors causing Serious Harm (no.) 16 External Monthly DoNQ 0 0 0 0 0 0 0

Falls resulting in severe injury or death (no.) External Monthly DoNQ 28 0 0 1 3 1 5 Falls reported on Steis. Exception Report at page 30.

Duty of Candour - Failure to notify relevant person of a reportable incident (no) External Monthly DoNQ 0 0 0 0 0 0 0

Healthcare Care Associated Infections - MRSA bacteraemia (no.) 16 External Monthly DoNQ 0 No target No target 0 0 0 0

Healthcare Care Associated Infections - Clostridium difficile (no.) 16 External Monthly DoNQ 12 10 3 0 0 0 0

Healthcare Care Associated Infections - Clostridium difficile -lapses count (no.) 16 External Monthly DoNQ 5 10 3 0 0 0 0

Healthcare Care Associated Infections - E Coli & MSSA (no) 16 External Monthly DoNQ 0 No target No target 0 0 0 0

Monitor Risk Assurance Framework Scorecard (RAF) (rating) External Monthly All 0 0 0 0 0 0 0

CQUIN Scorecard (rating) External Monthly DoSD

IWB Overall Measures (rating) External Monthly DoSD Integrated Wellbeing Contract with DCC. Exception report at pages 31 to 35.

ISH Overall Measures (rating) 12 External Monthly DoSD Integrated Sexual Health Contract with DCC. Under development.

CIP Achieved-Recurrent(%) Internal Monthly DoFPI 100% 19.7% 5.0% 10.8% 18.2% Discussed in the Finance Report

CIP Achieved-Non Recurrent (%) Internal Monthly DoFPI No target No target 0.2% 0.0% 0.0%

Positive media stories (no.) Internal Monthly DoSD 234 No target No target 15 12 10 37

MIU Activity (no.) 18 External Monthly DoSD 55,628 55,876 15,078 5,174 5,155 5,387 15,716

Pulmonary Rehab (no) 18 External Monthly DoSD 525 141 31 47 69 147

Outpatient and Daycase Activity (no.) 18 External Monthly DoSD 58,454 45,251 11,097 3,950 3,421 4,331 11,702

Vasectomy Service Activity (no.) 18 External Monthly DoSD 391 391 102 26 37 28 91 Exception report at page 36.

Podiatric Surgery Activity (no.) 18 External Monthly DoSD 14,865 15,378 3,562 1,317 1,264 1,432 4,013

Community Podiatry Activity-Non AQP (no.) 14 External Monthly DoSD 137,722 149,183 34,698 10,949 11,407 12,587 34,943

Community Podiatry Activity - AQP (no.) External Monthly DoSD 14,115 4,990 1,251 1,132 1,113 969 3,214

Physiotherapy Activity (no.) 15 External Monthly DoSD 120,208 118,833 28,578 9,556 9,461 10,711 29,728

Speech and Language Therapy Activity (no.) 14 External Monthly DoSD 18,639 22,301 5,110 1,966 1,715 1,757 5,438

Diagnostic Imaging (no.) External Monthly DoSD 2,617 2,598 641 217 200 203 620

BUSI

NES

S &

MAR

KETI

NG

ACTI

VITY

MET

RICS

ES

S

FIN

ANCE

CLIN

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EFF

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& P

LAN

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OTH

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AFET

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EASU

RES

82% 18.2%





Year to Date Target



Data Quality Score

Focus Area

Health Visiting Contract (rating) 18 External Monthly DoSD Exception report at page 37.

Health Visiting Activity (no.) 18 External Monthly DoSD 102,208 No target No target 8,002 7,511 8,089 23,602

Community Nursing Activity (no.) 10 External Monthly DoSD 529,084 550,592 136,915 43,887 44,436 47,525 135,848 Complaince shortfall in ecsac for June-Chesterfield 51.9%, Dales 33.3%, NE Derbyshire 22.1%

Community Matron Activity (no.) 15 External Monthly DoSD 17,471 No target No target 1,520 1,967 753 4,240

Rehabilitation and Intermediate Care Activity (no.) 9 External Monthly DoSD 100,924 No target No target 7,026 6,279 7,547 20,852 Community Therapy activity

Community Information Dataset Completeness-Referral to treatment information (%) External Quarterly DoFPI 83% >50% >50% 83% 83% 92% 92%

Community Information Dataset Completeness-Referral information (%) External Quarterly DoFPI 69% >50% >50% 69% 69% 85% 85%

Community Information Dataset Completeness-Treatment activity information (%) External Quarterly DoFPI 75% >50% >50% 75% 75% 85% 85%

Information Governance Incidents Reported via IG toolkit - Level 2 or above (no.) External Quarterly DoFPI 0 0 0 0 0 0 0

Information Governance Toolkit Achievement - measures scoring 2 or better (no) External Monthly DoFPI 39 Awaiting Awaiting 0 Toolkit not yet released.

Continuity of Services-Liquidity Ratio (days.) (Monitor Shadow Format) External Monthly DoFPI 4 4 4 4 4 4 4

Continuity of Services-Capital Servicing Capacity (times.) (Monitor Shadow Format) External Monthly DoFPI 4 4 4 1 2 4 4 Discussed in the Finance Report

Continuity of Services-Risk Rating (Monitor Shadow Format) External Monthly DoFPI 4 4 4 3 3 4 4 Discussed in the Finance Report

FT Membership (no.) Internal Monthly DoSt 12,520 12,500 12,500 12,514 12,505 12,523 12,523

QU

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SIN

IM&

TFT

REG

IME



Measure Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 YTD

ESBL - Avoidable (No.) 0 0 0 0

ESBL - Possible (No.) 0 0 0 0

ESBL - Unavoidable (No.) 0 0 0 0

MRSA Infections Incidence 0 0 0 0

MRSA Infections Lapse in care 0 0 0 0

ESBL Infections Incidence 0 0 1 1

ESBL Infection Lapse in care 0 0 0 0

Norovirus outbreaks Incidence 0 1 0 1

Norovirus outbreaks Lapse in care 0 0 0 0

MRSA Bacteraemia Incidence 0 0 0 0

MRSA Bacteraemia Lapse in care 0 0 0 0

Clostridium Difficile Incidents 0 0 0 0

Clostridium Difficile Significant Lapse in care 0 0 0 0

Clostridium Difficile Minor Lapse in care 0 0 0 0

MSSA Bacteraemia Incidence 0 0 0 0

MSSA Bacteraemia Lapse in care 0 0 0 0

E.coli Bacteraemia Incidence 0 0 0 0

E.coli Bacteraemia Lapse in care 0 0 0 0

HEALTHCARE ASSOCIATED INFECTION SCORECARD 2015-16

Focus AreaSE

RVIC

E U

SER

SAFE

TY

HCAI

There are no MRSA infections to report for June 2015

ESBL infection Patient One – Rowsley Ward, Newholme Hospital (22.06.2015)This patient was transferred from Chesterfield Royal Hospital Foundation Trust following a fall resulting in a fractured femur. On admission to Rowsley Ward, the patient is immobile and their continence needs are met using continence pads. Due to the patient’s reduced mobility and the use of continence pads, this patient is at risk of urinary tract infection. It is not clear what the trigger was for this episode of infection. The patient was effectively treated with antibiotics.

Clostridium difficile infectionsThere are no C difficile infections to report for June 2015

Norovirus OutbreaksThere were no outbreaks during June 2015.



Measure TypeFrequency of

ReportingDirector 2014/15 Full Year Target YTD Target Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 YTD

Forecast Outturn

Narrative

Dementia and Delirium N1a (i) Monthly DoNQPatients aged 75 years who are appropriately

assessed (%)90% or > from Q3 100.0% 79.0%

Dementia and Delirium N1a (ii) Monthly DoNQThose identified as potentially having dementia or

delirium who are appropriately referred on to a specialist service (%)

90% or > from Q3 47.0% 83.0%

Dementia and Delirium N1a (iii) Monthly DoNQ

Those identified, and referred for further diagnostic advice in line with local pathways agreed with

commissioners, who have a written care plan on discharge which is shared with the patient’s GP (%)

90% or > from Q3 86.0% 33.0%

Dementia and Delirium N1bMonthly data,

quarterly reporting

DoNQTo ensure that appropriate dementia training is available to staff through a locally determined

training programme% of staff trained - TBC Q1

Training part of rolling programme being delivered across community services. Internal trajectories being

developed.

Dementia and Delirium N1cMonthly data,

biannual reporting

DoNQEnsure carers of people with dementia and delirium

feel adequately supportedNo. of carers supported

First contact form in use on wards and being rolled out to community. To be incorporated in Quality Always

Reducing Avoidable Emergency Admissions

To HospitalN2

Monthly data, quarterly reporting

DoNQReducing the proportion of avoidable emergency

admissions to hospital (%)

TBC - Baseline and targets for increase in MIU ambulance transfers to be agreed Q1

DCHS pending KPIs from EMAS following launch of Paramedic Pathfinder Triage tool

Pressure Ulcers L3 Quarterly DoNQContinued focus in the good work undertaken in

2014/15 with patients and carers relating to pressure ulcer prevention and care

Impovement against baseline RCA position following training

Workshops with commnity nursing pilot teams has now commenced

Compassion and Culture

L4 Quarterly DoNQ

DCHS will continue to enhance patient experience of compassionate care across the organisation and

ensure delivery of a relevant work programme to improve care

Delivery against KPIs - TBC Q1Compassion and Culture KPIs now agreed with

commissioners

End of Life L5Monthly data,

quarterly reporting

DoNQImprove communication and coordination of patient

care at their End of Life.% of staff training - TBC

End of Life training programme continuing to roll out. Internal trajectories being developed.

Community Nursing and Therapy

L6 Quarterly DoNQImplementation of the key workstreams following the

Community Nursing activity review undertaken in 2014/15

Quarterly report on progressBRAVO tool roll-out commenced 15th June 2015 for 2

weeks. Analysis and results to be undertaken in Q3.

Transfer of Care and Patient Flow

L7 Quarterly DoNQImprove the transfer/admission of appropriate in-patients from Stockport NHS Foundation Trust into

DCHS through joint workingQuarterly report on progress Action plan now agreed.

NHS DERBYSHIRE COUNTY CCGs AND ASSOCIATES CONTRACT

Focus Area

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PATI

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EXPE

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AFET

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CQUIN INDICATORS 2015-16

We are still currently embedding the data collection process for the Dementia CQUIN this year and so only

have partial results and which are subject to lower scores due to completion errors. Work is ongoing to

further develop the pathway with clinical staff.



AHP-Led Referral to Treatment Schedule in Weeks (June 15) - Clocks ended in June

Service Line 0-6 7 - 12 13 - 17 18+Total

WaitersMax

Waiter>6 week

waiter total% Waiting over 6w

>13 week waiter total

% Waiting over 13w

Planned CareAVE MOPP 2409 353 15 3 2780 30 371 13.3% 18 0.6%CHE MOPP 1896 265 15 3 2179 20 283 13.0% 18 0.8%HPD MOPP 1376 74 0 0 1450 11 74 5.1% 0 0.0%Speech and Language Therapy 586 113 8 1 708 29 122 17.2% 9 1.3%

ICBSAV 330 41 6 3 380 27 50 13.2% 9 2.4%ERE 317 42 0 1 360 27 43 11.9% 1 0.3%SDSD 220 16 1 0 237 17 17 7.2% 1 0.4%CHE 225 66 2 0 293 13 68 23.2% 2 0.7%Disability Services 11 1 0 0 12 8 1 8.3% 0 0.0%Respiratory Services 69 64 2 0 135 15 66 48.9% 2 1.5%Learning Disabilities 24 10 1 12 47 91 23 48.9% 13 27.7%

All Services 7463 1045 50 23 8581 91 1118 13.0% 73 0.9%

Specialty 0-6 7 - 12 13 - 17 18+Total

WaitersMax

Waiter>6 week



% Waiting over 18w

General Surgery 13 19 31 0 63 17 50 79% 0 0%Urology 15 30 5 1 51 18 36 71% 1 2%Trauma & Orthopaedics 14 32 11 7 64 28 50 78% 7 11%Ear, Nose & Throat (ENT) 0 1 4 1 6 26 6 100% 1 17%Ophthalmology 20 49 13 1 83 21 63 76% 1 1%Oral Surgery 0 0 0 0 0 0 0 0% 0 0%Neurosurgery 0 0 0 0 0 0 0 0% 0 0%Plastic Surgery 0 0 0 0 0 0 0 0% 0 0%Cardiothoracic Surgery 0 0 0 0 0 0 0 0% 0 0%General Medicine 0 0 0 0 0 0 0 0% 0 0%Gastroenterology 0 0 0 1 1 19 1 100% 1 100%Cardiology 0 0 0 0 0 0 0 0% 0 0%Dermatology 10 24 17 3 54 20 44 81% 3 6%Thoracic Medicine 0 0 0 0 0 0 0 0% 0 0%Neurology 0 0 0 0 0 0 0 0% 0 0%Rheumatology 0 0 0 0 0 0 0 0% 0 0%Geriatric Medicine 0 0 0 0 0 0 0 0% 0 0%Gynaecology 0 0 0 0 0 0 0 0% 0 0%Other 0 0 0 0 0 0 0 0% 0 0%DCHS Dental 66 53 6 0 125 16 59 47% 0 0%Leics Dental 25 30 5 8 68 31 43 63% 8 12%All Services 163 238 92 22 515 31 352 68.3% 22 4.3%

Consultant-Led Referral to Treatment Schedule in Weeks (June 15) - Clocks ended in June - Admitted Patient Care (Part 1A - Adjusted)



Specialty 0-6 7 - 12 13 - 17 18+Total

WaitersMax

Waiter>6 week



% Waiting over 18w

Planned CareGeneral Surgery 30 5 6 2 43 22 13 30% 2 5%Urology 5 5 5 0 15 17 10 67% 0 0%Trauma & Orthopaedics 57 32 17 9 115 23 58 50% 9 8%Ear, Nose & Throat (ENT) 29 40 14 4 87 22 58 67% 4 5%Ophthalmology 60 32 20 1 113 18 53 47% 1 1%Oral Surgery 0 0 0 0 0 0 0 0% 0 0%Neurosurgery 0 0 0 0 0 0 0 0% 0 0%Plastic Surgery 0 0 0 0 0 0 0 0% 0 0%Cardiothoracic Surgery 0 0 0 0 0 0 0 0% 0 0%General Medicine 0 0 0 0 0 0 0 0% 0 0%Gastroenterology 7 4 3 0 14 17 7 50% 0 0%Cardiology 3 2 0 0 5 9 2 40% 0 0%Dermatology 25 72 6 0 103 17 78 76% 0 0%Thoracic Medicine 0 0 0 0 0 0 0 0% 0 0%Neurology 0 0 0 0 0 0 0 0% 0 0%Rheumatology 0 0 5 0 5 16 5 100% 0 0%Geriatric Medicine 4 1 1 0 6 15 2 33% 0 0%Gynaecology 17 8 6 1 32 18 15 47% 1 3%Other 12 7 1 0 20 14 8 40% 0 0%

Total 249 208 84 17 558 23 309 55.4% 17 3.0%

Specialty 0-6 7 - 12 13 - 17 18+Total

WaitersMax

Waiter>6 week



% Waiting over 18w

Planned CareGeneral Surgery 91 63 21 1 176 18 85 48% 1 1%Urology 65 15 5 1 86 19 21 24% 1 1%Trauma & Orthopaedics 174 67 36 9 286 19 112 39% 9 3%Ear, Nose & Throat (ENT) 29 45 7 1 82 19 53 65% 1 1%Ophthalmology 126 48 23 4 201 19 75 37% 4 2%Oral Surgery 0 0 0 0 0 0 0 0% 0 0%Neurosurgery 0 0 0 0 0 0 0 0% 0 0%Plastic Surgery 0 0 0 0 0 0 0 0% 0 0%Cardiothoracic Surgery 0 0 0 0 0 0 0 0% 0 0%General Medicine 0 0 0 0 0 0 0 0% 0 0%Gastroenterology 16 14 1 0 31 17 15 48% 0 0%Cardiology 22 11 2 2 37 19 15 41% 2 5%Dermatology 21 47 0 0 68 12 47 69% 0 0%Thoracic Medicine 0 0 0 0 0 0 0 0% 0 0%Neurology 0 0 0 0 0 0 0 0% 0 0%Rheumatology 0 6 2 0 8 17 8 100% 0 0%Geriatric Medicine 5 1 0 0 6 8 1 17% 0 0%Gynaecology 45 16 2 0 63 17 18 29% 0 0%Other 10 10 7 0 27 17 17 63% 0 0%

DCHS Dental 95 21 3 0 119 16 24 20% 0 0%Leics Dental 25 30 5 8 68 31 43 63% 8 12%Total 724 394 114 26 1258 31 534 42.4% 26 2.1%

Consultant-Led Referral to Treatment Schedule in Weeks (June 15) - Clocks ended in June - Non-Admitted Patient Care (Part 1B)

Consultant-Led Referral to Treatment Schedule in Weeks (June 15) - Clocks still running (Part 2)



DCHS Performance Exception Reports July 2015



Measure Type Frequency Director

2015/16 Full Year Target

YTD Target Q1 Apr-15 May-15 Jun-15 YTD

Staff with appraisal completed (% compliance) External Monthly DoHR 100% 100% 90% 93% 92% 90% 90%

1-Summary of Issues:

2-Action Plan: (actions taken, including assignment of responsibility for this plan)

3-Timescales

Forecast plan is to reach a compliance of 95% by January 2016 and maintain this until the end of the financial year.

4-Effect of this Exception on the Forecast Plan (how we get to our final forecast position from here)

No changes to forecast plan.

Exception Report Analysis

Information Governance training is below target at 90% compared to a target of 95% of staff trained.

All managers and staff receive a notification through ESR to alert them when their IG training is due to expire. Regular compliance reports are sent out by the People and Organisational Effectiveness Team and these are reviewed at performance meetings.There are a variety of methods by which staff can complete IG training and therefore meet their training competency on ESR.All staff are reminded of the need to complete mandatory IG training in the IG Bulletin and should be reminded by managers at appraisal.

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

% o

f Sta

ff Tr

aine

d

Month

Information Governance Training (% compliance) - June

% Staff Compliant

% Target Profile

Forecast (%)




2015/16 Full Year

TargetYTD Target Q1 Apr-15 May-15 Jun-15 YTD

Fire Training (% compliance) External Monthly DoHR 100% 100% 89% 92% 91% 89% 89%



3-Timescales

Target figure of 95% should be achieve by the end of the financial year.


We would expect that the overall figure will rise in the later months of the year when the main holiday period comes to an end, this coupled with the proactive approach of monitoring attendance at training by the managers and directors as recommended in 2 above should see the target figure of 95% achieved by the end of the financial year.


Fire safety training for the last 12 months from the end of June 2015 is shown as 89% against a target figure of 95%. This isn't unusual for this time of year which includes holiday times etc. and the figures usually take an upturn during the later months.

Fire training along with all other essential training is managed by the staff managers and departments who should be proactive in ensuring that their staff have undertaken the respective training, Directors should also be ensuring that their department managers are effectively overseeing staff training and achieving the relevant attendance figures.

These figures can, however, be deceptive in that staff can have some difficulty booking onto essential training days before their training runs out because the courses can be fully subscribed.

If staff can't get onto an Essential Training day there are several other options available for them to be able to achieve their training in the respective time frame.

These are ELearning, fire workbook or attendance at one of the “on site” fire training sessions undertaken throughout the trust.

The “on site” fire training sessions are rarely over subscribed, so there appears to be plenty of capacity available. It’s the actual attendance that requires a proactive approach by managers.

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%


% o

f Sta

ff Tr

aine

d

Month

Fire Training Exception Report (% compliance) - June

% Staff WithTrainingCompleted

% Target Profile

Forecast



Measure Type Frequency Director2015/16 Full Year Target


Resus Training (% compliance) External Monthly DoSD 95% 95% 89% 87% 88% 89% 89%


2. Action Plan

3-Timescales



Although there is a further slight improvement this month, training compliance remains below target. Training places are still being lost, either through remaining as unbooked or through non-attendance - It is vital that all places are fully utilised in order to ensure sufficient capacity to provide training for all staff by the end of the year.

The overall forecast figures are based on numbers of staff whose competency expires in any given month compared with the number of training places currently booked. An allowance of 11% (based on the current 89% compliance rate) is also made, to allow for staff who are overdue for their training. However, the forecast figure does not reflect the variations in compliance within the different elements of Resuscitation training, so work needs to be done to ensure that the supply of training places for each element meets the demand. It should be noted that forecast compliance will be expected to improve throughout the year as more staff book on to courses. It also needs to be borne in mind that the staff booked on the training may not be the staff whose competency expires in that particular month. Attendance can be improved by further clarification, and simplification, of resuscitation training requirements so that

l l f h i ff h i li i h h i d i f ll ili i f i i l

The revised resuscitation training matrix has been operational from 1 April 2015

An over-supply of places is planned on resuscitation courses to ensure there is capacity and flexibility to meet demand, and allow for non-attendance for reasons such as sickness. However, if large numbers of training places are unfilled, there will be insufficient capacity for staff who should have attended courses earlier in the year to be accommodated on later sessions - managers must plan release of staff throughout the year to ensure that utilisation of available training places is maximised. This message will be reiterated via the Workforce Planning and Development sub-group, for cascading to service leads and managers. The team also continues to work to ensure that the appropriate training is identified for all roles, and that staff and managers are clear about the training they need to do.

87% 88% 89%

0%

20%

40%

60%

80%

100%

120%


%ag

e Co

mpl

ianc

e

Month

Resus Training (%)

YTD Target (%)

Forecast (%)

Resus Training (% Compliance) - June



Measure Type Frequency Director 2015/16 Full Year Target


Resus Training (% compliance) External Monthly DoSD 95% 95% 86% 100% 100% 86% 86%


2. Action Plan

3-Timescales



Whist the data shows a 14% decrease in compliance rates for the period 31st May - 30th June 2015, there were an outstanding number of June new starters who had not been entered onto ESR in a timely manner.

This has been due to a time lag in the administration processes. The status of some have staff had not been updated to that of ‘employee’. New Starter competences were therefore unable to be added to their account by the month end.

This has resulted in a low compliance rate on ESR.

Timely entery of training data will ensure accurate reporting. This should signficantly improve compliance resulting in acheivement of full year target set at 100%

A forecast of 100% compliance is anticipated by end of March 2016 .

it is anticapated that all oustanding staff will be entered onto ESR as an urgent action. This will ensure accurate data will be reported in all future reports, This inturn should positively impact on compliance rates.

100% 100%

86%

75%

80%

85%

90%

95%

100%

105%


%ag

e Co

mpl

ianc

e

Month

StartersAttendingTraining (%)

YTD Target(%)

Forecast (%)

New Starters Attending Induction (% Compliance) - June






Staff with appraisal completed (% compliance) External Monthly DoHR 100% 100% 89% 93% 91% 89% 89%



3-Timescales

A forecast of 100% compliance is anticipated by end of March 2016 .


It is anticipated that the proposed additional training, re-issuing of guidelines and further reminder letters and direct contact with line mnagers should signficantly improve compliance resulting in acheivement of full year target set at 100%


For the period 31st May - 30th June 2015 there has been a 2% decrease in compliance rates falling from 91- 89%. This still falls below the forecast target of 91% .

The workforce Planning and development team will continue to monitor compliance on a monthly basis. Inorder to address inputting errors the Workforce Planning and Development Team will re issue ESR mangers guide and tips with balance score card to service mangers so as to clarify the process for those staff whom have more than one assignment number. At the request of service additioanl ESR training sessions have been arranged for 2015/16.

75%

80%

85%

90%

95%

100%

105%

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 % o

f Sta

ff W

ith C

ompl

eted

App

rais

als

Month

Staff With Appraisals Completed (% compliance) - June

% Staff WithAppraisalCompleted

% Target Profile

Forecast





YTD Target Apr-15 May-15 Jun-15 YTD

RTT Waiting Times-Consultant Led-APC-Dental Services Leicester(no) National Monthly DoSD 0 0 7 6 8 8

RTT Waiting Times-Consultant Led-APC-Dental Services Leicester(%) National Monthly DoSD 10% 10% 11.1% 8.6% 11.8% 11.8%

53.4% 53.4%



3-Timescales



Until additional funding secured from NHS England the service will not be able to consistently meet RTT.

End of August

To date - additional waiting list theatre sessions held, relationships develop with University Hospital Leciester, and development of 18 RTT rule suite with TDA.

Further actions required - Funding bid submitted to NHS England to fund additional assessment clinics and theatre slots. Commissioners have approved four additional general aneasthetic sessions, however still awaiting decision on clinic assessments.

Ongoing capacity and demand issues across the Leciester Dental General Aneasthetic service in both assessment clinics and theatre slots resulting in the inability to achieve a 18 week pathway.

23.7% 11.3% 11.1% 8.6% 11.8%

27

15

7 6

8

0%

5%

10%

15%

20%

25%

0

5

10

15

20

25

30

Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16

% o

f Pat

ient

s >1

8 W

eeks

Num

ber o

f Pat

ient

s

Month

% Patients >18weeks

Number ofPatients >18weeks

ForecastNumber ofPatients >18weeks

RTT Waiting Times - Consultant Led - APC - Dental Services - Leicester (no & %) - June





Inpatient Average Length of Stay (days) External Monthly DoSD 20 20 21.6 21.4 21.3 21.3



3-Timescales



There were 4 breaches in June:-

Clay Cross ( 25.1days), Whitworth (29.3 days), Ilkeston ( 22.1 days) and St Oswalds (26.8) days.

Clay Cross length of stay decreased significantly, from 33.2 days the previous month. This was because of family dynamics and Home of Choice arrangements, another patient required a specialist wheelchair before discharge. 2 further patients opted to receive complex rehab at Clay Cross, one of those declined transfer to a specialist unit in Sheffield.

On Oker ward at Whitworth delays were attributed to:- 2 non weight bearing patients. 1 very complex discharge involving safeguarding. Dispute with social care regarding capacity assessment. 2 patients who were rehabilitated but than became clinically unwell. Oker ward have also struggled to get care managers assigned for patients from the Chesterfield area, this has been escalated.

St Oswalds too had a significant increase in length of stay up from 18.2 days in May. Reasons here were attributed to:- 1 patient non weight bearing and refused to consider respite care. 2 patients wanted to return home but, then, changed their mind and required placement. 1 patient waited for continuing care assessment and decision for 3 weeks. 2 patients were delayed due to patient choice re care home. During the month we also had limited occupational therapy due to AL and sickness.

Ilkeston only had a very small increase in length of stay from 19.9 to 22.1. Reasons being:-3 complex patients all requiring additional rehab and then some delays in d/c.2 were from out of area and both needed 4 calls, with one of these we also struggled to get equipment from different equipment provider, the third was trying to find placement in a suitable care home (was declined by a couple ) and was under home of choice.

3 wards Bolsover ( 17.3), Cavendish (17.0) and Newholme( 16.4) were all down from breaching LOS in May. Babington (18.7) and Ripley (10.3) maintained their LOS under the target. The table embedded shows the length of stay at all wards over the last 3 months.

The LOS will be reviewed at the bi-monthly patient flow strategy meeting with the GMs present. LOS is also discussed with GMs at the locality performance management meeting with the Deputy Director of Ops and also with the GMs in their 1:1 meetings with the Deputy Director. Individual GMs are putting in action plans in place with their MDTs.

21.6 21.4 21.3

22.2 21.9 21.3 15.0

16.0

17.0

18.0

19.0

20.0

21.0

22.0

23.0


Days

Month

Monthly Length of Stay(days)

Average Length of Stay(3 month rolling ave)

Target

Monthly Length of StayForecast (days)

Inpatient Average Length of Stay (days) - June






Falls resulting in severe injury or death (no.) External Monthly DoNQ 0 0 5 1 3 1 5


2-Action Plan: (actions taken, including assignment of responsibilty for this plan)

3-Timescales



Incident ref W47986 During a falls assessment at home Patient complained of pain when transferring out/in to bed. On examination her right leg appeared shortened and externally rotated. A fracture right neck of femur was confirmed. Reported as STEIS as patient under the care of Community Matron prior to referral.

DCHS' Falls Strategy for 2015/16 has been submitted to the June 2015 QSC meeting and further revised points are being drafted. On its completion, falls reduction targets will be identified. A number of initiatives for reducing falls include a wristband scheme (where patients at risk are easily identified to enable early assistance) also Paroseals (http://www.parorobots.com/) have been purchased which will be introduced onto the wards including OPMH ward - these robots have been shown to have a psychological effect on patients, improving their relaxation and motivation and have been found to be an improvement factor in other NHS Trusts. Whilst falls remain a major concern for patient safety and the number of falls is seen as a marker of care quality, DCHS' Falls Strategy will base itself on the premise outlined by NHS England which is to reduce the overall harm from falls without compromising the dignity, independence and rehabilitation of our patients.

0

1

2

3

4


No

Month

Falls Resulting in Severe Injury or Death - June

Falls Resultingin Severe Injury(no)



Measure Type Frequency Director2015/16 Full Year Target (Nov-Dec)


IWB Overall Measures (rating) External Monthly DoSD

CO or Cotinine Verified Quits At 4 weeks (%) cumulative External Monthly DoSD 85% 75% 10.2% 7.4% 8.8% 10.2% 10.2%

CO or Cotinine Verified Quits At 12 weeks (%) cumulative External Monthly DoSD 85% 75% 3.1% 2.7% 3.7% 3.1% 3.1%

4 Week Quitters (no) cumulative External Monthly DoSD 400 200 205 135 171 205 205



3-Timescales



Most of the stop smoking support within the Specialist Stop Smoking Service is delivered by telephone support. This method of support is popular with clients and results in high quit rates, however, it is challenging encouraging clients to attend a face to face session at 4 and 12 week follow points simply to obtain a CO reading.

Face to face sessions set up and clients being booked on so an increase in CO monitored 4 week quits is already seen in June and this should continue to increase for July reporting and an increase in CO monitoring of 12 week quits in September resulting directly from these sessions. Once there is agreement from Pharmacy Providers to undertake the CO monitoring on behalf of the Specialist Stop Smoking Service a further increase in CO monitored quits will be seen. Face to face sessions are continually being reviewed to ensure that they are delivered in areas and venues that clients want to attend. Chesterfield and Swadlincote drop ins have proved very popular and these are not being converted to rolling groups which evidence shows allow more clients to attend and with the support of fellow quitters results in increased quit rates.The resolution of this and date for such is entirely dependant on DCC PH Commissioners.Currently we are in discussion with DCC commissioners and Execs re resolution of the Accredited Provider Market issue. Latest deadline for position from DCC 21st July. DCHS Execs will then make a decision re how to manage the continuing financial and service risk.

In order to improve the CO validation rate. Clients are informed at booking onto the service and at each weekly follow up that they will be required to attend a local venue to undertake a CO reading at the 4 and 12 week follow up point. In addition to this a number of face to face Stop Smoking sessions have been set up at venue across the county to encourage clients to attend regular sessions where CO readings will be taken routinely. Work still continues with engaging Pharmacy providers within the Accredited Provider network to undertake routine CO monitoring for Specialist Service clients at the points that they collect their NRT or other Stop Smoking medication.Commissioners have agreed to lower CO validation required to 75% for the first year to reflect challenge with telephone support which are also reflected nationally. Various new and innovative options for obtaining CO validation are being explored and costed if appropriate. This options include saliva and urine cotinine testing (only possible if clients are not using nicotine products), incentivising pharmacies to undertake CO monitoring, visiting clients in their own home to obtain readings etc. DCHS in ongoing discussion with DCC PH Commissioners regarding the CO verification requirement and its link to remuneration for 4 and 12 week quits.

26 30 68

94

135

171 205 238

271 304

337 370

0.0% 5.0%

9.7% 6.9% 11.4% 14.3%

17.6% 17.6% 17.6% 17.6% 17.6% 17.6%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

0

50

100

150

200

250

300

350

400

450

Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15

Num

ber o

f Clie

nts

Month

4 Week QuittersCumulative (Actual)

4 Week QuittersCumulative (Forecast)

CO or Cotinine VerifiedQuits At 4 WeeksMonthly % (Actual)

5 Week QuittersCumulative (Forecast)

4 Week QuittersCumulative (Target)

CO or Cotinine VerifiedQuits At 4 WeeksMonthly % (Target)

IWB Overall Measures - Specialist Stop Smoking Services - June






Pregnant Smokers Enrolled (no) cumulative External Monthly DoSD 456 228 133 74 82 133 133

Smokers Setting Quit Date - At Least 1 Incentive (no) cumulative External Monthly DoSD 283 142 65 33 34 65 65



The annual target takes into account the number of pregnant smokers across Derbyshire including women who will be delivering their babies at Royal Derby Hospital and other out of area hospitals where Derbyshire women will deliver. Currently only Chesterfield Royal Hospital are partners in the Pregnancy Financial incentives scheme and only women who are seen by Midwife from this Hospital are able to be supported to stop smoking on the scheme. It is the responsibility of Commissioners to engage other Hospitals to enable DCHS to deliver PFIS in other Hospital settings.

The roll out to Royal Derby Hospitals will depend on DCC Public Health Commissioners, Public Health Commissioners in Derby City and Royal Derby Hospital. Within the service specification it claerly states that Commissioners will need to support the engagement from other Acute settings.At the DIWA strategy meeting(Derbyshire Integrated Wellbeing Approachg) on 16th July it was raised and minuted that without DCC providing the agreement for PFIS from Derby Royal ,the KPI target will have to be reviewed and reflect that the service is only being delivered from Chesterfield. Additional Midwife training at Chesterfield Royal Hospital is planned to be completed by end of July 2015. The training has been carried out but there are still some Midwives who are yet to have the training due to pressure of work, annual leave etc. Further training is being arranged.

In order to ensure that all women seeing midwives at Chesterfield Royal Hospital are referred into the scheme further training is being undertaken with midwives. The Live Life Better Service Manager is liaising closely with Public Health



3-Timescales

0 4 23

37

74 82

133

0 3 14 23 33 34 65

152 171

190 209

228

74 93

112 131

150

0

50

100

150

200

250

300

350

400

450

500


Num

ber o

f Clie

nts

Month

Smokers EnrolledCumulative (Actual)

Smokers Setting QuitDate - At Least 1Incentive Cumulative(Actual)

Smokers EnrolledCumulative (Forecast)

Smokers Setting QuitDate - At Least 1Incentive Cumulative(Forecast)

Smokers EnrolledCumulative (Target)

Smokers Setting QuitDate - At Least 1Incentive Cumulative(Target)

IWB Overall Measures - Specialist Stop Smoking - Pregnancy - Cumulative - June






Achieving >5% Weight Loss at 12 Weeks (no) cumulative External Monthly DoSD 586 293 252 147 201 252 252

Achieving >5% Weight Loss at 52 Weeks (no) cumulative External Monthly DoSD 586 293 33 16 33 33 33





We have the capacity re sessions now in place but are reliant on the referrals into the service. We expect to deliver the 60% target against current Dec-November activity required however the Commissioners are currently reprofiling the activity to align the 'Contract years' with Financial years.Reprofiling due in July. Launch of website which will support increase in referrals to the service is still awaiting agreement between DCHS and DCC re change to service specification for Website. DCC considering varaition to contract to allow DCHS to transact this. Next DIWA(Derbyshire Integrated Wellbeing Approach) Strategy Meeting 3rd August. DCHS will then be able to proceed with website development. Planning for website to be in place for end of September . To achieve the number of clients needed through the service is dependant on this which has an 8 month delay from where we expected to be due to requirements of procurement processes and commissioners requirements.

More groups have been set up and are running, but not yet to full capacity. Leaflets and posters have now been agreed with commissioners and are being distributed across the county. MECC training is beginning to escalate and is raising awareness. Plan to introduce our LLBD MECC training within ICBS and planned care teams within DCHS. Numbers are increasing month on month and we are on track to achieve the commissioner year 1 target of 60%, but we need the full 100% year 2 target to cover the staffing costs which are not achievable in year 1. Continued discussion with PH commissioners at fortnightly Strategic implementation meetings.

Higher number of referrals into the service needed in order to meet targets which are linked to payments. There is likely to be a shortfall of income to meet the staff costs in the first year due to time needed to set up new courses and inability to launch and market the service effectively due to DCC branding and lack of accredited provider market. 5% 52 week weight loss will not be against targets until start of 2nd year.

3-Timescales

9 9 9 15 16 33 33 15 55 75

110 147

201 252

38 42 47 52 57

288 324

360 396

432

0

100

200

300

400

500

600

700


Num

ber o

f Clie

nts

Month

Achieving >5% WeightLoss at 52 Weeks(Actual)Achieving >5% WeightLoss at 12 Weeks(Actual)Achieving >5% WeightLoss at 12 Weeks(Forecast)Achieving >5% WeightLoss at 52 Weeks(Forecast)Achieving >5% WeightLoss at 52 Weeks(Target)Achieving >5% WeightLoss at 12 Weeks(Target)

IWB Overall Measures - Community Weight Management - Cumulative - June






Community Smoking Cessation - 4 week Quitters (no) cumulative External Monthly DoSD 2,257 1,129 438 253 334 438 438

Community Smoking Cessation - 12 week Quitters (no) cumulative External Monthly DoSD 752 376 64 9 21 64 64



Despite the lack of engagement the number of quits delivered by the accredited provider network continues to increase. One Accredited Providers Schenk Walker who is contracted to deliver a Telephone support helpline and workplace stop smoking support continues to provide a large proportion of the quits from the network and is achieving good quit rates and client satisfaction. However, obtaining CO validated quits is also challenging for this provider to such an extent that the Provider is considering the viability of continuing to deliver.

The £3.80 supply fee for NRT has currently been extended until the end of July 15. A new module has been developed on the current Quit Mnager system to simplify the claiming process for Accredited Providers for NRT Provision and 4 and 12 week quits. This should be ready for roll out early September. It is intended to pilot the new module with a small number of Accredited Providers in August 15. The increase in activity for this service is entirely dependant on agreement with DCC and DCHS Execs regarding the finacial risk attached to this to enable re enagement with Accredited Providers with an acceptable financial remuneration for Counselling and NRT supply. Feedback due to DCHS re this 21st July 2015.



The establishment of a robust Accredited Provider Network has faced a number of challenges over the last few months. The initial expressions of interest provided by DCC prior to the award of the tender failed to reflect the level of engagement from Accredited Providers that had been anticipated. There was an initial uptake by Pharmacy providers including two of the larger chains (Peak and Manor Pharmacies) to deliver the NRT supply element of the contract and also to a lesser degree the provision of stop smoking support. This was being delivered by sign up to an MOU. Even with the large chains on board there were some areas of the county where clients found it difficult to access NRT supply locally. In April when the contract setting out the requirements for provision of support and NRT provision were distributed to Accredited Providers there was a general disengagement from Providers. The reasons for this disengagement ranged from the onerous requirement for staff training to the fact that there was no supply fee paid for NRT and this rendered the contract not economically viable.

3-Timescales

Two of the larger Pharmacy chains (Peak and Manor Pharmacies) are still relunctant to deliver the NRT supply element of the contract and also to a lesser degree the provision of stop smoking support until a contract that is more sustainable and long term than being reviewed on monthly basis is available. There remain some areas of the county where clients find it difficult to access NRT supply locally. Tentative agreements to deliver both NRT supply and Stop Smoking Support have been obtained from Co op and Lloyds Pharmacies. Support and encouragment is being offered to the individual Pharmacies in these chains to enable them to deliver services. In April when the contract setting out the requirements for provision of support and NRT provision were distributed to Accredited Providers there was a general disengagement from Providers. The reasons for this disengagement ranged from the onerous requirement for staff training to the fact that there was no supply fee paid for NRT and this rendered the contract not economically viable. In order to re-engage with these providers it was agreed to pay a fee of £3.80 for each NRT supply during the month of June, this has been extended to end of July. There are still many areas of the county where clients do not have a local pharmacy who can supply NRT. Once a network of pharmacy providers has been established to supply NRT then it will be possible to explore other organisations including the voluntary sector who may wish to provide stop smoking support.Continues to be discussed fortnightly with Commissioers at Strategic Implementation meeting.

7 7 67 121 253

334 438

0 0 3 11 20 21 64

544 650

756 862

968

128 192 256 320 384

0

500

1,000

1,500

2,000

2,500


Num

ber o

f Qui

tter

s

Month

4 week Quitters(Actual)

12 week Quitters(Actual)

4 week Quitters(Forecast)

12 week Quitters(Forecast)

4 week Quitters(Target)

12 week Quitters(Target)

IWB Overall Measures - Community Smoking Cessation - Cumulative - June






Percentage of People Taking Up Offers to Attend a Programme (Cumulative) (%) External Monthly DoSD 80% 80% 41% 40% 42% 41% 41%

Number of People Taking up Offers to Attend a Programme (all Type 2 diabetes) (Cumulative) (no) External Monthly DoSD 1,200 300 246 94 168 246 246



3-Timescales



The clients referred to the service are able to choose whether to attend the session or not. Clients referred to the service are sent a letter saying that DAY has received a referral for them and inviting them to book onto a course, dates are provided. Where there is no response the service will try to contact the client directly by phone. Of the clients that the service is able to make contact with there is a high level of take up. In Q1 600 clients were referred to the service; of these the service has had no response from 335; of the contacts made 248 have accepted and only 17 declined the service. Referrals are largely through joint referral with retinopathy and some clients may not be aware that this is the case. There has been a gap in staffing whilst a new co-ordinator was appointed. However we must consider that if more clients took up the service we would not be able to meet the demand. The service is working close to capacity currently and is close to meeting the target around numbers taking up the offer. It would not be able to deliver a service to 80% of referrals which would exceed the 1200 target for clients attending the programme.

It is anticiapted that within Q2 the service will meet the half year target of 600 participants completing the programme.

Extra sessions developed for evening and weekends to allow more choice for clients. Admin support are trying to contact clients by phone out of normal office hours to fill available places on available courses. GP practices are being contacted with up to date information re the programme to try to ensure that patients are provided with more information about the referral process. One of the admin team is changing their working pattern to work later 3 days per week.

94 168 246

373

500 600

700 800

900 1,000

1,100 1,200

40% 42% 41%

80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%

30%

40%

50%

60%

70%

80%

90%

0

200

400

600

800

1,000

1,200

1,400


Num

ber o

f Clie

nts

Month

Number of PeopleTaking up Offers(Cumulative) Actual

Number of PeopleTaking up Offers(Cumulative) Forecast

People Taking UpOffers to Attend(Cumulative) Actual (%)

Number of PeopleTaking up Offers(Cumulative) Target

People Taking UpOffers to Attend(Cumulative) Target(%)

IWB Overall Measures - Diabetes - June





Vasectomy Service Activity (no.) External Monthly DoSD 391 102 91 26 63 91 91

ACTION PLAN: 1-Summary of Issues:

3-Timescales

Today confirmed completed operations- 125. July 34 completed with 10 more to the end of the month.1 session cancelled in August due to staff annual leave, but a recovery day is booked in Sept.


Confirmed target of 391. A consultant has now left the Service and a new consultant has been appointed to continue with his work in Vasectomy Services.

Monthly meetings to review latest Vasectomy completed operations and pending Consultaions. Operation lists are planned according to this figure. Long Eaton and Wheatbridge remain constant. A review of GP referrals into Cavendish remains unpredicatable. Consultaion appointments now planned for an evening to boost uptake of appointnets in Buxton.

Figures as of today are encourging and on target.



26

63

91 22

62

102

0

50

100

150

200

250

300

350


Activ

ity

Month

CumulativeActual (no)

CumulativeTarget (no)

VasectomiesForecast (no)

Vasectomies (no.) - June



Measure Type Frequency Director2014/15 Full Year

TargetYTD Target Q1 Apr-15 May-15 Jun-15 YTD

Health Visiting New Birth Visits within Contract Terms-10-14 days (%) External Monthly DoSD 100% 100% 94.3% 93.0% 93.3% 94.5% 94.3%

Health Visiting 2-2.5 year Development Assessment Completed (%) External Monthly DoSD 100% 100% 94.9% 92.2% 97.1% 94.9% 96.5%

Health Visiting - Number of mothers who have received a first face to face antenatal contact (%) External Monthly DoSD 100% 100% 84.1% 86.5% 77.0% 89.7% 84.1%



3-Timescales

Monthly audits of the reviews to identify any data quality issues, identify and support teams where improvemnts to appointment scheduling will enable reviews to be completed within timescale and increase performance figures towards target.


Aug-15


1 New Birth Visits- In June there were 587 birth visits due, 558 of these births received a visit within 10 - 14 days, 29 were completed late or outstanding. DCHS have agreed the exceptions with the DCC Commissioners which include babies in Neonatal units and transfer in and outs, there were 6 exceptions ( 4 in NNU, 1 baby poorly in hospital, 1 transfer in) which gives a revised performance figure of 96.77%. Of the remaining 18 visits 4 were cancelled by parent at short notice, 10 No Access visits 3 appointment errors, 1 late notifications from child health. 2 Antenatal Contacts - this performance is currently measured against average births in same month previous year. Audit completed of 574 births in June, 489 of these births received an Antenatal contact which is 85.19% achieved. DCHS have agreed the exceptions with the DCC Commissioners which include babies born premature, mothers who actively refuse the visit and transfer ins and out of area. There were 85 mothers who did not receive an antenatal contact, valid and agreed exceptions account for 35, which gives a revised performance of 91.28%. Reasons for the remaining 50 AN visits not being undertaken include 12 x no referral received from Midwives, 13 no access visits, 25 not scheduled for appointment.

1. New Birth Visits- Continue to audit records monthly to identify any team/practitioner appointment scheduling processes that need improvement. 2. Antenatal contacts - Continue to audit births monthly to see if mother recieved Antenatal contact. Team leaders to identify capacity or scheduling issues in teams to try to improve the number of women offerred an antenatal appointment, work with Midwifery providers where referrals not recieved and evidence via DATIX. SystmOne Admin Coordinator supporting and offering 1:1 training for practitioners to correct any data quality issues.Healthy Child Programme Lead and Quality Professional Lead will review these reports monthly to identify any data quality and workforce capacity issues.

93.0% 93.3% 94.5%

92.2% 97.1%

94.9%

86.5% 77.0%

89.7%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

110.0%


Perc

enta

ge o

f co

ntac

ts

Month

No. of Actual Visits 10-14 days (%)

Health Visiting 2-2.5year DevelopmentAssessment Completed(%)Actual First Face to FaceAntenatal Contacts (%)

Target %

Forecast - Overall (%)

Health Visiting (%) - June



Main QBC and Board Reports

QBC Board Comm Measure Description

Total Workforce Cost (£000s) Includes agency & bank. Plan revised to match QBC Finance report

Temporary Staffing Costs - Agency (£000's) Agency costs, usually funded by vacancies budget

Temporary Staffing Costs - Bank (£000's) Bank costs, usually funded by vacancies budget

Agency & Bank Spend as a % of Turnover (%) Agency & bank costs / Income

Agency & Bank Spend (Clinical) as a % of total workforce costs (%)

Total WTE - Contracted - All Assignments (no)

Total Headcount (no)

Health Visitor WTE (no.) Health visitors as reported by POEP within ESR

Staff Attendance (%) Staff attendance in month and on a ytd 12 month average

Staff Turnover (%) Staff turnover in month and on a ytd 12 month average

Board Turnover (no.)

Redundancy (no.) All posts made redundant to RATs for authorisation

Vacancies - Average Length of Time To Recruit (days)The average length of time from an approved vacancy being advertised on NHS Jobs to an agreed start date of employment being confirmed including time taken to complete pre-employment checks.

Vacancies - Average Length of Time From Offer to 1st Working Day (days) The average length of time from an agreed offer of employment being made to the applicant commencing employment with DCHS.

Vacancies - Average Length of Time For Pre Appointment Checks (days) The average length of time for pre-employment checks to be completed.

Vacancies - Externally Filled (no.) New measure

Vacancies - Internally Filled (no.) New measure

Advertised Vacancies (no.)

Essential Learning completed (% compliance) Year to Date is rolling 12month average - wte data

Information Governance Training (% compliance) Year to Date is rolling 12 month average-assignment data

Fire Training (% compliance) Year to Date is rolling 12 month average-assignment data

New starters attending induction (compliance %) New starters attending induction within 3 months / new starters requiring induction

Training - Resuscitation (% compliance)

Training - Safeguarding Children L2 (% compliance)

Training - Safeguarding Children L3 (% compliance)

Training - Safeguarding Adults L2 (% compliance)

Staff with appraisal completed (% compliance) Staff who have a current completed appraisal

Improvement in Staff Engagement Score (%) Total staff participating / Total staff

Staff Survey - Recommend DCHS to Friends and Family If They Needed Care or Treatment (%)

Staff Survey- recommend DCHS to friends and family as a place to work (%)

Staff Survey - Participation Rates (%)

Pulse Check - Participation Rate (%)

Pulse Check - Recommend DCHS to Friends and Family If They Needed Care or Treatment (%) Quarterly survey score

Pulse Check - Recommend DCHS to Friends and Family as a Place to Work (%) Quarterly survey score

Patient Revolution Friends & Family Test Recommended Score (%) Service scores by patients

Complaints Received (no.) Level 2 and above complaints

PLACE (score)Q1-Looks at the environment in which care is provided and the quality of non-clinical services - food and privacy and dignity. Q2-Looks at cleanliness. Q3-external verification.Q4-PLACE

Certification against compliance with requirements regarding access to healthcare for people with a learning disability

To be reported to EDS & quarterly to QSC

A&E Targets (rating) Composite A&E targets measure

A&E 4 Hour Wait for A&E Attendances (%) The percentage of people who are seen within A&E in under 4 hours

A&E Unplanned Re-attendance Rate (%) Unplanned attendances within 7 days of discharge / total attendances

A&E Left Without Being Seen Rate (%) The percentage of people who leave the A&E without being seen

A&E Time to Initial Assessment - 95th percentile (mins) The time below which 95% of patients arriving by emergency ambulance are assessed

A&E Time to Treatment - Median (mins) The time below which 50% of attendances were treated

A&E Total Time in the A&E Department (non admitted) - Longest (mins) Single longest time recorded from arrival at A&E to transfer or discharge

A&E Total Time in the A&E Department (non admitted)-95th percentile (mins) 95% of patients have spent up to this time in the A&E Department

RTT Targets (rating) RTT composite measure

RTT Waits - incomplete pathway 92nd percentile (weeks) 92nd percentile of incomplete pathways whose clocks stopped during the period on an adjusted basis

RTT Waits - admitted patients 90th percentile (weeks) 90th percentile time waited for admitted patients whose clocks stopped during the period on an adjusted basis

RTT Waits - non admitted patients 95th percentile (weeks) 95th percentile time waited for admitted patients whose clocks stopped during the period on an adjusted basis

RTT Waits - admitted patients seen within 18 weeks - 90% (target) (1A) 90% target for admitted patients

RTT Waits - admitted patients seen within 18 weeks - 90% (target) (1A) - Planned Care

RTT Waits - admitted patients seen within 18 weeks - 90% (target) (1A) - DCHS Dental

RTT Waits - admitted patients seen within 18 weeks - 90% (target) (1A) - Leicestershire Dental

RTT Waits - non admitted patients seen within 18 weeks - 95% (target) (1B) 95% target for non admitted patients

RTT Waits - Incomplete pathway - 92% (target) (2)

RTT Waits - pathways greater than 52 weeks for completed admitted pathways (un-adjusted), completed non-admitted pathways and incomplete pathways.

Patient pathways greeter than 52 weeks

RTT Waiting Times (Scorecard)

Diagnostics - Patients exceeding 6 weeks wait (%)

Choose and Book Targets (rating) Composite of Choose and Book targets

Choose & Book - Appointment slots available - no of patients unable to book (%)

Choose & Book - Eligible Services Directly Bookable (%)

Choose & Book-Unpublished Services in Directory of Services (%)

Choose & Book-Minimise Number of "Do Not Use" or "Test" Services in Directory Of Services (No)

Choose & Book-Age range added to all services in the Directory Of Services (%)

Choose & Book-Provide advice & guidance for all included services (%)

Choose & Book - Patients Contacted Within 3 days of Being Reported on ASI (%)

Patients who have operations cancelled for non clinical reasons on the day (%)

Patients who have operations cancelled for non clinical reasons receiving treatment within 28 days (%)

Mixed Sex Accommodation Breach Rate (No)

Delayed Transfer of Care (%) Number of breaches / number of Finished Consultant Episodes

Delayed Transfer of Care for Inpatient (Rehab & Urgent Care) - contract calculation (%) Number of delayed transfers of care as a proportion of the number of occupied beds

QU

ALIT

Y PE

OPL

E

SERV

ICE

USE

R EX

PERI

ENCE

WO

RKFO

RCE

MET

RICS

TRAI

NIN

G A

ND

APR

AISA

LFE

EDBA

CKPA

TIEN

T SA

TISF

ACTI

ON

CHO

OSE

& B

OO

KN

TS

Focus Area

DCHS COMMITTEES PERFORMANCE REPORT BALANCED SCORECARD

A&E

REFE

RRAL

TO

TRE

ATM

ENT




QBC Board Comm Measure DescriptionFocus Area


Delayed Transfer of Care for OPMH - contract calculation (%) Delayed patient transfers from DCHS to other organisations

Delayed Transfer of Care for OPMH - Monitor compliance framework calculation (%) Delayed patient transfers from DCHS to other organisations

Inpatient (Rehab & Urgent care) Average Length of Stay (days) Composite of Rehab and Urgent Care length of stay

Older Peoples Mental Health Average Length of Stay (days) Average time in Urgent Care wards

Inpatient and Older Peoples Mental Health Occupancy (%) Bed Occupancy rates

Inpatient (RUC) Occupancy (%)

Older Peoples Mental Health Occupancy (%) Bed Occupancy rates

LD Occupancy (%) Bed Occupancy rates

Achievement of consultation /involvement/engagement inclusion priorities (%) Bed Occupancy rates

New or revised policies/procedures/strategies supported by EIAs (%) Equality and diversity measure

CQC Registration - Overall (rating) Equality and diversity measure

CQC Warning Notices currently in effect (no)

CQC Compliance Action Outstanding (no)

CQC Non-Compliance with Essential Standards resulting in Enforcement Action (no)

CQC - Moderate concerns or impacts regarding the safety of healthcare provision (as at time of submission) (no)

Internal rating against CQC measures

CQC Financial Penalties (no)

CQC Enforcement action within last 12 months (no)

CQC - Major concerns or impacts regarding the safety of healthcare provision (as at time of submission) (no)

CQC Enforcement action (including notices) currently in effect (no)

Total Harm Free Care, in accordance with Safety Express (%)

Inpatients who have harm free care, in accordance with Safety Express (%)

LD patients who have harm free care, in accordance with Safety Express (%)

Community Nursing patients who have harm free care, in accordance with Safety Express (%)

Avoidable Grade 2, 3 & 4 Pressure Ulcers developed or deteriorated in DCHS care (no.)

Total Grade 3 & 4 Pressure Ulcers developed or deteriorated in DCHS care (no.)

Incidence of Newly Acquired Pressure Ulcers (no.)

Medication Errors causing Serious Harm (no.)

NHSLA Rating (no.)

Open Serious Incidents Requiring Investigation (SIRI) (no.)

Never Events (no.)

Falls resulting in severe injury or death (no.)

Open Central Alert System (CAS) Alerts (No.)

100% compliance with WHO surgical checklist (Yes/No) Total number of alerts open on final day on month

Venous Thromboembolism (VTE) Screening (%)

Incidence of health care-related Venous Thromboembolism (No.)

Duty of Candour - Failure to notify relevant person of a reportable incident (no)

Crude Mortality Rate (%)

Healthcare Care Associated Infections - Targets (ratings)

Healthcare Care Associated Infections - MRSA bacteraemia (no.)

Healthcare Care Associated Infections - Clostridium difficile (no.)

Healthcare Care Associated Infections - E Coli & MSSA (no)

Healthcare Care Associated Infections - Clostridium difficile -lapses count (no.)

Breastfeeding sustainment from 10 days to 6-8 weeks after birth (%) Number of partially and fully breastfed infants / total infants due a 6-8 week check

Smoking Quitter Targets Number of partially, fully and none breastfed infants / total infants due a 6-8 week check

CQUIN Scorecard (rating)

Monitor Risk Assurance Framework Scorecard (RAF) (rating)

IWB Overall Measures (rating)

ISH Overall Measures (rating) Composite of quit smoking targets

CIP Achieved-Recurrent(%)

CIP Achieved-Non Recurrent (%) CIP Achieved / Total CIP required

Continuity of Services-Liquidity Ratio (days.) (Monitor Shadow Format)

Continuity of Services-Capital Servicing Capacity (times.) (Monitor Shadow Format)

Continuity of Services-Risk Rating (Monitor Shadow Format)

FT Membership (no.)

Positive media stories (no.)

Available Bed Days-Inpatients (RUC) (no.)The number of positive media stories reported for DCHS across all media outlets. A positive media story is classed as one that enhances the reputation of DCHS

Available Bed Days-OPMH (no.)

Occupied Bed Days-Inpatients (RUC) (no.)

Occupied Bed Days-OPMH (no.)

Available Beds-Inpatients (RUC) (no.)

Available Beds-OPMH (no.)

MIU Activity (no.) All contract activity, compared against profiled activity plan

Community Beds -Discharged Occupied Bed Days (no) All contract activity, compared against profiled activity plan

Clinical Navigation Service Contacts & Service Outcome (no.)

In-Reach Service Contacts & Service Outcome (no.)

Outpatient and Daycase Activity (no.) All contract activity, compared against profiled activity plan

Vasectomy Service Activity (no.) All contract activity, compared against profiled activity plan

Podiatric Surgery Activity (no.) All contract activity, compared against profiled activity plan

Community Podiatry Activity (no.)

Community Podiatry Activity-Non AQP (no.) All contract activity, compared against profiled activity plan

Community Podiatry Activity - AQP (no.) All contract activity, compared against profiled activity plan

Physiotherapy Activity (no.) All contract activity, compared against profiled activity plan

CLIN

ICAL

EFF

ECTI

VEN

ESS

& P

LAN

NIN

G

EQU

ALIT

Y &

D

IVER

SITY

INPA

TIEN

QU

ALIT

Y SE

RVIC

E

OCC

UPA

NCY

HCA

IO

THER

SAF

ETY

MEA

SURE

S

QU

ALIT

Y BU

SIN

ESS

CON

TRAC

T AC

TIVI

TY

BUSI

NES

S &

MAR

KETI

NG

FIN

ANCE

FT R

EGIM

E

SERV

ICE

USE

R SA

FETY

CAPA

CITY

CQC

HAR

M F

REE

CARE

PRES

SURE

ULC

ERS




QBC Board Comm Measure DescriptionFocus Area


Speech and Language Therapy Activity (no.) All contract activity, compared against profiled activity plan

Diagnostic Imaging (no.) All contract activity, compared against profiled activity plan

Pulmonary Rehab (no)

Rehabilitation and Intermediate Care Activity (no.) All contract activity, compared against profiled activity plan

Health Visiting Activity (no.)

Health Visiting Contract (Rating)

Health Visiting New Birth Visits within Contract Terms-10-14 days (%)

Health Visiting 2-2.5 year Development Assessment Completed (%)

Health Visiting - Number of mothers who have received a first face to face antenatal contact (%)

Community Nursing Activity (no.)

Community Matron Activity (no.)

Community Information Dataset Completeness-Referral to treatment information (%)

Community Information Dataset Completeness-Referral information (%)

Community Information Dataset Completeness-Treatment activity information (%)

Mental Health Data Completeness - identifiers %

Information Governance Incidents Reported via IG toolkit - Level 2 or above (no.)

Information Governance Toolkit Achievement - measures scoring 2 or better (no)

SUS Dataset Validation (%)

SUS / SLAM Variation (%)

SUS Dataset Altered Between 5 days After Month End & Inclusion Point (%)

Sickness & Absence Rates - Long Term Absence (%)

Sickness & Absence Rates - Short Term Absence (%)

Turnover - Planned (%) DCHS planned turnover changes

Turnover - Unplanned (%) Employee generated turnover changes

New SIRIs reported per month (excluding pressure ulcers) (no.)

Percentage of deaths in community hospitals (expected and unexpected) compared to all discharges (excl Palliative Care and End of Life)

Injurous Falls per 1,000 inpatient occupied bed days (no.)

Injurious and non Injurious Falls per 1,000 Inpatient Occupied Bed Days

Number of incidents (causing harm or otherwise) per 1,000 WTE budgeted staff (no)

Number of Formal Complaints Reported per 1,000 WTE Budgeted Staff

Safety Thermometer - Percentage of 'Harm Free' Care (New harms only)

Face to face contacts per whole time equivalent (wte) community nurse per working day (no.)

Total pay cost per wte community nurse (£)

Face to face contacts per whole time equivalent (wte) health visitor per working day (no.)

Total pay cost per wte health visitor (£)

Average length of stay (days)

Percentage occupancy of community hospital beds (%)

Data Completeness-NHS Number (%)

Data Completeness-Ethnicity code (%)

Data Completeness-Postcode (%)

Data Completeness-GP Practice code (%)

HCAI Report

QBC Board Comm Measure Description

ESBL - Avoidable (No.) Extended Spectrum Beta Lactamases

ESBL - Possible (No.) Extended Spectrum Beta Lactamases

ESBL - Unavoidable (No.) Extended Spectrum Beta Lactamases

MRSA Infections Incidence

MRSA Infections Lapse in care

ESBL Infections Incidence

ESBL Infection Lapse in care

Norovirus outbreaks IncidenceConsidered unavoidable because DCHS is unable to influence transmission. Number of ‘outbreaks’ and therefore may include more than one patient.

Norovirus outbreaks Lapse in care

MRSA Bacteraemia Incidence

MRSA Bacteraemia Lapse in care

Clostridium Difficile Incidents

Clostridium Difficile Significant Lapse in care

Clostridium Difficile Minor Lapse in care

MSSA Bacteraemia Incidence

MSSA Bacteraemia Lapse in care

E.coli Bacteraemia Incidence

E.coli Bacteraemia Lapse in care

Q

UAL

ITY

SERV

ICE

SERV

ICE

USE

R SA

FETY

& E

XPER

IEN

CE

HCA

I

QAU

ALIT

Y PE

OPL

E

H

EALT

H V

ISIT

ING

Focus Area

INFO

RMAT

ION

QU

ALIT

Y BU

SIN

ESS

QU

ALIT

Y BU

SIN

ESS

COM

M

NU

RSIN

G

QU

ALIT

Y SE

RVIC

E

INFO

RMAT

ION



KEY TO COLOUR CODINGS

Indicator / Measure has met or exceeded targetIndicator / Measure has not met target but is within acceptable tolerances. An action plan is in place and is being monitoredIndicator / Measure has not met target and is beyond accepted tolerances. Immediate action and investigation has been instigated. An action plan is in place and is being monitored. Indicator / Measure is not available or in development

KEY TO SYMBOLS

↑ Performance has improved / is above target

↓ Performance has declined / is below target

↔ Performance is stable and on target to be delivered

Data Quality Kitemark scoring

Using data collected interview sessions with service staff; each system has been marked on the criteria of Audit, Timeliness, Sign off, Granularity, Completeness and Source/Process. A system can score as Not Sufficient, Sufficient or Exemplary in each of the six areas. These areas make up the outer segments of the Data Quality Kitemark Shield eg: A score of Sufficient or Exemplary marks the system as Green on the Kitemark Shield for that section and a score of Not Sufficient marks the system as red.

Data Confidence Score Each system will receive a Data Confidence Score calculated by the total overall scoring given by four key members of staff relating to the specified system from Information, Performance and within the service. Each contact is asked to give the system a confidence rating out of 5 to state how accurately the system data reflects service activity, where 5 is Complete Confidence and 1 No Confidence. The total of the four scorings will be displayed in the centre of the Data Quality Kitemark Shield.

Timeliness

Source/process

Sign off

Completeness

Granularity

Audit

12



TRUST BOARD Document Title: Financial Performance Report

Presenter/Title: Chris Sands, Director of Finance, Performance and Information Contents of Paper were previously discussed by: QBC held on Wednesday 22 July 2015

Author/Title: David Gray Head of Management Accounts Contact Email and Telephone Number: [email protected] 01246 253046




Purpose of Paper

The paper sets out the financial performance of the Trust as at 30th June 2015. The report details performance against statutory and internal targets. The Trust is reporting a surplus position of £0.87m at month 3, which represents a £0.13m favourable variance against the planned surplus of £0.74m. A year end surplus of £1.6m is forecast, which assumes full delivery of the CIP programme. The Trust is forecasting that it will meet all its statutory financial duties for the year

Recommendations

The Board is asked to discuss the report and note the actions being taken to improve performance.


3.2.3 There is a risk to the organisation due to the inability to meet financial targets specifically cost improvement plans as set out in the Annual Plan and IBP resulting in financial risk and reputational damage.

Financial Impact

The report contains a number of issues and risks that have a financial impact on the organisation. The most significant of which are the delivery of the CIP programme and the activity underperformance in the new sexual health service. The report updates Committee members regarding the actions that are currently being taken.


212�Financial�Performance�RepoOverall�Page�175�of�211Page�1�of�13





Governors will hold the Board to account around its financial position

What are the Equality and Diversity implications? No


No

Risk Register





WORKING CAPITAL15.06 G 13.17 G0.69 G 0.05 G

£m % £m % % £m % £m % £m % (0.50) G (0.14) GEBITDA (2.28) (5.45) (2.42) (5.86) 6.24 (7.81) (4.65) (7.73) (4.59) 0.09 (1.13)

Net (surplus)/deficit (0.74) (1.77) (0.87) (2.10) 17.32 (1.60) (0.95) (1.60) (0.95) 0.00 0.00 RISK RATINGSContinuity of service - Liquidity (days) 16.62 G 13.39 GContinuity of service - Liquidity rating 4 G 4 G

I&E SURPLUS (excl. IMPAIRMENT) I&E SUMMARY AS AT 30 JUNE 2015 Continuity of service - Capital Servicing (x times) 3.83 G 3.09 GContinuity of service - Capital Servicing 4 G 4 G

DERBYSHIRE COMMUNITY HEALTH SERVICES NHS FOUNDATION TRUST FINANCIAL PERFORMANCE REPORT

PLAN ACTUAL VARIANCE PLAN FOT VARIANCE

JUNE 2015 KEY FINANCIAL INDICATORS

EBITDA AND SURPLUS AS AT 30 JUNE 2015YTD 2015/16 FULL YEAR

JUNE 2015

FOTYTD

Current Assets Variance (£m)Cash at bank as per the ledger (£m)

Current Liabilities Variance (£m)£m

VAR

FOT

PLAN

FULL YEAR

(0.13)

(0.14)

JUNE 2015

YTD

FOTYTD

VAR

ACTU

AL

PLAN

Overall CoS rating 4 G 4 GFinancial efficiency - I&E margin (%) 2.03 0.95

Financial efficiency - I&E margin rating 4 3

(£m) (£m) (£m) (£m) (£m) (£m) Financial efficiency - I&E margin variance (%) 17.3 0.0

(41.74) (41.24) 0.49 (168.18) (168.37) (0.19) Financial efficiency - I&E margin variance rating 4 4

PAY 28.25 28.26 0.01 114.50 115.65 1.15 Financial efficiency - Capex variance (%) -31.4 0.0

NON-PAY 11.22 10.57 (0.65) 45.87 44.99 (0.88) Financial efficiency - Capex variance rating 1 4

OTHER 1.54 1.55 0.01 6.21 6.13 (0.09) Overall shadow rating 4 4

(0.74) (0.87) (0.13) (1.60) (1.60) (0.00)

PERFORMANCE AND CIP YTD FOTContract over/(under) performance (£m) 0.57 R 0.00 G

CAPITAL PROGRAMME MONTH END CASH BALANCE Over/(under)achievement of CIP target (£m) (0.09) R (0.04) R(Over)/underspend against investments (£m) 0.00 G 0.00 GNet impact of CIP/investments/NR savings (£m) (0.09) R (0.04) R

ADDITIONAL TRIGGERS YTD FOTReceivables aged over 90 days (%) 5.0 5.1 R 5.0 GPayables aged over 90 days (%) 5.0 61.1 R 5.0 GChange in Finance Director in last year 2 0 G 0 GInterim Finance Director in place over QE 2 0 G 0 GDays expenditure covered by QE cash 10 35.4 G 29.9 GCapital Expenditure % of plan (%) 75.0 68.6 R 100.0 G

VAR

FOT

PLAN

INCOME

TOTAL

JUNE 2015 VA

R

ACTU

AL

PLAN

-1.0

-0.5

0.0

0.5

1.0

1.5

2.0

2.5

Cum

ulat

ive

surp

lus

(£m

)

Plan Actual Forecast

0.0

5.0

10.0

15.0

20.0

Cas

h at

mon

th e

nd (£

m)


0.0

1.0

2.0

3.0

4.0

5.0

6.0

Cum

ulat

ive

capi

tal s

pend

(£

m)




DERBYSHIRE COMMUNITY HEALTH SERVICES NHS FOUNDATION TRUST

MONTHLY FINANCIAL PERFORMANCE REPORT FOR TRUST BOARD AS AT 30th JUNE 2015

1. Introduction

The purpose of this report is to update and inform the Board on performance against key financial criteria for month 3 of the current financial year, 2015/16. The Trust is reporting a surplus position of £0.87m at month 3, which represents a £0.13m favourable variance against the planned surplus of £0.74m. The move to a surplus position is following the re-profiling of Business Rates expenditure. This is now recognised across the whole year rather than profiled in month 1 as previously reported. A year end surplus of £1.6m is forecast, which assumes full delivery of the CIP programme. The general mitigation reserve remains uncommitted and unallocated at month 3.

2. Summary Financial Position The financial risk of the Trust is measured by the Continuity of Services (CoS) Rating as part of the provider license. A rating of 4 is low risk, whilst a rating of 1 is high risk. The Trust is forecasting a rating of 4 at the year-end. This reflects the strong balance sheet of the Trust. Table One – Continuity of Service rating

Measure Indicator Weight Year to date Forecast outturn Value Rating Value Rating

Liquidity

Number of days operating expenditure covered by current working capital balances

50% 16.62 4 15.07 4

Capital Servicing Capacity

Revenue cover available to service debt repayments

50% 3.83 4 3.09 4

To move to a CoS forecast outturn rating of 3, there would need to be a deterioration in the income and expenditure position of £3.4m. A further reduction to the position of £2.6m or a total of £6.0m would move the overall CoS rating to a 2. Monitor are currently out to consultation regarding some proposed changes to the Risk Assessment Framework for Foundation Trusts. As part of this it is proposed that the current financial risk ratings are enhanced to incorporate a number of additional metrics which, in conjunction with the existing CoS metrics, would result in a new overall rating. The additional metrics are concerned with the level of I&E margin delivered by a Trust as well as the robustness of the planning process both for income and expenditure and capital investment.



The Trust’s performance against the new proposed metrics are detailed in the table below. Year to date the Trust would record a score of a 4 against each of metrics proposed in the new rating framework with the exception of the capital plan variance which at month 3 stands at £164k behind plan or 31.4%. Scoring 1 on any metric with the exception of the capital plan measure limits the overall rating to a 2. The Trust will continue to monitor performance against the new proposed metrics pending the outcome of the consultation exercise. Table Two – “Shadow” metrics

Measure Indicator Weight Year to date Forecast outturn Value Rating Value Rating

Liquidity Days Number of days operating expenditure covered by current working capital balances

25% 16.62 4 13.39 4

Capital Servicing

Revenue cover available to service debt repayments

25% 3.83 4 3.09 4

I&E Margin (%)

Year to date I&E margin as a % of total income

25% 2.03 4 0.95 3

I&E Margin Variance (%)

Year to date variance from plan

12.5% 17.32 4 0 4

Capex Variance (%)

Year to date variance from plan

12.5% -31.4 1 0 4

Overall Rating 4 4

3. Income & Expenditure Appendix 1 details the Income & Expenditure Statement as at month 3. More detail on the income and expenditure position is provided below.

3.1 Clinical Income As at month 3 the clinical income position is showing £0.57m year to date under performance against plan. Activity monitoring for month 2 has been received which for the multilateral contract (Planned Care, MIU etc.) is showing a slight over-performance. This over performance has been reported in the



year to date position. The underperformance being reported relates to the recently tendered Public Health Commissioned services; Integrated Wellbeing and Sexual Health. Integrated Wellbeing is currently showing £0.23m underperformance year to date. This is based upon activity seen since the start of the new contract (December 2014) and is being driven by Smoking and Weight management targets currently not being delivered; partly due to issues with securing activity provision from accredited providers. This underperformance is however largely off-set by an under-spend against expenditure budgets. Work continues with the service and accredited providers to look at how activity can be increased. Positive discussions with commissioners are also taking place regarding identified issues and how this risk can be jointly managed and mitigated. The new Sexual Health service commenced on the 1st April 2015 and the Month 2 activity monitoring is showing a significant underperformance against plan of £0.57m. A paper is being presented to the Quality Business Committee outlining the current issues and actions being taken to mitigate against the identified financial risk. The underachievement of income is currently being offset within the position by corresponding underspends in expenditure, and through the release of a transition risk reserve which is in place to provide transition cover for the first 3 months of the financial year. Good progress has been made to clarify the payment mechanism and it is expected that this position will improve in future months. A robust forecast cannot yet be completed and therefore plan is currently forecast for the year end. Following further discussions with commissioners, and an assessment as to the impact of these discussions and other actions, a year-end forecast will be developed. Activity against plans will continue to be closely monitored throughout the year to ensure early identification of under / over –performance and any associated risks to income.

3.2 Non-Clinical and Other Income

Other Income is ahead of plan by £0.08m with all service divisions continuing to show improvements on last financial year.

3.3 Expenditure Overall, the Trust is reporting an under spend against the expenditure plan of £0.64m at month 3. Overall Pay costs are slightly over spending compared to plan by £0.12m. The majority of the underspends are due to vacancies within Health and Wellbeing, Corporate Services and the Facilities Management Divisions which are helping to offset the overspends caused by slippage on CIP Schemes within ICBS (£0.17m), Planned Care (£0.04m) and the increased Medical Locum and ANP requirements within Primary Care. Agency and Flexible Workforce costs in other staff disciplines remain consistent with previous months at £0.25m per month. Non-pay Costs are overall showing a significant underspend against plan of £0.65m. The vast majority of the underspend is within the Tendered Services of the Health and Wellbeing Division (£0.79m) caused by a reduction in activity which as reflected in reduced expenditure to Accredited Providers, Voluntary Sector and Chlamydia Screening. The cost improvement plan is £0.09m behind plan at month 3 due to delays in delivering the Service redesign and transformations relating to Bed Reductions and Corporate Services reviews



within People and Organisational Effectiveness Teams. Further detail is provided in section 3.4 below. 3.4 Cost Improvements Plan The Trust has a CIP target of £6.1m for 2015/16. An underachievement against the planned schemes both at month 3 and year end of £0.09m and £0.04m respectively are being forecast. This is the net position after mitigations have been included. The main areas of CIP slippage relate to delays in the implementation of the following schemes Reduction of the Inpatient bed base to 16, Dental Services Review, Occupational Health, Resolve and the Mobile Phone Policy. The Management Accounts Team are working with Service AD’s and Corporate Managers to develop Mitigation schemes to help reduce any further slippage. Further detail of the CIP position can be found in Appendix 2.

4.0 Statement of Financial Position Appendix 3 sets out the Statement of Financial Position.

4.1 Cash At the end of June the cash balance was £0.6m behind plan (actual: £15.1, plan £15.7m). This adverse variance is mainly being driven by working capital variations and in particular a lower payables balance than anticipated at the plan stage. The Trust continues to actively manage working capital, and is drawing up an action plan to make our management of working capital more forward looking. As usual, we focus on the areas we have the most control over, and so the focus is on managing debtors and keeping levels of accrued income as low as possible by raising invoices promptly. Further detail can be found in Appendix 4 attached.

5. Capital Plans and Expenditure

The Trust’s capital plan for 2015/16 is a total of £5,021k. At the end of June, expenditure is £359k against a plan of £529k. The year to date slippage is against IM&T schemes. Other significant schemes for 2015/16 include continued the developments on the Walton and Heanor Sites.

At this stage in the financial year there is no anticipated risk to the successful delivery of the Capital Programme. Further detail can be found in Appendix 5 attached.



6. Risks The key risk is the activity underperformance in the new sexual health service. Progress has been made in reducing this risk, which was reported through to Quality Business Committee at its July 2015 meeting. It has been agreed to provide a further update on progress against the agreed actions at the September meeting. Delivery of the CIP programme remains a risk and therefore ensuring that the Trust’s CIP programme is robustly managed through the PMO process is crucial.

7. Summary

Board members are asked to note the month 3 position against the financial targets. Chris Sands Director of Finance, Information and Strategy



Appendix 1

1 2 3 4 5 6 7 8 9 10 11 12

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

Actual Plan Variance Actual Actual Actual Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Outturn Plan

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

OPERATINGIncome

INC1 Clinical Income -38,898 -39,471 573 -13,072 -12,581 -13,245 -13,431 -12,999 -13,367 -13,521 -13,461 -13,065 -13,472 -13,447 -13,403 -159,064 -159,066

INC2 Other NHS Income -1,301 -1,327 26 -456 -436 -409 -436 -436 -436 -436 -436 -436 -436 -436 -436 -5,225 -5,357

INC3 Education and Training -224 -219 -5 -66 -84 -74 -75 -75 -75 -75 -75 -75 -75 -75 -75 -899 -827

INC4 Other Income -821 -721 -100 -255 -279 -287 -267 -267 -267 -260 -260 -260 -260 -260 -260 -3,182 -2,934

INCOME TOTAL -41,244 -41,738 494 -13,849 -13,380 -14,015 -14,209 -13,777 -14,145 -14,292 -14,232 -13,836 -14,243 -14,218 -14,174 -168,370 -168,184

Operating ExpensesEXP Employee Benefit Expenses 28,260 28,248 12 9,347 9,406 9,507 9,699 9,652 9,622 9,653 9,624 9,664 9,704 9,688 10,088 115,654 114,500

EXP Drugs 171 395 -224 93 45 33 71 70 71 70 71 71 70 71 71 807 1,582

EXP Clinical Supplies and Services 2,035 1,969 66 637 695 703 683 681 683 683 683 683 683 683 683 8,180 7,795

EXP4 Other Costs 8,361 8,851 -490 3,647 2,737 1,977 3,009 3,037 3,035 3,089 3,111 3,063 3,008 2,985 3,306 36,004 36,494

OPERATING EXPENSES TOTAL 38,827 39,463 -636 13,724 12,883 12,220 13,462 13,440 13,411 13,495 13,489 13,481 13,465 13,427 14,148 160,645 160,371

OPERATING (PROFIT) / LOSS EBITDA -2,417 -2,275 -142 -125 -497 -1,795 -747 -337 -734 -797 -743 -355 -778 -791 -26 -7,725 -7,813

NON OPERATINGNON Loss / (Profit) on Asset Disposal 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Impairment of non-current assets 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

NON Depreciation / Amortisation 939 923 16 300 313 326 313 313 313 300 300 300 300 300 300 3,678 3,763

NON Interest (Receivable) / Payable -13 -12 -1 -3 -4 -6 -4 -4 -4 -4 -4 -4 -4 -4 -4 -49 -50

NON Public Dividend Capital 624 625 -1 208 208 208 208 208 208 208 208 208 208 208 208 2,496 2,500

NON OPERATING TOTAL 1,550 1,536 14 505 517 528 517 517 517 504 504 504 504 504 504 6,125 6,213

RETAINED (SURPLUS) / DEFICIT -867 -739 -128 380 20 -1,267 -230 180 -217 -293 -239 149 -274 -287 478 -1,600 -1,600

ADJUSTMENTS TO RETAINED SURPLUSINC5 Donated Asset Income 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

NON Donated Asset Depreciation 30 0 30 10 10 10 10 10 10 10 10 10 10 10 10 120 0

NON Impairment of non-current assets 0 0 0 0 0 0 0 0 0 2,100 0 0 0 0 0 2,100 2,100

TOTAL ADJUSTMENTS 30 0 30 10 10 10 10 10 10 2,110 10 10 10 10 10 2,220 2,100

ADJUSTED RETAINED (SURPLUS) / DEFICIT -837 -739 -98 390 30 -1,257 -220 190 -207 1,817 -229 159 -264 -277 488 620 500

STATEMENT OF INCOME & EXPENDITUREJUNE 2015

Category

Year to Date Monthly Actual / Forecast

As at 30 June 2015



Appendix 2

Plan £'000Plan % of

Annual ActualActual % of

Annual Risk RatingPlan

£'000Out-turn

Actual Risk Rating FYE Forecast FYE Plan

Total CIP 15/16 1,201 19.7% 1,106 18.2% -95 -8% 6,091 6,051 -40 -1% 6,419 6,091

Programme Project Programme Lead PlanPlan % of Annual Actual Plan

Out-turn Actual FYE Forecast FYE Plan

£'000 £'000 £'000 £'000 % £'000 £'000 £'000 % £'000 £'000Clinical Environments

Reduction of 1 ward Bolsover Jo Furley 155 18.2% 82 9.6% -73 -47% 853 620 -233 -27% 930 930Clinical Environments

Reduction of bed base on general wards to 16 Jo Furley 91 25.0% 29 8.0% -62 -68% 363 317 -46 -13% 363 363Clinical Environments

Ilkeston MIU Reduced opening hours Jo Furley 14 25.0% 14 25.0% 0 0% 54 54 0 0% 54 54

HWI Sexual Health Tender Reduction County Jayne Needham 63 25.0% 63 25.0% 0 0% 250 250 0 0% 250 250

HWI Sexual Health Tender Reduction City Jayne Needham 50 25.0% 50 25.0% 0 0% 200 200 0 0% 200 200

HWI IWBS Tender Reduction Jayne Needham 75 25.0% 75 25.0% 0 0% 299 299 0 0% 299 299

HWI Childrens Services Tender Reduction Jayne Needham 0 0.0% 0 0.0% 0 0% 300 300 0 0% 300 300

Planned Care Admin Integration Brenda Page 48 25.0% 48 25.3% 1 1% 190 190 0 0% 190 190

Planned Care Dental Services Review Brenda Page 50 25.0% 34 17.0% -16 -32% 200 200 0 0% 200 200

IFM Catering Richard Lyne 0 0.0% 10 3.6% 10 0% 280 280 0 0% 280 280

IFM Laundry Richard Lyne 0 0.0% 8 6.6% 8 0% 121 121 0 0% 121 121

Total PMO 544 17.5% 412 13.2% -132 -24% 3,110 2,831 -279 -9% 3,187 3187

Programme Project Programme Lead PlanPlan % of Annual Actual

Actual % of Annual Plan


£'000 £'000 £'000 £'000 % £'000 £'000 £'000 % £'000 £'000Clinical Environments

Medical Contract Savings Jo Furley 13 25.0% 0 0.0% -13 -100% 50 50 0 0% 50 50Clinical Environments

ICBS Reduction of Management Post Jo Furley 0 0.0% 0 0.0% 0 0% 51 51 0 0% 68 68Clinical Environments

ICBS Restructure Jo Furley 0 0.0% 0 0.0% 0 0% 150 150 0 0% 150 150Clinical Environments

ICBS Management Structure - Non Recurrent Jo Furley 20 25.0% 35 44.9% 16 79% 78 162 84 108% 0 0

Planned Care Management Integration Brenda Page 25 25.0% 25 25.0% 0 0% 100 100 0 0% 100 100

IFM Room Utilisation Richard Lyne 47 25.0% 47 25.0% 0 0% 188 188 0 0% 188 188

IFM Ash Green Richard Lyne 0 0.0% 0 0.0% 0 0% 40 40 0 0% 40 40

IFM Vacation of Premises Richard Lyne 0 0.0% 0 0.0% 0 0% 53 53 0 0% 211 211

IFM Walton Soft FM Savings Richard Lyne 2 25.0% 2 25.0% 0 0% 6 6 0 0% 6 6

IFM Heanor Capital Charges - Non Recurrent Richard Lyne 11 25.0% 11 25.0% 0 0% 45 45 0 0% 0 0

Estates Estates Staffing Review Peter West 30 25.0% 30 25.0% 0 0% 120 120 0 0% 120 120

Corporate CNST Reduction Kirteen Farrar 11 25.0% 11 25.0% 0 0% 44 44 0 0% 44 44

Corporate Mobile Working Contract Review Alvaro Pancisi 10 25.0% 10 25.0% 0 0% 40 40 0 0% 40 40

Corporate Review of Audit Fees Chris Sands 8 25.0% 8 25.0% 0 0% 30 30 0 0% 30 30

Corporate Renegotiation of SBS Contract Chris Sands 18 25.0% 18 25.0% 0 0% 71 71 0 0% 71 71

Corporate Finance Non Pay Chris Sands 1 25.0% 1 25.0% 0 0% 5 5 0 0% 5 5

Corporate Occupational Health Services Tender Jen Guiver 15 25.0% 2 3.3% -13 -87% 60 33 -27 -45% 60 60

Corporate POE Staff Savings Jen Guiver 4 25.0% 4 25.0% 0 0% 16 16 0 0% 16 16

Corporate Resolve Service Review Jen Guiver 33 25.0% 8 6.2% -25 -75% 130 64 -66 -51% 130 130

Corporate Mitigation Plans from Resolve Reduction Jen Guiver 14 25.0% 14 25.0% 0 0% 54 54 0 0% 83 83

Corporate Corporate Overhead Review Chris Sands 75 25.0% 82 27.3% 7 9% 300 328 28 9% 400 372

Corporate MRSA reduction in tests Sue Dakin 2 25.0% 2 25.0% 0 0% 8 8 0 0% 8 8

Corporate Mobile Phone Policy Brian Summerfield 10 10.0% 0 0.0% -10 -100% 100 20 -80 -80% 100 100

Corporate Procurement Efficencies Brian Summerfield 125 25.0% 125 25.0% 0 0% 500 500 0 0% 500 500

Total Trans 471 21.0% 434 19.4% -38 -8% 2,239 2,178 -61 -3% 2,420 2,392

Year to Date Annual


Actual % of Annual Variance Risk Rating Plan

Out-turn Actual Variance Risk Rating FYE Forecast FYE Plan

£'000 £'000 £'000 £'000 % £'000 £'000 £'000 % £'000 £'000

IFM Walton Capital Depreciation Richard Lyne 36 25.0% 36 25.0% 0 0% 144 144 0 0% 144 144

Corporate Trust Reserves Released Chris Sands 103 25.0% 103 25.0% 0 0% 412 412 0 0% 368 368

Corporate Trust Reserves Released - Non Recurrent Chris Sands 47 25.0% 47 25.0% 0 0% 186 186 0 0% 0 0

Total Trans 186 25.0% 186 25.0% 0 0% 742 742 0 0% 512 512


Actual % of Annual Plan


£'000 £'000 £'000 £'000 % £'000 £'000 £'000 % £'000 £'000

Planned Care Derby FT T&O shift to Ilkeston Brenda Page 0 25 25 0 100 100 100 0

Corporate Additional Income Chris Sands 0 - 20 - 20 0% 0 82 82 0% 82 0

Corporate ICBS Central Reserves Chris Sands 0 - 30 - 30 0% 0 118 118 0% 118 0

Total Mitigation 0 - 75 - 75 0% 0 300 300 0 300 0

Transactional Schemes 2015/16

Year to Date Annual

PMO Schemes 2015/16

Actual % of Annual

Variance

Risk Rating

Variance

Risk Rating

Variance

Variance

Risk Rating

Variance

Risk Rating

Risk RatingVariance

Risk Rating

Reserves/Non Cash Releasing Schemes 2015/16

Mitigations 2015/16

Year to Date Annual

PMO and Transactional CIP Monitoring 2015/16 June 2015

Summary of Overall CIP Monitoring 2015/16

Variance Variance

Year to Date Annual



Appendix 3

1 2 3 4 5 6 7 8 9 10 11 122014-15 Annual Annual

Year Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Outturn PlanEnd Actual Plan Variance Actual Actual Actual Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Outturn

£'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s

ASSETSNon Current

Tangible Assets 83,074 82,557 82,713 (156) 82,792 82,530 82,557 83,267 83,477 83,406 81,694 82,057 82,129 82,158 82,092 82,785 82,808

Intangible Assets 1,178 1,095 1,146 (51) 1,150 1,123 1,095 1,118 1,091 1,463 1,436 1,408 1,431 1,403 1,376 1,348 1,348

Total Non Current Assets 84,252 83,652 83,858 (206) 83,942 83,653 83,652 84,385 84,568 84,869 83,130 83,465 83,560 83,561 83,468 84,133 84,156

CurrentInventories 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

NHS Trade Receivabes 812 1,061 1,247 (186) 3,865 982 1,061 1,251 1,251 1,909 1,255 1,520 1,255 1,261 1,394 995 995

Non NHS Trade Receivabes 1,031 1,928 1,101 827 1,617 1,415 1,928 1,101 1,101 1,101 1,342 1,342 1,342 1,342 1,342 1,325 1,325

Bad Debt Provision (255) (180) (200) 20 (204) (186) (180) (192) (188) (184) (180) (176) (172) (168) (166) (164) (200)

Capital Receivables 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Accrued Income 2,064 2,385 1,541 844 1,711 2,037 2,385 1,731 1,581 2,031 2,631 2,806 2,506 2,256 2,356 1,106 1,106

Prepayments 621 922 916 6 916 940 922 966 1,016 966 1,066 1,016 816 856 986 640 620

Other Receivables 509 628 800 (172) 498 1,087 628 500 502 802 502 504 804 504 506 606 606

Cash and Cash Equivalents 16,739 15,062 15,716 (654) 11,277 17,280 15,062 14,200 13,771 12,066 12,647 10,645 11,261 13,295 13,521 13,165 13,233

Total Current Assets 21,521 21,806 21,121 685 19,680 23,555 21,806 19,557 19,034 18,691 19,263 17,657 17,812 19,346 19,939 17,673 17,685

TOTAL ASSETS 105,773 105,458 104,979 479 103,622 107,208 105,458 103,942 103,602 103,560 102,393 101,122 101,372 102,907 103,407 101,806 101,841

LIABILITIESCurrent

Trade Payables (8,739) (2,557) (3,008) 451 (3,917) (3,666) (2,557) (3,676) (3,416) (3,655) (4,107) (3,637) (3,735) (3,797) (3,875) (4,289) (4,140)

Other Payables (3,409) (3,445) (3,472) 27 (3,473) (3,469) (3,445) (3,470) (3,468) (3,466) (3,464) (3,462) (3,460) (3,458) (3,456) (3,454) (3,454)

Public Dividend Capital Payable (49) (674) (673) (1) (257) (466) (674) (882) (1,090) 0 (208) (416) (625) (833) (1,041) 0 0

Capital Payables (565) (412) (220) (192) (386) (393) (412) (218) (243) (293) (233) (248) (348) (323) (273) (623) (623)

Accrued Expenditure (973) (5,407) (4,647) (760) (3,691) (4,387) (5,407) (2,647) (3,197) (3,797) (3,821) (2,621) (2,671) (3,671) (3,711) (2,207) (2,207)

Annual Leave Accrual (465) (465) (465) 0 (465) (465) (465) (465) (465) (465) (465) (465) (465) (465) (465) (440) (440)

Deferred Income, Current (194) (305) (262) (43) (434) (3,398) (305) (290) (211) (160) (188) (137) (86) (114) (63) (12) (12)

Provisions, Current (1,378) (1,373) (1,394) 21 (1,389) (1,384) (1,373) (1,254) (662) (667) (667) (667) (672) (672) (672) (672) (672)

Total Current Liabilities (15,772) (14,638) (14,141) (497) (14,012) (17,628) (14,638) (12,902) (12,752) (12,503) (13,153) (11,653) (12,062) (13,333) (13,556) (11,697) (11,548)

Non CurrentDeferred Income, Non Current 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Provisions, Non Current (20) (20) (20) 0 (20) (20) (20) (20) (20) (20) (20) (20) (20) (20) (20) (20) (20)

Total Non Current Liabilities (20) (20) (20) 0 (20) (20) (20) (20) (20) (20) (20) (20) (20) (20) (20) (20) (20)

TOTAL LIABILITIES (15,792) (14,658) (14,161) (497) (14,032) (17,648) (14,658) (12,922) (12,772) (12,523) (13,173) (11,673) (12,082) (13,353) (13,576) (11,717) (11,568)

TOTAL ASSET EMPLOYED 89,981 90,800 90,818 (18) 89,590 89,560 90,800 91,020 90,830 91,037 89,220 89,449 89,290 89,554 89,831 90,089 90,273

TAXPAYERS EQUITYPublic Dividend Capital 243 243 243 0 243 243 243 243 243 243 243 243 243 243 243 243 243

Retained Earnings 68,852 69,671 69,689 (18) 68,461 68,431 69,671 69,891 69,701 69,908 68,091 68,320 68,161 68,425 68,702 68,214 68,398

Revaluation Reserve 20,886 20,886 20,886 0 20,886 20,886 20,886 20,886 20,886 20,886 20,886 20,886 20,886 20,886 20,886 21,632 21,632

TOTAL TAXPAYERS EQUITY 89,981 90,800 90,818 (18) 89,590 89,560 90,800 91,020 90,830 91,037 89,220 89,449 89,290 89,554 89,831 90,089 90,273

Year to DateAs at 30 June 2015

Monthly Actual / Forecast

STATEMENT OF FINANCIAL POSITION 2014-1530 JUNE 2015



Appendix 41 2 3 4 5 6 7 8 9 10 11 12

Annual Annual

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Outturn PlanActual Plan Variance Actual Actual Actual Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Outturn£'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s

Surplus / (Deficit) 837 739 98 (390) (30) 1,257 220 (190) 207 (1,817) 229 (159) 264 277 (488) (620) (500)

Non Operating Income / ExpenditureFinance Income / Charges (14) (12) (2) (3) (5) (6) (4) (4) (4) (4) (4) (4) (4) (4) (4) (50) (50)

Depreciation and Amortisation 969 923 46 310 323 336 323 323 323 310 310 310 310 310 310 3,798 3,764

Impact of Legacy Balances 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

PDC Dividend Expense 624 625 (1) 208 208 208 208 208 208 208 208 208 208 208 208 2,496 2,500

Impairment Losses 0 0 0 0 0 0 0 0 0 2,100 0 0 0 0 0 2,100 2,100

Operating Cashflows before Movements in Working Capital 2,416 2,275 141 125 496 1,795 747 337 734 797 743 355 778 791 26 7,724 7,814

Increase / (Decrease) in working capitalInventories 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

NHS Trade Receivabes (249) (435) 186 (3,053) 2,883 (79) (190) 0 (659) 654 (265) 266 (6) (133) 399 (183) (183)

Non NHS Trade Receivabes (972) (125) (847) (637) 184 (519) 839 (4) (4) (245) (4) (4) (4) (2) 15 (385) (294)

Accrued Income (321) 523 (844) 353 (326) (348) 654 150 (450) (600) (175) 300 250 (100) 1,250 958 958

Prepayments (301) (295) (6) (295) (24) 18 (44) (50) 50 (100) 50 200 (40) (130) 346 (19) 1

Other Receivables (119) (291) 172 11 (589) 459 128 (2) (300) 300 (2) (300) 300 (2) (100) (97) (97)

Trade Payables (6,182) (5,634) (548) (4,822) (251) (1,109) 1,119 (260) 239 452 (470) 98 62 78 414 (4,450) (4,586)

Other Payables 36 63 (27) 64 (4) (24) 25 (2) (2) (2) (2) (2) (2) (2) (2) 45 45

Accrued Expenditure 4,434 3,674 760 2,718 696 1,020 (2,760) 550 600 24 (1,200) 50 1,000 40 (1,504) 1,234 1,234

Annual Leave Accrual 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (25) (25) (25)

Deferred Income, Current & Non Current 111 68 43 240 2,964 (3,093) (15) (79) (51) 28 (51) (51) 28 (51) (51) (182) (182)

Provisions, Current & Non Current (5) 16 (21) 11 (5) (11) (119) (592) 5 0 0 5 0 0 0 (706) (777)

Increase / (Decrease) in working capital (3,568) (2,436) (1,132) (5,410) 5,528 (3,686) (363) (289) (572) 511 (2,119) 562 1,588 (302) 742 (3,810) (3,906)

Net Cashflow from Operations (1,152) (161) (991) (5,285) 6,024 (1,891) 384 48 162 1,308 (1,376) 917 2,366 489 768 3,914 3,908

Investing ActivitiesProperty, Plant & Equipment Expenditure (385) (529) 144 0 (33) (352) (1,056) (506) (624) (671) (645) (405) (311) (217) (228) (5,048) (5,021)

Proceeds on Disposal of Property, Plant & Equipment 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

(Increase) / Decrease in Capital Receivables 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Increase / (Decrease) in Capital Payables (154) (345) 191 (180) 7 19 (194) 25 50 (60) 15 100 (25) (50) 350 57 58

Net Cashflow from Investing Activities (539) (874) 335 (180) (26) (333) (1,250) (481) (574) (731) (630) (305) (336) (267) 122 (4,991) (4,963)

Financing ActivitiesPDC Dividends Paid 0 0 0 0 0 0 0 0 (1,297) 0 0 0 0 0 (1,250) (2,547) (2,545)

PDC Received 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Interest Received on Cash and Cash Equivalents 14 12 2 3 5 6 4 4 4 4 4 4 4 4 4 50 50

Net Cashflow from Financing Activities 14 12 2 3 5 6 4 4 (1,293) 4 4 4 4 4 (1,246) (2,497) (2,495)

NET CASH INFLOW / (OUTFLOW) (1,677) (1,023) (654) (5,462) 6,003 (2,218) (862) (429) (1,705) 581 (2,002) 616 2,034 226 (356) (3,574) (3,550)

Opening Cash Balance 16,739 16,739 0 16,739 11,277 17,280 15,062 14,200 13,771 12,066 12,647 10,645 11,261 13,295 13,521 16,739 16,739

Net Cash Inflow / (Outflow) (1,677) (1,023) (654) (5,462) 6,003 (2,218) (862) (429) (1,705) 581 (2,002) 616 2,034 226 (356) (3,574) (3,550)

Closing Cash Balance 15,062 15,716 (654) 11,277 17,280 15,062 14,200 13,771 12,066 12,647 10,645 11,261 13,295 13,521 13,165 13,165 13,189

12 MONTH ROLLING CASHFLOW STATEMENT30 JUNE 2015

As at 30 June 2015

Monthly Actual / ForecastYear to Date2015-16



Appendix 5

Capital Number Scheme Description Category 2015/16 Plan Month 1

ActualMonth 2 Actual

Month 3 Actual

Month 4 Forecast

Month 5 Forecast

Month 6 Forecast

Month 7 Forecast

Month 8 Forecast

Month 9 Forecast

Month 10 Forecast

Month 11 Forecast

Month 12 Forecast

Full Year Forecast

Plan v Forecast

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000A5028 Additional Car Park - Ilkeston Hospital Estates 350.0 -4.0 89.0 88.0 88.0 89.0 350.0

A5037 Replacement Valves on Water System - Bolsover Hospital Backlog 18.8 9.4 9.4 18.8

A5040 Upgrade Kitchen/Ventilation - Cavendish Hospital Backlog 8.8 8.8 8.8

A5041 Upgrade Kitchen/Ventilation - Ilkeston Hospital Backlog 8.8 8.8 8.8

A5043 Replacement Boiler - Shirebrook HC Backlog 20.2 20.2 20.2

A5047 Site Development - Walton Hospital Estates 320.0 -8.0 3.0 125.0 200.0 320.0

A5050 Site Development - Heanor Hospital Estates 254.0 4.0 1.0 40.0 32.0 31.0 22.0 22.0 22.0 22.0 22.0 36.0 254.0

A5057 Belper Health Facilities Estates 176.0 15.0 15.0 15.0 15.0 15.0 56.0 15.0 15.0 15.0 176.0

A5067 Opthalmic Microscope, DTC - Ilkeston Hospital Equipment 100.8 100.8 100.8

A5068 Theatre Lighting, DTC - Ilkeston Hospital Equipment 47.5 47.5 47.5

A5074 Upgrade External Lighting - Ash Green Backlog 17.0 1.0 16.0 17.0

A5075 Replacement Windows - Brimington Clinic Backlog 22.0 22.0 22.0

A5076 Flat Roof Repairs - Buxton Hospital Backlog 25.0 15.0 10.0 25.0

A5077 New Sub Mains - Cavendish Hospital Backlog 11.0 1.0 10.0 11.0

A5078 Water Header Tank and Asbestos Removal - Cavendish Hospital Backlog 20.0 10.0 10.0 20.0

A5079 Lightning Protection - Cavendish Hospital Backlog 10.0 1.0 9.0 10.0

A5080 Asbestos Removal and Window Replacements - Chapel HC Backlog 150.0 50.0 50.0 50.0 150.0

A5081 Replacement Valves on Water System - Ilkeston Hospital Backlog 30.0 15.0 15.0 30.0

A5082 Fire Precautions - Ilkeston Hospital Backlog 35.0 20.0 15.0 35.0

A5083 MIU Lighting - Ilkeston Hospital Backlog 12.0 12.0 12.0

A5084 Boiler and Flues - Killamarsh Clinic Backlog 22.0 11.0 11.0 22.0

A5085 Clinic Refurbishment - New Mills Clinic Backlog 40.0 10.0 20.0 10.0 40.0

A5086 Fire Precautions - Ripley Hospital Backlog 10.0 5.0 5.0 10.0

A5087 Slack Lane Plant Room Switch Gear - Ripley Hospital Backlog 14.0 14.0 14.0

A5089 The Lodge Replacement Windows - Ripley Hospital Backlog 21.6 10.0 11.6 21.6

A5090 Road Resurfacing - Whitworth Hospital Backlog 30.0 15.0 15.0 30.0

A5092 Nursery Alterations incl. New Sub Main - Walton Hospital Estates 200.0 2.0 48.0 50.0 50.0 50.0 200.0

A5093 Additional Car Parking Spaces - Walton Hospital Estates 562.6 45.0 20.0 250.0 92.5 82.5 72.6 562.6

A5095 Upgrade and Refurbishment - 84 Whitecotes Lane Estates 20.0 20.0 20.0

A5432 IM&T Desktop Renewal & Windows 7 IM&T 250.0 13.0 21.0 46.0 80.0 90.0 250.0

A5433 IM&T System Procurement IM&T 350.0 -1.0 46.0 305.0 350.0

A5434 IM&T Communications Infrastructure IM&T 75.0 12.0 63.0 75.0

A5435 IM&T PAS Replacement IM&T 390.0 36.0 212.0 32.0 32.0 44.0 34.0 390.0

A5439 Fire Alarm - Ash Green Backlog 75.0 3.0 22.0 25.0 25.0 75.0

A5454 Full Load Generator - Ilkeston Hospital Backlog 150.0 1.0 1.0 68.0 80.0 150.0

A5473 IM&T Mobile Working - Trust Wide IM&T 300.0 26.0 137.0 137.0 300.0

N/A Car Park - Rhoslyn Estates 70.0 70.0 70.0

TBC Endoscopy Kit - Ilkeston Hospital Equipment 195.0 195.0 195.0

TBC Building Management Systems - Trustwide Backlog 48.8 20.0 20.0 8.8 48.8

2015-16 Capital Programme (Not yet approved) Contingency 300.0 -14.0 2.0 44.0 36.0 32.0 20.0 20.0 20.0 50.0 50.0 40.0 300.0

Site Development Contingency - Walton Hospital Estates 260.1 37.0 37.0 37.0 37.0 37.0 37.0 38.1 260.1

Capital Programme Expenditure 5,021.0 33.0 326.0 1,056.3 506.2 624.0 671.0 645.0 404.5 310.5 216.6 227.9 5,021.0

CAPITAL PROGRAMME 2015/1630 JUNE 2015



TRUST BOARDDocument Title: Monitor Self-Certification – Quarter 1

Presenter/Title: Kirsteen Farrar, Trust Secretary


Executive’s Meeting – 2 July 2015, Audit and Assurance Committee - 17 July 2015

Author/Title: Chief Executive’s and Finance Department

Contact Email and Telephone Number: 01773 525065



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

Purpose of Paper

The purpose of the paper is to provide assurance to enable the Board to approve the Self-certification return for Quarter 1.

Recommendations

The Board is asked to consider the Self-certification, discuss the issues and approve the Quarter 1 return.


4.2.1 - There is a risk to the organisation due to not meeting regulatory, contractual or legal obligations resulting in sanctions.

Financial Impact

The financial implications are detailed within the report.


DCHS became a Foundation Trust (FT) on the 1 November 2014 and as such we are required to provide in-year submissions to Monitor on a quarterly basis based upon the reporting requirements in Monitor’s Risk Assessment Framework (RAF) - March 2014.

The RAF provides a framework to assess individual NHS foundation trusts’ compliance with two specific aspects of their work: ‘the continuity of services’ (CoS) and ‘governance conditions in their provider licenses’. The RAF confirms that the Governance rating will be based on:

performance against selected national access and outcomes standards outcomes of CQC inspections and assessments relating to the quality of care provided relevant information from third parties a selection of information chosen to reflect organisational health at the organisation

213�Monitor�Self-Cert�Q1.docxOverall�Page�188�of�211Page�1�of�9


the degree of risk to continuity of services and other aspects of risk relating to financial governance and

any other relevant information.

Appendix 1 details what could give Monitor cause for concern and affect our Governance Rating.

The Trust has submitted two returns for Quarter 3 and 4 and feedback from Monitor confirmed our Governance Risk Rating of Green and our CoS of 4.

To comply with the governance conditions of our licence we are required to provide a statement (the Corporate Governance Statement) detailing:

Any risks to compliance with the governance condition Actions taken or being taken to maintain future compliance

Appendix 2 details the Corporate Governance Statement, the sources of assurance and the Executive Lead for that area. It also cross references the Board Assurance Framework.

DCHS must report to Monitor any in-year material, actual or prospective changes which may affect our ability to comply with any aspect of our licence. There is currently nothing to report to Monitor.

In addition, the Board is required to make a declaration:

For Finance, that: The Board anticipates that the Trust will continue to maintain a Continuity of Service Risk Rating of at least 3 over the next 12 months.

Based upon the evidence provided, it is proposed that the Board makes a positive submission, please see Appendix 3 and the Financial Performance Report for more detail.

For Governance, that: The Board is satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing targets (after the application of thresholds) as set out in Appendix A of the Risk Assessment Framework; and a commitment to comply with all known targets going forward.

The Board needs to review the Performance Report and the Healthcare for All Report in order to confirm our ongoing compliance.

Otherwise: The Board confirms that there are no matters arising in the quarter requiring an exception report to Monitor (per the Risk Assessment Framework page 21, Diagram 6) which have not already been reported.

There are no matters to be reported to Monitor as an exception, please see Appendix 4.

The Board is asked to agree the statements and approve the submission to Monitor.



Monitoring Information Brief Summary and References

What are there Governor Involvement implications?

The Governors will require the information to perform their statutory duties of holding the Board to account.

What are there Equality and Diversity implications?

Equality and Diversity (E&D) is included in the detail which constitutes the Self-certification, for example the performance metrics include Healthcare for All.

What are there Patient, Public and Stakeholder Involvement implications? The Self-certification is a publicly available document

Risk Register

Is the issue on the current Risk Register? Yes If yes, what is the Risk Number? Risk Reg ID

2384




APPENDIX 1 Indicators of Governance Concerns (Risk Assessment Framework, Page 38)



APPENDIX 2Corporate Governance Statement 2014/15

(Risk Assessment Framework, Appendix D)

Corporate Governance Statement Assurance Frequency BAF Ref:

Lead

1) The Board is satisfied that DCHS NHS Foundation Trust applies those principles, systems and standards of good corporate governance which reasonably be regarded as appropriate for a supplier of heath care services to the NHS

BAF

AGS

External Assurance from Head of Internal Audit Opinion

External Audit Governance Report

Summary Report from AAC

Quarterly

Annual

Annual

Annual

Quarterly

4.1.1 Trust Secretary

2) The Board has regard to such guidance on good corporate governance as may be issued by Monitor from time to time

Reports to Board or delegated Committee

As issued by Monitor


3) The Board is satisfied that DCHS NHS Foundation Trust implements:

(a) effective board and committee structures

Review of Terms of Reference and Committee structure

Annually 4.1.1 Trust Secretary

(b) clear responsibilities for its Board, for committees reporting to the Board and for staff reporting to the Board and those committees and;

(c) Clear reporting lines and accountabilities throughout its organisation

Terms of Reference

Summary Reports

Governance Structure

Annually

After each meeting

Annually


4) The Board is satisfied that DCHS NHS Foundation Trust effectively implements systems and/or processes:

(a) to ensure compliance with the Licence holder’s duty to operate efficiently, economically and effectively;

Performance, Finance and Quality Reports

Monthly All sections

Director of Finance

(b) for timely and effective scrutiny and oversight by the Board of the Licence holder’s operations;

Performance and Quality Reports Monthly All sections

Director of Operations

(c) to ensure compliance with health care standards binding on the Licence holder including but not restricted to standards specified by the Secretary of State, the Care Quality Commission, the NHS Commissioning Board and statutory regulators of health care professions;

Quality Report

Summary Report from QSC

Monthly

Monthly

Section 1.0

Chief Nurse

(d) for effective financial decision-making, management and control (including but not restricted to appropriate systems and/or processes to ensure the Licence holder’s ability to continue as a going concern);

Finance Report

Summary Report from QBC

Summary Report from AAC

Monthly

Bi-monthly

Quarterly

3.2.6 Director of Finance

(e) to obtain and disseminate accurate, comprehensive, timely and up to date information for Board and Committee decision-making;

Board and Committee Forward Agendas

Quarterly 4.1.1 Trust Secretary




Lead

(f) to identify and manage (including but not restricted to manage through forward plans) material risks to compliance with the conditions of its Licence;

Risk Report

Summary Reports from the Sub-Committees

Monthly

After each meeting

4.2.2 Chief Nurse

(g) to generate and monitor delivery of business plans (including any changes to such plans) and to receive internal and where appropriate external assurance on such plans and their delivery; and

Summary Reports from QBC

Board Development Sessions

Bi-monthly

As required

3.1.3 Director of Finance

(h) to ensure compliance with all applicable legal requirements.

Summary Report from AAC Quarterly 4.2.1 Trust Secretary

5) The Board is satisfied:a) that there is sufficient capability at

Board level to provide effective organisational leadership on the quality of care provided;

Outcome of Appraisal Report for Executive Team

NED Appraisal

Job Descriptions for Board members

Succession plans

Fit and Proper Persons Register

Annually 2.2.1 Chair

b) that the Board’s planning and decision-making processes take timely and appropriate account of quality of care considerations,

Quality Report Monthly 4.1.1 Chief Nurse

c) the collection of accurate, comprehensive, timely and up to date information on quality of care;

Quality Dashboard

Business Information System

Ongoing 3.2.6 Director of Finance

d) that the Board receives and takes into account accurate, comprehensive, timely and up to date information on quality of care;

Quality Report

Performance Report

Monthly

Monthly

3.2.6 Chief Nurse

e) that DCHS NHS Foundation Trust including its Board actively engages on quality of care with patients, staff and other relevant stakeholders and takes into account as appropriate views and information from these sources; and

Patient Stories

Spotlight on local Services at each Board meeting

Council of Governors Summary Report

Quality Services Committee Summary Report

Quality People Summary Report

Patient Experience Annual Report

Staff Survey Results

Monthly

Monthly

After each meeting

After each meeting

After each meeting

Annual

Annual

1.3.2 Chair

f) that there is clear accountability for quality of care throughout DCHS NHS Foundation Trust including but not restricted to systems and/or processes

Risk Report

Quality Assurance Framework

Monthly 4.2.2 Chief Nurse




Lead

for escalating and resolving quality issues including escalating them to the Board where appropriate,

Ward to Board Escalation Framework

6) The Board of DCHS NHS Foundation Trust effectively implements systems to ensure that it has in place personnel on the Board, reporting to the Board and within the rest of the Licence holder’s organisation who are sufficient in number and appropriately qualified to ensure compliance with the Conditions of this Licence.

Staffing for Quality

Appraisal

Essential Learning

Summary report from QPC

Monthly

Annually

Annually

Bi-monthly

Section 2.0

Director of People

Key:

AAC Audit and Assurance Committee

AGS Annual Governance Statement

BAF Board Assurance Framework

NED Non-Executive Director

QBC Quality Business Committee

QPC Quality People Committee

QSC Quality Service Committee



APPENDIX 3Continuity of Service Risk RatingFrom 1st October 2013, Monitor’s regulatory regime moved to a Continuity of Service rating, which replaces the Financial Risk Rating. The Risk Assessment Framework guidance does not specifically identify a quarterly declaration that needs to be made on finance. All Commissioner Requested Services (CRS) providers are required to provide financial information to Monitor during the year so that financial risk and the continued provision of CRS can be assessed. Monitor will use this information to update the continuity of services risk rating.

Under their governance condition, NHS foundation trusts will submit a corporate governance statement which requires Boards to confirm forward compliance with the governance condition for the current financial year. It is therefore proposed to declare quarterly against the following financial statements:

Statement Evidence ConclusionThe Board anticipates that the trust will continue to maintain a Continuity of Services rating of at least 3 over the next 12 months

Long Term Financial Model

Annual Plan Monthly Financial

Report PwC Review of

Working Capital and Financial Reporting procedures

Future 2 year plan forecasts a CoS of 4.

The Board is satisfied that the trust shall at all times remain a going concern, as defined by the relevant accounting standard in force from time to time.

Long Term Financial Model

Annual Plan Monthly Financial

Report Board Memorandum on

Working Capital Financial Viability

Review PwC Review of

Working Capital and Financial Reporting procedures

Confirmation that the Trust will remain a going concern as defined by the relevant accounting standard in paper to April 2015 Audit and Assurance Committee. Rolling cashflow does not highlight any liquidity concerns.

PwC review of Working Capital provides external assurance as to the trust’s view that it will remain a going concern for the foreseeable future

Based upon the evidence provided, it is proposed that the Board makes a positive submission against both statements.



APPENDIX 4

Examples of Exception Reporting

(Risk Assessment Framework, page 21)



TRUST BOARDDocument Title: Counter Fraud, Corruption and Bribery Policy

Presenter/Title: Chris Sands, Director of Finance, Information and Strategy

Contents of Paper were previously discussed by: Audit and Assurance Committee, 17th July 2015

Author/Title: Chris Sands, Director of Finance, Information and Strategy

Contact Email and Telephone Number: [email protected]



Document is for:(more than one box can be ticked) Information Decision X Assurance

Purpose of Paper

The Counter Fraud, Corruption and Bribery Policy is due for its bi-annual review. This paper undertakes this review, and asks the Board to ratify the updated policy.

Recommendations

Board members are asked to ratify the policy.


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

Financial Impact

None


The policy has been reviewed by the Local Counter Fraud Specialist, Director of Finance, Information and Strategy and Acting Trust Secretary. It was approved by the Audit and Assurance Committee at its July 2015 meeting. Only minor amendments are being proposed to the policy to reflect the achievement of foundation trust status, the updating of titles and contact details and the conversion of the document into the latest Trust format for policies.

215�Fraud�Policy.docxOverall�Page�197�of�211Page�1�of�15



What are the Governor involvement implications? No implications


An E&D impact assessment has been completed as part of the policy


The Trust will need to ensure that stakeholders abide by the policy

Risk Register


No If yes, what is the Risk Number?




POLICY NAME/SUMMARY TITLE

Version Number Page 1 of 15 Policy date

COUNTER FRAUD, BRIBERY AND CORRUPTION POLICY

Document History

Modified Date: July 2015 (Draft)

Version Number: 3.0 Reference Number:Next Revision Due: September 2017

Author: Chris Sands, Director of Finance, Information and Strategy

Policy Sponsor: Chris Sands, Director of Finance, Information and Strategy

Approved by: Audit and Assurance Committee Date: 17th July 2015

Ratified by: Board of Directors Date:

Category: Finance

Sub Section: FinanceType of Document: Policy

Have you assessed the Equality Impact of this policy?

(please see section 10)

Please indicate which groups have discussed this policy:

None

Date(s) discussed:

Has this Policy previously been known under another title? If so please state previous title.

No

Date changed:

Revision History





Version Revision date

Summary of Changes

2 July 2013 Inclusion of bribery offences (following the introduction of the Bribery Act 2010).

Revision of the generic areas of counter fraud, bribery and corruption work (which link to the latest NHS Protect Anti-Crime Strategy)

Incorporation of NHS Protect Standards for Providers: Fraud, Bribery and Corruption

Revision of the Policy taking account of the recently updated NHS Protect template Fraud, Bribery & Corruption policy.

3 July 2015 Updated for achievement of foundation trust status

Updated for minor issues

To help ensure that this policy is as accessible as possible, it has been left-aligned and is available in alternative formats and languages. To obtain a copy of the policy in large print, audio, Braille (or other format) or in a different language, please contact The Communications Team, by Tel: 01773 525099 or email [email protected]






Table of Contents

Aim /Purpose ...........................................................................................................................4

Intended Users .........................................................................................................................5

Disclaimer Statement................................................................................................................5

Full Details of Policy .................................................................................................................6

Support and Additional Contacts ..........................................................................................11

Supporting Documents or Relevant References .................................................................11

Approval and Ratification Route ...........................................................................................11

Monitoring/Audit .....................................................................................................................11

Equality Impact........................................................................................................................11

Appendices..............................................................................................................................12





1. AIM /PURPOSE

This policy is intended as a guide for all staff within the Trust on countering fraud, bribery and corruption (collectively referred to within this policy as financial crime). It details the Trust’s commitment to the proper use of public funds and outlines roles and responsibilities for the prevention of fraud, bribery and corruption within DCHS, in addition to the approach to be taken regarding matters of suspected financial crime.

Derbyshire Community Health Services NHS Foundation Trust has zero tolerance to fraud, bribery and corruption within the organisation.

The Board of Directors is committed to the elimination of fraud, bribery and corruption by ensuring there is a strong anti-fraud, bribery and corruption culture, proactive prevention, detection and deterrence through widespread awareness and rigorously investigating any such cases, and where proven, to ensure wrong doers are appropriately dealt with, which includes taking steps to recover assets lost as a result of fraud, bribery and corruption.

Any apparent fraud, bribery, corruption or financial irregularity will be investigated and disciplinary action, including reference to any relevant professional organisation, will be taken. Cases will be referred for formal investigation where there is prima facie evidence of a criminal offence. Where disciplinary action is taken, this will follow the Trust disciplinary policy.

Criminal and civil prosecutions from individuals found to have committed fraud, bribery or corruption will be pursued.

The seeking of financial redress and recovery of losses will always be considered in cases of fraud, bribery or corruption that are investigated by either the Local Counter Fraud Specialist (LCFS) or the NHS Protect National Investigation Team. Recovery of the loss caused by the perpetrator will always be sought.

Redress allows resources that are lost to fraud, bribery and corruption to be returned to the NHS for use as intended for the provision of high quality patient care and services.

All staff have a duty to protect the assets of the Trust and also to cooperate with any investigation and the Board recommends anyone having suspicions of fraud, bribery or corruption to report them. All reasonably held suspicions will be taken seriously.

For concerns which relate to fraud, bribery or corruption these should be reported through the provisions within this policy, rather than through the raising concerns policy.

This document states the Trust policy in relation to fraud, bribery and corruption and provides some guidance to directors, managers and employees who find themselves having to deal with, or who become aware of suspected fraud, bribery or corruption. Further guidance may be obtained by contacting Penny Gee, the Trust’s LCFS on 0115 8835323 or by email to [email protected] or [email protected].

This section should include why the policy is needed in DCHS, it can also include any National, Department of Health and legislative requirements and explain any medical or technical terms.






2. INTENDED USERS

Table of Intended Users:

DCHS Chief Executive’s Department YES

Finance Performance and Information YESQuality YES

Strategy YESOperations YES

People & Organisational Effectiveness YES

Within this policy where it states “all employees”, please note, that it relates to all the employees who are highlighted in the table above

3. DISCLAIMER STATEMENT

It is a requirement that the reader follows this policy and accepts professional accountability and maintains the standards of professional practice as set by the appropriate regulatory body applicable to their professional role and to act in accordance with the express and implied terms of your contract of employment, in accordance with the legal duties outlined in the NHS Staff Constitution (section 3b). If there are any concerns with this document then the reader should initially discuss the specific issue with their line manager or raise it through appropriate “raising concerns” channels. The line manager should agree a course of action that is appropriate and reflect this in the patients notes and with the policy sponsor.

4. DEFINITIONS AND AN EXPLANATION OF TERMS USED

Fraud

The Fraud Act 2006 came into force on the 15 January 2007 and introduces the general offence of fraud. Fraud involves dishonestly:

Making a false representation; or

Failing to disclose information; or

Abusing a position held;

with the intention of making a gain for oneself or causing a loss to another.

Other Fraud-related Offences

The following offences are not contained in the Fraud Act 2006 but may nevertheless be used to prosecute in cases of fraud against the NHS:

Conspiracy to defraud





Forgery & Counterfeiting

Dishonestly retaining a wrongful credit

Computer misuse

Bribery and Corruption

Bribery and corruption involves offering, promising or giving a payment or benefit-in-kind in order to influence others to use their position in an improper way to gain an advantage.

The Bribery Act 2010 replaces the fragmented and complex offences at common law and in the Prevention of Corruption Acts 1889-1916. There are two general offences of bribery within the Act:

o Offering or giving a bribe to induce someone to behave, or to reward someone for behaving, improperly; and

o Requesting or accepting a bribe either in exchange for acting improperly, or where the request or acceptance is itself improper.

The Act also introduced a new corporate offence of negligently failing by a company or limited liability partnership to prevent bribery being given or offered by an employee or agent on behalf of that organisation. DCHS (in common with other NHS bodies) falls under the definition of a ‘company’ for the purposes of the Act.

5. FULL DETAILS OF THE POLICY

Response Plan

In accordance with Ministry of Justice guidance, DCHS has undertaken a risk assessment to determine the extent to which bribery and corruption may affect the Trust. Proportionate procedures in place to mitigate the identified risk include the following requirements:

All staff must disclose their business interests, prior to commencement of employment with DCHS;

All staff must declare hospitality (other than modest hospitality) received by or offered to them as DCHS employees;

All hospitality (other than extremely minor hospitality) provided by DCHS staff to third parties must be declared; and

Staff must not solicit personal gifts and must declare all gifts received (in excess of £20 in value).





Guidance regarding the above requirements can be found in the Trust Standards of Business Conduct Policy. Staff must also comply with the Trust General Code of Conduct.

In compliance with NHS Protect Standards for Providers: Fraud, Bribery and Corruption, DCHS will minimise losses to financial crime through:

Creating a strong counter fraud, bribery and corruption culture

We all have a responsibility to protect our organisation and its resources. Everyone, including the public, DCHS staff, professionals, managers and policy makers (the honest majority), must work together to raise awareness of the Trust’s zero tolerance approach to fraud, bribery and corruption, to report concerns and enforce the message to the dishonest minority that such matters are not acceptable within the NHS and will be dealt with accordingly.

The most effective deterrent will come from those of us within the NHS who value the service provided and disapprove of those who abuse the system through fraud, bribery, corruption and other dishonest acts. In addition, publicity surrounding counter fraud, bribery and corruption work will deter some who perpetrate or consider perpetrating related offences. DCHS will publicise successful investigation outcomes both internally and externally as appropriate in order to aid the deterrent effect.

Proactively preventing and detecting fraud, bribery and corruption

DCHS will ensure (through ‘fraud-proofing’) that its systems, policies and processes are sufficiently robust so that the risk of fraud, bribery and corruption is reduced to a minimum. Checks will be conducted in areas identified to be most at risk to fraud, bribery or corruption in order to proactively detect instances that might otherwise be unreported.

All staff must be aware of and comply with the DCHS Standing Financial Instructions (SFIs), Standards of Business Conduct Policy, General Code of Conduct Policy, Secondary Employment Policy, Close Personal Relationships at Work Policy and their related requirement to declare relevant information.

Conducting professional investigations of all instances of suspected fraud, bribery and corruption

Criminal offences of fraud, bribery or corruption will be investigated in a professional, objective and timely manner by an accredited NHS LCFS. Parallel internal investigations may also be carried out by DCHS managers (supported by the People and Organisational Effectiveness Team) as part of disciplinary procedures. Such parallel investigations will be conducted in accordance with the agreed HR/LCFS liaison protocol.

Applying effective sanctions

Where fraud, bribery or corruption offences are committed criminal sanctions (including prosecution) will be pursued. DCHS employees found to have committed such offences will also be dealt with in accordance with internal disciplinary procedures and referral to professional bodies where appropriate.





Seeking effective redress

Redress allows resources that are lost to fraud, bribery and corruption to be returned to the NHS for use as intended for the provision of high quality patient care and services. The Trust will consider initiating civil recovery action if this is cost-effective and desirable for deterrence purposes. This could involve a number of options such as applying through the Small Claims Court and/or recovery through debt collection agencies. Each case will be discussed with the Director of Finance, Information and Strategy to determine the most appropriate action.

Duties

Chief ExecutiveAs the DCHS Accounting Officer, the Chief Executive has overall responsibility for funds entrusted to DCHS. The Chief Executive must ensure that adequate policies and procedures are in place to protect the Trust and the funds it receives from fraud, bribery and corruption.

Director of Finance, Information and Strategy

The Director of Finance, Information and Strategy has overall responsibility for ensuring that counter fraud, bribery and corruption arrangements are in place. A key element of these responsibilities is to ensure that there is counter fraud, bribery and corruption awareness across the organisation and that all suspected instances of financial crime are appropriately investigated. Further detail as to how this will be achieved is included in section 11.

Internal and External AuditThe Trust’s internal and external auditors review and report on the adequacy of Trust controls and systems and ensure compliance with financial instructions. They have a duty to report any suspicions of fraud, bribery or corruption identified during the course of their work to the Trust’s LCFS.

People and Organisational Effectiveness DirectoratePeople and Organisational Effectiveness Directorate staff provide advice, guidance and support to Trust managers and officers investigating disciplinary matters. All disciplinary matters which involve suspected fraud, bribery or corruption offences will also be subject to parallel criminal investigation by the Trust’s LCFS. A liaison protocol is in place which details arrangements for the conduct of parallel disciplinary and criminal investigations.

Local Counter Fraud Specialist (LCFS)The LCFS is responsible for taking forward all counter fraud, bribery and corruption work within the Trust in accordance with NHS Protect Standards for Providers: Fraud, Bribery and Corruption and this policy. The LCFS reports to the Director of Finance, Information and Strategy and the Trust’s Audit and Assurance Committee.

The LCFS is professionally trained and accredited to conduct counter fraud, bribery and corruption work. All criminal investigations undertaken by the LCFS are conducted in accordance with relevant legislation.





ManagersAll DCHS managers are responsible for ensuring compliance with Trust policies, procedures and processes applicable to their area of work, for applying controls to prevent financial crime and for identifying and reporting to the LCFS any identified weaknesses which might allow fraud, bribery or corruption to occur. Managers are also responsible for ensuring that staff are aware of what constitutes fraud, bribery and corruption within the NHS and that they understand the importance of protecting the Trust from it.

Managers must report any instances of actual or suspected fraud, bribery and corruption (in accordance with section 8 of this policy) immediately concerns are identified or brought to their attention and refrain from undertaking any investigations of financial crimes themselves.

EmployeesIt is the responsibility of all individuals to ensure that they comply with this, and all other Trust policies and procedures relevant to their area of work and to ensure that they recognise fraud, bribery and corruption, which might occur within the organisation.

Fraud, bribery and corruption training is available to all staff through eLearning, completion of workbooks and face to face presentations. The eLearning module and workbook are available from the Counter Fraud page on the Trust intranet. Face to face presentations can be arranged by contacting the LCFS on 0115 8835323 or by email to [email protected] or [email protected].

Countering fraud, bribery and corruption is the responsibility of all Trust staff. All individuals within the organisation are responsible for reporting any concerns regarding fraud, bribery and corruption immediately they arise (in accordance with section 8 of this policy).

We must all work together to be effective in reducing fraud, bribery and corruption to an absolute minimum.

The Trust recognises the potential impact on individuals who have been affected by fraud, bribery or corruption within their working environment, therefore support and advice will be made available.

Reporting Fraud, Bribery and Corruption

If fraud, bribery or corruption is discovered or suspected it must immediately be reported directly to the LCFS, the Trust Director of Finance, Information and Strategy or NHS Protect. Contact details are as follows:

LCFSPenny Gee Tel: 0115 8835323

Mobile: 07715 807250Email: [email protected] or [email protected]

Director of Finance, Information and StrategyChris Sands Tel: 01629 817892

Mobile: 07827 356506Email: [email protected]








If there is a concern that the LCFS or the Director of Finance, Information and Strategy is, themselves, implicated in suspected fraud, bribery or corruption then the concerns should be reported directly to NHS Protect.

NHS ProtectFraud and Corruption Reporting Line Tel: 0800 028 40 60 (Freephone)Secure Website www.reportnhsfraud.nhs.uk

You do not have to tell us who you are when raising concerns under this policy however, this may make it more difficult for your concerns to be investigated.

Acting on Your Suspicions – The Dos and Don’ts

If you suspect fraud, bribery or corruption within the NHS, there are a few simple guidelines that should be followed:

DO

Note your concerns

Make an immediate note of your concerns – note all relevant details, such as the nature of your concerns, names, dates, times and details of conversations and possible witnesses. Time, date and sign your notes.

Retain evidence

Retain any evidence that could be destroyed, or make a note of available evidence and immediately advise the LCFS.

Report your suspicions

Deal with the matter promptly – any delay may case DCHS to suffer further financial loss.

DON’T

Confront the suspect or convey your concerns to anyone other than the LCFS, Trust Director of Finance, Information and Strategy or NHS Protect.

Try to investigate the matter yourself

Never attempt to gather evidence yourself unless it is about to be destroyed or could be tampered with. Gathering evidence must be done in line with legal requirements in order for it to be useful. The LCFS will conduct any investigation in accordance with relevant legislation.

Be afraid of raising your concerns

The Public Interest Disclosure Act 1998 protects employees who have reasonable concerns. You will not suffer any recrimination from the Trust as a result of voicing a


http://www.reportnhsfraud.nhs.uk/




reasonably held suspicion. The Trust will treat any matter raised with sensitivity and confidentiality.

Do nothing

6. SUPPORT AND ADDITIONAL CONTACTS

The Director of Finance, Information and Strategy, and the Local Counter Fraud Specialist are the people responsible for developing the document and from whom additional support and advice can be obtained in order to implement the document.

7. SUPPORTING DOCUMENTS OR RELEVANT REFERENCES

This is a standalone policy. Readers may find it useful to refer to the Trust Standing Financial Instructions (SFIs).

8. APPROVAL AND RATIFICATION ROUTE

The policy will be approved by the Audit and Assurance Committee and ratified by the Board of Directors on a 2 yearly basis

9. MONITORING/AUDIT

It is necessary to routinely check whether or not a policy is being followed. Appendix 1 sets out how the policy will be monitored.

10. EQUALITY IMPACT

We welcome feedback on this policy and the way it operates. We are interested to know of any possible or actual adverse impact that this policy may have on any groups in respect of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation.

The person responsible for equality impact assessment of this policy is the Director of Finance, Information and Strategy – 01629 817892.

This policy has been screened to determine equality relevance for the following equality groups: age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation. The policy is considered to be equality relevant for none of the groups. A full impact assessment has been conducted and the report is attached to this policy in Appendix 2.





11. APPENDICES

Appendix 1

Monitoring

Monitoring and/or AuditMeasurables Lead

OfficerFrequency Reporting

toAction Plan/Monitoring

Delivery of Counter Fraud, Bribery and Corruption Plan

LCFS Quarterly Audit and Assurance Committee

Audit and Assurance Committee

Staff questionnaire on fraud, bribery and corruption awareness

LCFS Bi-Annually Audit and Assurance Committee

Audit and Assurance Committee





APPENDIX 2 - EQUALITY & DIVERSITY IMPACT ASSESSMENT: LEVEL I SCREENING Race Gender Disability Age Sexual

OrientationWhich of the following diversity profiles could suffer detriment as a result of this policy / procedure /process?

X X X X X

What is the purpose of the policy under assessment?It details the Trust’s commitment to the proper use of public funds and outlines the approach to be taken regarding matters of suspected fraud, bribery or corruption.

What is the background to the policy? (e.g. in response to a statutory requirement, development of good practice, organisational review etc..)

The policy is a requirement for all trusts under Secretary of State Directions. Providers of NHS funded healthcare services are required to comply with NHS Protect standards for countering fraud, bribery and corruption.

Who is intended to benefit from the proposed policy?The Trust’s control framework and use of resources is intended to benefit from this policy.

Is there any potential for impact on non-beneficiaries?No

Is there up to date data on the groups/individuals on whom there may be impact?

It is not anticipated that any groups will be affected

Have there been changes to the equalities profile of the above groups/individuals since the collection of the data?

No

Does the policy influence in a positive way relations between different groups of people?

The policy does not influence in either a positive or negative way.

Does it promote equality of opportunity?The policy does not influence in either a positive or negative way.

Does the function either eliminate or contribute to the elimination of unlawful; discrimination across all equalities themes?

No

Are there any concerns expressed about the policy having the potential for adverse impact on any group/s of people?

No

Assessment Outcomes No further action X Revisions not required

Level 1 assessment – signing off date: 29th June 2015 Assessment carried out by: Chris Sands, Director of Finance, Information and Strategy

