agenda part 1 (public session) · 1 10.25 apologies and declarations of interest 2 10.25 minutes of...

BOARD OF DIRECTORS

AGENDA – PART 1 (PUBLIC SESSION)

Thursday 26 July 2018

J1 Board Room, BGH, Elm Grove, Brighton BN2 3EW 10.00 a.m. – 12.45 p.m.

No Approx time

Item Director

10.00 Welcome and introduction Chair

10.00 Employee of the Month Chair

10.05 Staff Story CN

MEETING ADMINISTRATION

Please note this meeting may be live-streamed on the internet so care should be taken not to use people’s names in questions unless their permission has been given in advance.

1 10.25 Apologies and declarations of interest

2 10.25 Minutes of the previous meeting 31 May 2018 Enclosure Chair

3 10.25 Matters arising and actions log Enclosure Chair

PERFORMANCE AND QUALITY ITEMS

4 10.30 Integrated Performance Report (IPR): Month 3 To seek assurance

Enclosure DPI

5 10.50 Quality Report To receive/discuss

Enclosure CN

6 11.10 Quarterly Serious Incidents Report To receive/discuss

Enclosure MD

7 11.20 Strategic Workforce Report To receive/discuss

Enclosure CN

8 11.40 Finance Report: Month 3 To receive/discuss

Enclosure DoF

9 11.50 Corporate Objectives and BAF Quarterly Review To receive/discuss

Enclosure CEO

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GOVERNANCE ITEMS

10 12.05 Information Governance & Caldicott Guardian Annual Report To receive

Enclosure DoF/MD

11 12.15 Quarterly Mortality Report To receive/discuss

Enclosure MD

12 12.20 Guardian of Safe Working Quarterly Report To note

Verbal MD

13 12.25 Revised Standing Orders (SOs), Standing Financial Instructions (SFIs) and Scheme of Delegation (SoD) To approve

Enclosure (+ full

document on VBR shared documents)

DoF

STRATEGIC ITEMS

14 12.30 Digital Strategy To approve

Enclosure DPI

ITEMS FOR INFORMATION (no discussion on these

items unless request is made to Chair before meeting)

15 Annual Health and Safety Report Enclosure CN

16 Duty of Candour Annual Compliance Report Enclosure MD

17 Board Schedule of Business 18/19 Enclosure

12.45 Close of Meeting

Date of next meeting: Thursday 27 September 2018, J1 Board Room, BGH, Elm Grove, Brighton BN2 3EW, 10.00 a.m. start

Note: Questions from Governors and/or the public will be taken on each item during the meeting. Any other, general questions should be submitted to the following email address for a response outside the Board meeting:

[email protected]

Resolution: That the remainder of the meeting shall be held in private because publicity would be prejudicial to the public interest, by reason of the confidential nature of the business to be transacted in accordance with the Public Bodies (Admissions to Meetings) Act 1960 s1(2)

LUNCH 12.45 – 1.15 p.m.

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MINUTES OF THE TRUST BOARD MEETING HELD IN PUBLIC

Thursday 31 May 2018

J1 Board Room, Jevington Building, Brighton General Hospital, BN2 3EW

Present

Peter Horn PH Trust Chair (Chair)

Siobhan Melia SMe Chief Executive

Stephen Lightfoot SL Non-Executive Director (NED)

Elizabeth Woodman EW Non-Executive Director

David Parfitt DP Non-Executive Director

Janice Needham JN Non-Executive Director

Maggie Ioannou MI Non-Executive Director

Mike Jennings MJ Director of Finance and Estates (DoF)

Richard Quirk RQ Medical Director

Richard Curtin RC Chief Operating Officer (COO)

Susan Marshall SM Chief Nurse

In Attendance

Anuschka Muller AM Director of Performance and Improvement (DPI)

Caroline Haynes CH Director of HR and OD (DHR)

Margaret Godfrey MG Company Secretary

Observers

Dave Romaine Public Governor

Andrew Partington Public Governor

Representative of Royal College of Nursing

1 member of public

Apologies

Kate Pilcher KP Director of Operations (DOO)

BoD18/108 Welcome and introduction

The Chair welcomed those present to the meeting. He stated that the Employees of the Month for May were Alex Brewer and Paula Lover. He said that Alex had been nominated for his work with the Quality Improvement team and the invaluable advice and support he had given them as they developed the communications for Our Community Way. He said that Paula had been nominated for the compassionate care she had shown a patient and her family and her dedication to always putting the patient first. He congratulated Alex and Paula on their awards and thanked them on behalf of the Board for their excellent work.

BoD18/109

Staff Story

The Chief Nurse introduced David Feakes, Head of Safeguarding and Looked After Children, who spoke about his role in supporting patients, their families and staff who experienced safeguarding issues. He described the governance arrangements supporting safeguarding, including the five local Safeguarding Boards and partnerships

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with the local authorities and Clinical Commissioning Groups (CCGs), which were working well. He said that the main challenges for the service were that the caseload volume was unpredictable and prone to fluctuation and the lack of capacity to provide supervision to junior staff on the Healthy Child Programme. In response to questions, he said that one aim for the service was to secure more funding for adult safeguarding as demand was increasing in this area, and a further aim was to embed safeguarding into normal business practice, rather than be perceived as separate in terms of business planning and the allocation of supervision resources. He said that safeguarding should be seen as part of everyone’s work. He confirmed to NEDs that he felt adequately supported by the Trust to cope with the emotional demands his role could sometimes place on him and his team, adding that the Trust empowered its staff to raise concerns through its open culture. The Board discussed the difficulties of working on the prevention of safeguarding issues and noted that training staff to spot potential safeguarding issues at an early stage was important. The Board also noted that the safeguarding remit was increasing with new societal issues emerging such as social media bullying and modern slavery. The Chair thanked the Head of Safeguarding and Looked After Children for talking to the Board and his and his team’s excellent work for the Trust and for patients and families.

BoD18/110

Apologies, declarations of interest

The Chair formally opened the meeting and explained the process for taking questions from Governors, staff and/or members of the public relating to items on the agenda. He informed attendees that the meeting was one held in public and not a public meeting and added that the Board meeting was being live streamed on the internet and reminded speakers to maintain patient and staff confidentiality at all times. There were apologies from Kate Pilcher. There were no declarations of interest.

BoD18/111

Minutes of the last meeting

The draft minutes of the Board meeting held on 26 April 2018 were approved as a true and accurate record.

BoD18/111

Matters Arising and Actions Log

The Board noted updates on the following actions from previous meetings: BoD18/079: Review of Caravelle Ward: The Chief Nurse said that a further review of the ward, including an observational visit, had been done with no issues identified and good care observed. She said that the Deputy Chief Nurse had met with the family who had attended the previous Board meeting, to talk of their mother’s death, to go through the review findings with them and the resulting actions to be taken to improve communications between staff and families, especially where patients have complex health needs. She said that the family was satisfied with the outcomes of the review and felt that they had been listened to by the Board and action had been taken as a result of their concerns. BoD18/089: The Chief Executive confirmed that progress on strategic enablers would be reported separately to that on corporate objectives during 18/19. BoD18/056: The DHR confirmed the planned survey of bank staff would take place in

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Q1. The Board noted that all other actions from previous meetings were complete, on the agenda, or not yet due.

BoD18/112

Integrated Performance Report (IPR): Month 1

The Chief Executive presented a previously circulated report containing the IPR for month 1, which was in a new format aimed at focusing on the key performance metrics required to drive improvement through the organisation. She added that the report would evolve over time as information requirements were finalised and would be supported by separate detailed Quality, Workforce and Finance Reports. The DPI explained how the new IPR should be interpreted and how trends for the last rolling 12 month period would be shown. The Board reviewed the report by Care Quality Commission (CQC) domain, in the course of which a number of issues were discussed, including: Safe: The Chief Nurse highlighted the slight increase in the falls resulting in harm rate and said that falls prevention remained an area of focus to maintain the good work already done. She added that the frail elderly patient cohort, particularly those with dementia, was at a higher risk of falling, so falls risk assessments were key. The Board noted that further details on the falls data, underlying context and any trends, would be provided in the Quality Report, with the aim of the new IPR to provide a high-level overview. The Board discussed the importance of setting meaningful metrics for inclusion in the IPR and noted that performance against those metrics omitted from the 18/19 IPR was still being measured and would be reported against in the Quality Report to the Board. The Board also discussed whether the targets set for each metric had been arrived at using national benchmarking information or purely internal performance. The DPI said that the performance team had done a considerable amount of work to develop the appropriate targets for each metric and to set stretch targets to drive improvement. She said that metrics and targets had been set using what benchmarking data was available and taking clinicians’ views into account. The Board asked the DPI to include a statement on the rationale for each IPR metric and target in the month 2 IPR.

ACTION: AM Effective: The Board noted that all metrics in this domain were financial and included in the Finance Report and asked the Medical Director to review whether more appropriate metrics could be set for this domain.

ACTION: RQ Responsive: The COO highlighted that Delayed Transfers of Care (DToCs) continued to be a challenge although performance remained good. He said that Community Trusts were expected to achieve 100% in the 4-hour A&E waits target and the Trust was just below that level now and working with NHS Improvement (NHSI) to identify steps to get to 100%. NEDs asked whether the spike in DToCs over the Easter period had been a surprise. The COO said that this was due to deficiencies in discharge planning for the period immediately after Easter and learning from this experience would be taken forward in conjunction with social care partners.

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Caring: The Chief Nurse highlighted the increase in Friends and Family Test (FFT) response percentages of people saying that they would not recommend Crawley Urgent Treatment Centre as a place to have treatment. She said that the Trust was carrying out a full review of FFT including the way responses were collected in an effort to increase response rates and decrease percentages of negative responses. Well-led and Workforce: The Chief Nurse said that the metrics for this domain focused on retention and diversity in the workforce and the remainder of the workforce priorities for the year would be reported through the Workforce Report. She reported that 5 racist incidents had been reported in month 1, with 4 resulting in no harm and 1 in low harm. NEDs asked whether retention data and diversity data was triangulated to identify whether diversity issues were a factor in staff leaving. The DHR said that this was done to an extent at the Workforce Committee, but further analysis was required and ways of doing this would be developed. The Board discussed whether the number of racist incidents was the best metric for measuring diversity and noted that further details on diversity data and actions would be included in the Workforce Report. The Chief Nurse said that this metric required a focus at present in light of the 5 racist incidents reported in month 1 of 18/19 comparted to 22 reported for the whole year in 17/18. The Board noted that this metric had been set in consultation with the Trust’s Black Asian and Minority Ethic Network as a way of quantifiably measuring progress, rather than have to rely on people’s perceptions of what constitutes racism, as this is subjective. The Board discussed the metrics in the IPR and how exceptions on metrics not included in the report would be escalated to the Board. The Chief Executive pointed out that exceptions were currently escalated to the Board via the Risk Management process and/or flash reports from Executive Directors and this would continue to be the case in 18/19. Sustainable: The DoF said that the financial position for month 1 would be discussed under the following agenda item. Top Operational Risks: The Board noted the risk relating to staffing levels at Midhurst Hospital, which had increased to a score of 15. The Chief Nurse said this stemmed from high vacancy rates in qualified staff and added that mitigating actions had been taken including block bookings of temporary staff and the reduction in open beds. She said the position was monitored on a weekly basis and there were no safety concerns at present, but the sustainability of the unit remained questionable. She added that the Trust was liaising with the CCG on the situation and the long-term position. NEDs asked why the current situation had arisen given the success of the last recruitment campaign at Midhurst. The COO replied that Midhurst was always subject to high levels of churn and nursing jobs were plentiful regionally and nationally. He said that mainly local staff had been recruited during the previous campaign and this was a small pool to draw on, so it was unlikely a similar approach would work again but all avenues were being explored. NEDs asked if the remaining staff were being supported to cope with the additional demands the vacancies placed on them. The COO said that support was being provided by General Managers, Matrons and Deputy Chief Nurses. The Chief Executive said that the Sustainability and Transformation Partnership (STP) was looking at creating “step up/step down” capacity for the system to create flexibility and a review of community bed stock would be included in this exercise, which should be completed by December 18. She added that the Trust was leading on this piece of work. The Board noted that the Trust currently had no cyber security risks. The DPI explained

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that NHSI now required Boards to regularly review their cyber security risks and reassured members that the Trust’s cyber security arrangements were robust. The Board discussed the challenges associated with assessing cyber security risks as these were largely unknown and subject to human factors. [Governors and the public asked questions regarding the IPR, diagnostic tests, length of stay, the Sussex Rehabilitation Centre and mental health services provision.]

BoD18/113

Finance Report Month 1

The DoF presented a previously circulated report containing the month 1 Finance Report. He said that the Trust had delivered a surplus of £124k against a plan of £97k, which was positive although it was early in the year. He said that the Trust would be eligible for Provider Sustainability Funding (PSF) for month 1 and the underlying position excluding PSF was break-even. He highlighted the slight increase in agency costs due to the impact of the Easter holiday and staffing shortages in some standalone units. He reported that the cash position was good and the capital programme was on track. He indicated that contract variations for 18/19 had not yet been signed but invoices submitted had been paid and it was hoped to get contract variations signed by the end of June. The Chair of the Finance and Investment Committee (FIC) stated that the Committee had reviewed the month 1 position in detail at its meeting earlier in the week and agreed it was a good start to the year but had some concerns on agency spend and the Cost Improvement Programme.

BoD18/114

Safer Staffing Report

The Chief Nurse presented a previously circulated report containing the Q4 safer staffing data. She said that the format of the report would be changed for 18/19 to include care hours/day data. She reported that Q4 had been challenging especially in Central Area, with the acute in that region on Opal 4 for much of the quarter, in addition to dealing with a flu outbreak. She said that daily risk assessments of staffing levels were carried out and reminded the Board that she had warned members in advance of the impact of staffing challenges on levels of Harm Free Care (HFC). She said that the Trust had signed up to the Enhanced Care Collaborative with NHSI to look at ways of improving HFC and added that measures taken already included table top reviews of falls and pressure damage and the introduction of safety huddles. She said that recruitment fayres were being used to attract staff in specific areas with shortages. NEDs asked why the Trust’s pay rates for bank staff varied from other organisations. The DHR said that there was currently no national framework for bank pay but the local system was working together to standardise bank pay and thus prevent competition. NEDs expressed concern at the staffing shortages at the Finches and Chailey and the risk of cancelling Finches breaks at short notice. The Chief Nurse said that this was only done as a last resort and the Trust worked closely with commissioners and the families affected at such times to try to identify alternative solutions. NEDs commented that the level of medication incidents appeared high in Children’s Services. The Chief Nurse said that this had been reviewed and the data related to the use of out-of-date medicines handed in by patients and reported by Trust staff, although not caused by the Trust. She added that a considerable amount of work had been done

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at Chailey to strengthen medicines management and the numbers of medication incidents was now low. She added that the introduction of electronic prescribing in the next 12 months should help to eliminate them. The Chair of the FIC indicated that he would be willing to assist review the action plan on medications incidents if helpful. NEDs asked how the care hours/day data for Midhurst was in line with that of other units given its staffing shortages. The Chief Nurse said this resulted from some inconsistency of applying the care hours/day methodology, but added that good leadership was also a factor in ensuring that care hours/day levels were as high as possible. The Board commended the improvement in recruitment levels in the East Area and noted that learning from this would be shared with other Areas.

BoD18/115

Board Self-Certification on Compliance with Provider Licence Conditions G6, FT4, CoS7 and Governor Training

The Company Secretary presented a previously circulated report containing the Board self-certification statements affirming compliance with Provider Licence Conditions G6, FT4, CoS7 and Governor Training. She reminded Board members that this was an annual requirement, although NHSI had changed the process last year in that Trusts no longer had to submit copies of their self-certifications to NHSI, but NHSI would carry out random audits instead. She asked the Board to review the drafted self-certification templates and the evidence upon which the Board was asked to base its self-certifications and then, if satisfied, to approve the completed templates. The Board reviewed the statements of compliance in the draft self-certification templates and the evidence underpinning each statement. NEDs asked whether the Trust’s Integrated Assurance Meetings with NHSI were flagging up any issues of concern. The Chief Executive said that NHSI had signaled that it did not have any issues with the Trust’s current quality standards, financial position, operational performance or governance arrangements. NEDs asked whether the self-certification statement relating to the training of Governors correlated to the outcomes of the survey carried out to take views from Governors on the Council of Governors’ (CoG) effectiveness over the past 12 months and to identify any areas for improvement or development. Governors in the audience confirmed they felt that they received sufficient training and development to help them carry out their roles and that this was an area the Trust took seriously. The Board approved the self-certification statements affirming compliance with Provider Licence Conditions G6, FT4, CoS7 and Governor Training and agreed that these could be published once signed.

BoD18/116

Nurse Revalidation Annual Report

The Chief Nurse presented a previously circulated report containing the annual update on nurse revalidation at the Trust. She said that the policy was well-embedded and fully implemented and was now part of “business as usual” at the Trust. She said that once staff had revalidated the first time, it became less onerous to go through the process again and added that the revalidation tool was very helpful in assisting the process. She said that staff due to revalidate but off on maternity or sick leave had to write to the Nursing and Midwifery Council explaining why they could not revalidate by their due

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date, but added that the numbers affected by this were very small. The Board noted the report and congratulated the Chief Nurse and her team on managing the nurse revalidation process so well. Members noted that staff approaching retirement were encouraged to maintain their revalidation so they could work on the bank if they chose to.

BoD18/117

Guardian of Safe Working (GoSW) Annual Report

The Medical Director presented the GoSW Annual Report 17/18 for the Board’s information. He indicated that it captured the data already presented to the Board in the quarterly GoSW reports. The Board noted the report.

BoD18/118

Information Items

The following items were presented for the Board’s information and noted:

a. Board Schedule of Business 18/19.

BoD18/119

Date of Next Meeting (open to the Public):

The Chair informed the meeting that the frequency and pattern of Board meetings in public was changing to bi-monthly. He reassured those present that this did not mean that the Board would engage less with Governors and the public but that alternative means would be adopted. The date of the next public meeting was scheduled for Thursday 26 July 2018, 10.00 a.m. – 1.00 p.m., J1 Board Room, Jevington, Brighton General Hospital, BN2 3EW.

Resolution:

That the remainder of the meeting shall be held in private Committee because publicity would be prejudicial to the public interest. By reason of the confidential nature of the business to be transacted in accordance with the Public Bodies (Admissions to Meetings) Act 1960 s1(2).

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ACTIONS LIST – TRUST BOARD PART 1 310518

Ser. BOARD DATE

ACTION WHO DUE DATE

STATUS

1 BoD18/112 310518 DPI to include a statement on the rationale for each IPR metric and target in the month 2 IPR.

AM Jun 18 Complete June 18.

2 BoD18/112 310518 Medical Director to review whether more appropriate metrics could be set for the Effective domain in the IPR.

RQ Jun 18 Complete June 18.

c/fwd from previous meetings

1 BoD18/056 290318 DHR to arrange for an internal survey of Bank Staff and report the findings through the Workforce Committee and, on an exceptions basis, to the Quality Committee.

CH Q1

2 BoD18/091 260418 Medical Director to schedule a Board discussion on risk appetite once the new BAF is available

RQ June/July 18

Scheduled for September.

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TRUST BOARD – PUBLIC MEETING 26 JULY 2018

Agenda Item: 4

Title: Integrated Performance Report (IPR) – Month 3 Report

Purpose: Approval x Assurance X Discussion x Briefing

Summary: The IPR provides a strategic view of the Trust’s performance against the five CQC domains and of any high level operational and cyber security risks. In response to the Board discussion in May, additional information is provided in relation to indicators and targets set, the provision of variance measures across the Trust for each indicator, SPC charts and Cyber Risks. RAG ratings against the targets are set as:

• Green - on target

• Amber - within 10% of target

• Red – 10% or more off target The dashboard provides an overview of all indicators on a page with individual metric arrows providing at a glance the relative performance compared to the previous month as either up, down or no change. In addition, arrows are colour coded to reflect the outcome of the change:

• Green - positive movement in relation to target

• Red - negative movement in relation to target

• Black – no target or no change Some metrics do not have targets set because neither high nor low activity is related to positive outcomes. These are reported to demonstrate trends or key changes in performance that may require further investigation. For example, reporting the number of racist incidents where by the Trust encourages an open and transparent reporting culture and therefore would not wish to set a low reporting target setting a high target would also not be appropriate as ideally, no incidents should happen at all.

Recommendation: The Board is asked to

• to discuss changes made to the IPR (replacement of ‘effective’ indicators, recommendation for replacement of ‘Falls’ indicators)

• to take note of the description for each indicator and the rationale for setting the targets,

• agree the IPR indicators and targets for 2018-19,

• to discuss the usefulness of SPC charts and

• agree ongoing use of SPC charts,

• to take note of the current performance, operational risks and cyber related risks.

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CQC Domains (Safe; Caring; Responsive; Effective; Well Led)

• The IPR covers each of the CQC domains.

Relevance to Strategic Goals:

• The IPR provides the strategic performance picture of the organisation with indicators directly linked to the delivery of the goals.

Equality and Diversity:

• Assessment completed: Yes

• Impact: No adverse impact on equality and diversity has been identified

Prepared by: Ceri Davies, Deputy Director Strategic Planning & Performance Business Intelligence Performance Team

Presented by: Anuschka Muller, Director of Performance and Improvement

IPR

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Sussex Community NHS Foundation Trust – Integrated Performance Report Month 3 (June) – Reported July 2018

Integrated Performance Report Month 3 (June) Report July 2018

Anuschka Muller Director of Performance and Improvement

IPR

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2

Integrated Performance Report Dashboard

DOMAIN ID MEASUREReporting

Cycle

2017-

2018

Outturn

Result

Aim

High /

Low

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

2018-2019

Year End

Target

0.0910.10Medication incidents: with harm as % of medication incidentsMT260 Monthly

0.03

SAFE

L3.6% 1.6% 2.6%

q q p

36 46 40

q p q

u u u

2 1 1

p q u

3 6 7

q p p

9.1%

7.5

No Target

No Target

10.2%

53

blank

Medication incidents: with harm as % of medication incidents

Falls: Total Inpatient Falls per 1,000 Occupied Bed Days

SIs - Serious Incidents reported as SI in month

MT275 Falls: Total Inpatient Falls Moderate and Above

Percentage compliance with directly applicable NICE guidelines

MT260

MT183

MT110

MT258

Monthly

Monthly

Monthly

Monthly

2.7%

16

122

SAFE

EFFECTIV

E

612MT276 Falls: Total Inpatient Falls Monthly

L

L

L

L

Monthly15

L4 No Target

100.0% 100.0% 100.0%

u u

99.9%

blankHMT262

No Target

99.5%

blank

99.7%Diagnostic wait <6 weeks for a diagnostic test

Percentage compliance with directly applicable NICE guidelinesMT258

MT031 Monthly

Monthly

100.0%

EFFECTIV

E

RESPONSIV

E

Percentage of clinical audit actions completed Monthly

H99.6% 99.6% 100.0%

p q p

99.6% 99.3% 99.4%

p q p

0 1 0

q p q

8.6% 7.3% 7.0%

p q q

26.6 24.9 23.3

q q q

1.1% 1.2% 1.2%

q p p

26.3% 91.2% 28.1%

q p q

12.7% 12.5% 15.5%

q q p

blank blank 68.6%

p

22 45 76

p p p

blank blank 1.45

q

76.6% 77.8% 77.4%

p p q

99.9%

MT223 Leading for Quality Masterclass Monthly113

H

MT088

1.89L

L

L

MT051 Patients Friends and Family Test - UTC/MIU response rate Monthly10.0%

H

68.5%H

MT050 Patients Friends and Family Test - Inpatients response rate Monthly55.3%

H

MT004

MT251

MT029

99.5%

% of clinical band 5 new starters still employed by SCFT within 2yrs of

joining

Staff FFT % who would recommend the Trust as a place to work

**(quarter end snapshot)

75.0%

1.0%

24.0

100.0%

0

7.5%

12

11.1%

25.0

Patients spending <4 hours in MIU/UCC

Emergency Admissions Breaching 12hrs

Delayed transfers of care % of days delayed

1.45

99.7%

Quarterly

MT047

MT212Relative likelihood of white people being appointed compared to

BAME (from shortlisting) (at quarter end)

Diagnostic wait <6 weeks for a diagnostic test

Patients Friends & Family Test - % Unlikely to Recommend

Average Length of Stay

MT159

MT031 Monthly

Monthly

Monthly

Monthly

Monthly

Quarterly

Monthly

WELL

-LED

RESPONSIV

E

CARING

L

L

H

MT263 Monthly75.3%

H

1.1%

26.2

98.1%

H

68.6%

99.4%

1

7.7%

1.2%

13.1% 15.0%

60.0%

77.4% 80.0%

1.5

143 300

49.7%

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3

Details for each IPR indicator Below is an overview of all indicators in the dashboard with details on meaning, calculation and the rationale behind the target setting.

DOMAIN ID MEASURE

Reporting

Cycle

(Quarterly/

Monthly)

Aim

High /

Low

Year End

TargetDescription Numerator Denominator Target

SAFE

MT260 Medication incidents: with harm as % of

medication incidents

M L 9.1% This is a measure of all medication incidents causing harm minor and

above across all services within the Trust against the total number of

medication incidents.

The number of medication incidents incurring

harm

The number of medication incidents 2017/18 medicine incidents causing harm (low

harm and above) was 10.1%. For 18/19 we have

set a 10% reduction target and therefore aim to

achieve 9.1% or lower this year.

MT276 Falls: Total Inpatient Falls M L No Target This is a measure of all Inpatient falls incidents within the Trust. Count of all Inpatinet falls incidents reported. TBC

MT183 Falls: Total Inpatient Falls per 1,000 Occupied

Bed Days

M L 7.5 This indictor measures the number of inpatient falls against 1000

occupied inpatient bed days. It excludes assisted falls, faints and

collapses

Count of falls in inpatient units Sum of occupied bed days divided by 1000 According to the national benchmarking data

for community hospitals the benchmark for

inpatient falls per 1000OBDs is 8.69. The target

has been set below the benchmark as SCFT

17/18 monthly performance was consistently MT275 Falls: Total Inpatient Falls Moderate and

Above

M L No Target The number of Inpatient falls resulting in moderate harm or above

(excluding assisted falls, faints and collapses.) Harm is defined

using the NPSA measurement of harm. (Moderate harm to severe

harm and death). All falls resulting in moderate harm and above,

including those categorised as severe harm or death are reported

Count of Inpatinet falls incidents reported

where the recorded harm was moderate, major

or catastrophic/death

TBC

MT110 SIs - Serious Incidents reported as SI in

month

M L No Target This is the number of serious incidents that have been reported in

month by the Trust.

Number of new serious incidents reported in

the month

This metric has no target. The indicator

monitors the number of SIs to help enable trend

analysis and provide the SCFT Board with a

clear signal of any increases or decreases in SIs

that they need to be aware of.

EFFE

CTIVE

SAFE

MT258 Percentage compliance with directly

applicable NICE guidelines

M H 95% This indicator measures the percentage of applicable NICE

guidelines issued in the previous 3 years which the Trust are

compliant with against the number that the Trust are due to be

compliant with in the relevant month.

Number of NICE guidelines the Trust were

compliant with.

Number of NICE guidelines the Trust were due

to be compliant with.

This is a new metric and a target of 95% has

been set for 18/19 in line with the CQC KLOE

(key lines of enquiry) dashboard.

MT262 Percentage of clinical audit actions

completed

M H No Target This indicator measures the percentage of clinical audit actions

generated in 18/19 which have been completed within the set

timescale in the relevant month against those due for completion.

Number of clinical audit actions the Trust

completed.

Number of clinical audit actions the Trust were

due to complete.

TBC

MT031 Diagnostic wait <6 weeks for a diagnostic

test

M H 99.5% The percentage of patients who are waiting for a diagnostic test at

the end of the month that have waited less than 6 weeks.

Number of patients waiting for a diagnostic

test who have waited less than 6 weeks at

month end.

Number of patients who are waiting for a

diagnostic test.

This target has been set at 99.5% in line with

the national target for community Trusts.

MT088 Patients spending <4 hours in MIU/UCC M H 100% This national indicator measures the percentage of MIU/UTC

attendees across the Trust who spent 4 or less from time of arrival at

the unit to departure.

Count of patients in MIU/UCC for under 4 hours

from arrival to departure.

Count of MIU/UCC attendances This target has been set at 100%. The national

target is 95% but NHSI have indicated their

expectation that the Trust will achieve 100%.

MT251 Emergency Admissions Breaching 12hrs M L 0 This measures the number of patients who waited more than 12

hours in MIU/UTC for an emergency admission from decision to

admit to admission.

The number of MIU/UTC patients who waited

more than 12 hours from decision to admit to

admission

This target has been set at 0 in line with

national guidance.

MT029 Delayed transfers of care % of days delayed M L 7.5% The delayed transfers of care is a measure across our inpatient units

of the days delayed expressed as a percentage of occupied bed days.

A patient is delayed if they are medically fit for discharge but are

unable to leave the unit for other reasons.

Sum of delayed transfers of care (excluding

local delays)

Sum of occupied bed days. This target has been set at 7.5% in line with the

national target for community Trusts.

MT004 Average Length of Stay M L 24 Average Length of Stay is a measure across our inpatient units of

how long a patient stays in our beds on average measured in

occupied bed days.

Sum of occupied bed days Count of discharges This target has been agreed at 24 days against

a 17/18 outturn of 26.2 days. This more

challenging target was set as this is an area of

focus for the organisation in 18/19.

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Details for each IPR indicator cont.

MT047 Patients Friends & Family Test - % Unlikely to

Recommend

M L 1% This indicator measures the percentage of patients responding either

“unlikely” or “very unlikely” to the Friends and Family Test question:

“How unlikely is it that you would recommend this service to friends

and family?” on their FFT response card.

Count of FFT cards received back where the

patient would not recommend the service

Count of FFT cards received back The outturn for 17/18 was 1.05% against a

national average published by NHSE as 2%. The

target of 1% was retained as the Trust did not

achieve this in 17/18 but note that the Trust is

performing much better than the national

average.

MT050 Patients Friends and Family Test - Inpatients

response rate

M H 60% This indicator measures the number of inpatients discharged who

completed an FFT card against the total number of FFT cards given

out.

Count of inpatient FFT cards received back Count of inpatient FFT cards given out This target has been set at 60% as per 17/18.

Please note that there is no national

benchmark for this measure as this metric is

not reported nationally.

MT051 Patients Friends and Family Test - UTC/MIU

response rate

M H 15% This indicator measures the number of UTC/MIU attendees who

completed an FFT card against the total number of attendances.

Count of MIU/UTC FFT cards received back Count of MIU/UTC attendances This target has been set at 15% as per 17/18.

Please note that there is no national

benchmark for this measure as this metric is

not reported nationally.

MT159 Staff FFT % who would recommend the Trust

as a place to work **(quarter end snapshot)

Q H 75% This indicator measures the percentage of staff who would

recommend the Trust as a place to work against the total number of

staff responding to the recommend question. The surveys take place

quarterly.

Number of staff who would recommend the

Trust as a place to work

Number of staff responding to the recommend

question.

NHSE Q4 national average for staff who would

recommend as a place to work was 63%. SCFT

performance was above this at 68.5%. In order

to set the target for 18/19 we have used a 10%

improvement on our outturn position.

MT223 Leading for Quality Masterclass M H 300 This indicator shows the number of staff attending Quality

Masterclasses against an agreed monthly trajectory.

Number of attendees at Quality Masterclasses The target for 18/19 at year end is 300. This

has been apportioned into a monthly trajectory

based on the number of masterclass places

available throughout the year.

MT212 Relative likelihood of white people being

appointed compared to BAME (from

shortlisting) (at quarter end)

Q L 1.5 This indicator measures the racial equity of the Trusts recruitment

process. It measures the proportion of people who were evaluated

successfully at shortlisting, to people who received a conditional

offer of employment by ethnic group. Within an equitabl

The proportion of applications from white

people that were shortlisted

The proportion of applications from BME that

were shortlisted

The target for 18/19 of 1.5 is in line with the

Q4 target for 17/18. The 17/18 outturn was

1.89.

MT263 % of clinical band 5 new starters still

employed by SCFT within 2yrs of joining

M H 80% The percentage of clinical band 5 new starters still employed by SCFT

within 2yrs of joining the organisation.

Number of Band 5 clinical new starters within

past 2 years

Number of Band 5 clinical new starters who are

still employed by SCFT within 2 years of joining

This is a new metric but the calculation for

17/18 was produced and used to set the 18/19

target at 80%.

WELL

-LED

CARIN

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Overview of Statistical Process Control (SPC) Charts A SPC chart shows data collected over a period of time. The time series is plotted on the horizontal or x axis. The centre line is the mean and the upper and lower control limits are calculated using the standard deviation from the mean. In using these charts we can put monthly variation in the long-term, strategic perspective and identify areas where the focus of work needs to be concentrated in order to make a difference. SPC charts can also be used to determine if an improvement is actually improving a process and also to ‘predict’ statistically whether a process is ‘capable’ of meeting a target.

The main aim of using Statistical Process Control (SPC) charts is to understand whether variations in the data are outside the ‘norm’. There are 2 types of variation found within SPC charts: Common cause variation If the process is stable and predictable any variation is known as ‘common cause variation’. A process is ‘in control’ if it only displays common cause variation. Special cause variation If the process is unstable or ‘out of control’ any variation is known as ‘special cause variation’. This means that it is not an inherent part of the process. Special cause variation highlights that something unusual has occurred within the process and is attributable to factors that were not within the original process design.

Action Here are some general rules:

• If the system is under control (no special-cause variation) and operating at an appropriate level, no action is necessary. However, you may still seek to further improve performance.

• If the system is operating at an appropriate level but there is special-cause variation, then investigating the cause may be appropriate.

• If the system is under control but operating at an inappropriate level (for example, targets not met or performance is poor when compared to peers), it may be necessary to change the system.

• In some situations, a system may be neither in-control nor operating at an appropriate level, in which case tackling special-cause variation before altering the process may be necessary.

Limitations To produce a control chart an absolute minimum of 10 continuous data points is needed to create a valid chart, however there is increased reliability when using 20 or more data points.

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New and quarterly metrics are not suitable for presentation as SPC charts due to lack of data and do not appear in the Integrate Performance Report. Interpreting Charts The following examples provide an overview of variation patterns that may occur.

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SPC Charts (please note as per the ‘limitations’ section on page 5, it is not possible to produce SPC charts for new and quarterly metrics, this means that there

are currently no available charts for the Effective Domain)

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Safe cont.

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Responsive

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Caring

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Well Led

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Exception Report

Safe (Chief Nurse)

A verbal update will be provided on the Serious Incidents. No further exceptions are to be reported this month.

Effective (Medical Director)

There are no exceptions to report for the effective domain.

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Responsive (Chief Operating Officer)

Patients spending <4 hours in MIU/UCC

Having assessed Q1 performance, the executive team recommends moving back to reporting against the nationally mandated target of 95% for 4 hour waits. SCFT will always aim to meet a 100% target, but reporting against a 100% target results in a sustained ‘amber’ position for the Crawley UTC, despite achievement against the 95% national target. The central area team is currently undertaking a review of the month 3 breach data to more fully understand reasons for the breaches, and to address these. Average Length of Stay

The Trust is performing well overall but Central has challenges in reducing length of stay as for example, one of the wards (Piper) is a stroke ward; stroke patients typically require a longer length of stay than patients in other community inpatient beds, due to the nature of their rehabilitation plans.

ID MEASURE Level Jun-18

2018-2019

Year End

Target

23.3

q

25.8

q

17.9

q

23.2

q

MT004 Average Length of Stay East Area24

24

MT004 Average Length of Stay Central Area

MT004 Average Length of Stay SCFT

24

MT004 Average Length of Stay West Area24

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Caring (Chief Nurse)

Patients Friends & Family Test - % Unlikely to Recommend

Overall, Central Area had the highest total for unlikely to recommend in June. Breaking this down to service level, the top 5 totals for unlikely to recommend were, CoP Haywards Heath (highest), Podiatry North and South, Crawley UTC and Horizon Ward. To provide context, the CoP team in Haywards Heath had 9 reviews returned in June and 2 patients were unlikely to recommend. A further explanation of the actions to address this are included in the quality report. Patients Friends & Family Test – Inpatient Response Rate and Patients Friends and Family Test - UTC/MIU response rate

In May 2018 (last results available) NHS Digital reported that SCFT was placed 14th for the highest number of FFT surveys submitted, out of the 145 Community Trusts who are required to submit data. There has been a drop in the number of completed surveys over the year as well as a fluctuation of the recommendation scores.

There are 2 main reasons for the detrimental impact:

Firstly, there are ongoing discrepancies on the number of FFT surveys recorded between services who report they have submitted completed FFT and our provider insisting they have not received them. The proposal being submitted to the Senior Leadership Executive Committee (SLEC) is to introduce a track and trace system to ensure the same number of FFTs sent by services is receipted and an equal number are reported upon. This will also ensure cards are coded to the correct service as mis-coding has also been a challenge, despite numerous reminders, bulletins, guidance and quick guides being communicated which can give a false result

ID MEASURE Level Jun-18

2018-2019

Year End

Target

1.20%

p

2.34%

q

0.51%

p

0.83%

p

0.79%

q

MT047 Patients Friends & Family Test - % Unlikely to Recommend East Area1.00%

1.00%

MT047 Patients Friends & Family Test - % Unlikely to Recommend Central Area

MT047 Patients Friends & Family Test - % Unlikely to Recommend SCFT

1.00%

MT047 Patients Friends & Family Test - % Unlikely to Recommend West Area

1.00%

1.00%

MT047 Patients Friends & Family Test - % Unlikely to RecommendChildren &

Specialist Services

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An example of a discrepancy is that one community hospital has not had FFT results recorded for 2 months (May and June 18) and yet for July 18 there are 37 results already recorded. In May and June the community hospital discharged a collective total of 37 patients. It is unlikely that 37 patients have been discharged so far in July so either the cards had been collected at the community hospital and sent late or the provider has not recorded the results in a timely way and will show July’s results at well over 100% response rate. Unfortunately because we don’t know the results until they are recorded by the external company it is difficult to monitor progress until they are formally reported.

The second issue is regarding the Trust’s smaller services. Where a service has a small number of FFT submissions each card represents a higher percentage value. For example, in a small service which submits 4 cards, (which may be an accurate representation of the number of patients discharged) each of these represent a 25% value of the overall FFT submission for that service. If just one FFT, from this service has a low recommendation rating the overall total recommendation will be only 75%. In larger services each card represents a smaller percentage value of the total and whilst the actual number of people unlikely to recommend the service may be considerably higher, than a small service, the overall recommendation rate remains relatively high. The Trust’s total percentage is based on all recommendation rates and therefore a smaller service with a lower rate can have an adverse negative impact on the Trusts overall reported recommendation percentage.

To mitigate this a review of service clusters has taken place and a recommendation is being made to SLEC that SCFT services cluster together. This will require further work and discussion with commissioners to ensure we continue to support the drive for service improvement. With proposals to bring FFT in house this will be worked through to ensure appropriate reporting.

Caring (Chief Nurse) cont.

Staff FFT % who would recommend the Trust as a place to work

The improvement trajectory has slightly stagnated since Q4 but remains 5% higher than in Q1 2017-18. The return rate for this survey reduced during 2017/18 and remained low in Q1 of 2018/19 with only 641 staff responding in the quarter. The survey is sent out by email currently and this may be affecting the return rate therefore the Trust is exploring ways to improve two-way communication through the use of an app, the refresh of the Staff Exchange, which has been renamed Community Conversations and will continue to include an Ask the execs session whereby individuals can ask the CEO and executive team any question anonymously.

The recommendation as a place to receive treatment is positive with 85.6% of respondents replying that they would be likely or highly likely to recommend the Trust as a place to receive treatment.

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Well Led (Chief Nurse)

% of clinical band 5 new starters still employed by SCFT within 2yrs of joining

The retention of Band 5 clinical staff within the first 2 years of employment with the Trust reduced slightly in June. It is still significantly better than 12 months ago and work is ongoing to reduce turnover (see separate Workforce report).

Relative likelihood of white people being appointed compared to BAME (from shortlisting)

White people were 1.45 times as likely to be appointed as BME people (from shortlisting) in this quarter. In this quarter there were 188 (85%) white people and 32 (15%) BME people shortlisted, with 17 (89%) white people and 2 (11%) BME people appointed within the Trust. Both of the BME people appointed were in the West Area.

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Risk Register Operational Risks scoring 15 or above There are no risks to report for June 2018.

Cyber Security Risks (Director of Performance & Improvement)

We currently have eight risks related to cyber security. The risks have been reported and reviewed at Finance and Investment Committee alongside a detailed report on Cyber Security activities by the IT team. Mitigations are in place for six of the risks, with Capital funding agreed to replace out of date technology or to buy additional technical solutions. Two risks are accepted risks but activities are continuing to monitor these and to explore mitigations with partners within the STP.

On a positive note, the Trust has recently been awarded the Cyber Essentials accreditation. The Government worked with the Information Assurance for Small and Medium Enterprises (IASME) consortium and the Information Security Forum (ISF) to develop Cyber Essentials, to help organisations protect themselves against common online security threats. The scheme enables organisations to gain one of two Cyber Essentials badges (Cyber Essentials and Cyber Essential Plus). It is backed by industry including the Federation of Small Businesses, the CBI and a number of insurance organisations which are offering incentives for businesses.

Only two other organisations within the Sussex and East Surrey STP have been accredited.

There is a requirement from NHS Digital and NHS England that all Trusts must achieve the cyber essentials plus accreditation by June 2021. The Trust’s IT team will work towards this alongside maintaining our existing accreditation.

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Agenda Item Number: 5

Report Title: Quality Report

Purpose:

Approval Assurance X Discussion Briefing X

Summary: The Quality Report is the first iteration seen by the Trust board and seeks to add additional information that is pertinent for the board’s attention, enabling greater assurance in relation to current issues, and a view of further developments. It is not intended to duplicate information seen within the Integrated Performance Report (IPR). The Quality report , as with other reports in the Trust, uses the framework used by the Care Quality Commission (CQC), namely the 5 domains of safety, effectiveness, caring , responsiveness and well led, that enable a view of delivery against essential standards for quality and safety.

This month, the report will focus on the following areas:

1) Safe: Information that is relevant that relates to key safety areas: i.e. Oversight of Quality and safety using the dashboard, Harm free care & a spotlight on insulin related incidents.

2) Effectiveness: Development of our year 5 QIP plan.

3) Caring: Progress with patient experience (Always events) and friends and family test development.

4) Responsiveness: Complaint’s responses and PALS activity.

5) Well led: Midhurst hospital and staffing

Previously reviewed by: The essence of the report has been discussed at TWGG and Quality Committee, in readiness for submission the Board.

Recommendation: To note the report and Board members should have assurance on the actions taken in relation to these areas.

CQC Domains (Safe; Caring; Responsive; Effective; Well Led) indicate which are relevant below: Relevant to all domains but in particular the safe domain.

Relevance to Trust’s Strategic Goals: We will provide excellent care every time to reinforce wellbeing and independence. Working with our partners we will personalise services for the individual. We will be a strong sustainable business, grounded in our communities and led by excellent staff.

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Equality and Diversity: It is not considered that there are any E&D implications.

Report author: Jane Corser Deputy Chief Nurse

Report owner: Susan Marshall Chief Nurse

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Quality Report July 2018 Trust Board: 26th July 2018

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Sussex Community NHS Foundation Trust – Quality Report – July 2018 Board

Page 2

Reader Box

Description An analysis of the key areas that are important for the Boards review in relation to quality and safety, adding additional information to the integrated performance report. (up to end June 18)

Date published 26 July 2018

Date due for review 26th July 2018

Executive Lead Susan Marshall/Richard Quirk

Author Jane Corser: Deputy Chief Nurse

Contact details 01273 696011 Ext 1471

Primary audience Trust board

Secondary audience(s)

TWGG/ Quality Improvement Committee

Notes Informed through discussion at TWGG and Quality Improvement Committee

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Table of Contents

1. Executive summary and

Introduction……………………………………………………………...4

2. Summary of key areas in relation to Quality and

safety………………………………………………………………………5

a) Safe Domain …………………………………………………………………..… 5 – 7

b) Effectiveness Domain……………………………………………………………….... 8

c) Caring Domain ………………………………………………………………………….. 8

d) Responsiveness Domain……………………………………………………………….. 9

e) Well led Domain………………………………………………………………… 9

3. Conclusion and Summary……………………………………………………………. 9

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1. Executive Summary and Introduction

The Quality Report is the first iteration seen by the Trust board and seeks to add additional information that is pertinent for the board’s attention, enabling greater assurance in relation to current issues, and a view of further developments. It is not intended to duplicate information seen within the Integrated Performance Report (IPR)

The Quality report , as with other reports in the Trust, uses the framework used by the Care Quality Commission (CQC), namely the 5 domains of safety, effectiveness, caring , responsiveness and well led, that enable a view of delivery against essential standards for quality and safety.

This month, the report will focus on the following areas:

1) Safe: Information that is relevant that relates to key safety areas: i.e. Oversight of Quality and safety using the dashboard, Harm free care & a spotlight on insulin related incidents.

2) Effectiveness: Development of our year 5 QIP plan.

3) Caring: Progress with patient experience (Always events) and friends and family test development.

4) Responsiveness: Complaint’s responses and PALS activity.

5) Well led: Midhurst hospital and staffing

Board members should have assurance on the actions taken in relation to these areas.

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2. Summary of Key areas related to quality and safety:

A) SAFE

Development of a Quality dashboard

The development of an overarching Quality dashboard continues and it will be refined in line with feedback and further intelligence gathering. Part of this sub set of data forms the IPR seen at Board level. The governance teams are working with the performance team to put the dashboard into scholar, including Area level data sets, allowing ease of access for the organization to use at different meetings as needed. It should be noted that a fuller review is intended at the Quality Improvement Committee and Trust wide Governance group in subsequent months, and that this report therefore will be more focused on exceptions or areas important to bring to the boards attention.

Overall across all areas in the Quality dashboard, it is rated that we continue to be good in terms of our compliance with essential standards and have good systems and processes in place for oversight.

The Chairs report from the most recent Quality committee will give reference to this piece of work.

Harm free care

The Board’s Integrated Performance report (IPR) presents some of the data in relation to harm free care, as well as a full summary on serious incidents tabled as a separate paper.

Of note, generally, incidents coded as causing moderate to severe harm remain well below

national average, and in comparison with figures for the same time last year, there is no

marked decrease or increase in any category. Falls, pressure ulcers and Medication remain

the top 3 incident categories which are consistent with national trends for community

providers.

Pressure Ulcer incidents: Grade 3 & 4 category

Year to date out of the 364 incidents reported, 346 (95%) were classified at grade 2 or

below. The majority of these reported (i.e. 86%) were not attributed directly to our care.

These are likely to be patients that we would have assessed, on admission into our care, for

example, who may already have a pressure ulcer. This suggests a very good reporting

culture from our staff.

The table below shows the actual cases which are related to SCFT care, in category 2, 3 and 4. There are 50 reported pressure ulcers, which equates to 14% of all pressure ulcers reported over the 3 month period. Note 18 or 5% of these reported have been classified at grade 3 or 4

Source: Scholar/safety thermometer

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All grade 3 or 4 pressure ulcers are investigated as serious incidents and the board should be assured that to date NO grade 3 or 4 pressure ulcers have been attributed as being caused as a result of a lapse in SCFT care.

Further analysis of all pressure ulcers has been undertaken in all adult Areas, and this forms a monthly review process at harm free care meetings involving key staff. This is good practice and enables any issues or trends to be picked up quickly.

This review process has seen a slight trend emerging related to overall numbers in the West Area (and evident in Q4 of last year), alongside a slight rise in more serious incidents. The outcome of this review has been discussed at the harm free care meeting and subsequently to the Trust Wide Governance Group (TWGG) in May 2018

The outcome demonstrated a variety of themes and trends which included the following:

- Initial holistic assessment missing/not being completed – this included the MUST Manual

Handling and Purpose T risk Assessment and formulation after of appropriate care plans and

care pathways.

- Variable Communication – between not only professionals but to carers on the importance of

alleviating pressure.

- Variation in ordering of equipment which is also appropriate for the individual needs of the

patient.

- Variation in response by staff when dressings have not arrived delaying treatment.

- Variation in practice involving the Tissue Viability Teams (TVN’s) for complex wounds and

ulcers which are Category 3 & 4.

There are clear actions related to the above areas, and lessons learnt have been

disseminated across the trust to be taken forward in all Areas. This will be monitored at the

Total care steering group, and an update on progress is expected to the TWGG meeting in

July. The

Spotlight on Insulin incidents

Question: What is the issue?

• There has been a marginal increase in the number of insulin related errors compared to

last year with the most incidents being seen in the West Area.

Area April 17 April 18 May 17

West 3 8* 4

East 5 2 3

Central 1 1 4

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• Concerns have been raised about ability to manage overall increase of insulin patients in

caseloads.

• Insulin has a particular window of time for effective treatment and therefore if overall

number of patients who require insulin is an increasing problem , there is more likelihood

of issues arising if administration is delayed

• There is inconsistency in practice across Areas and a need to standardise operating

procedures.

• The issue is highlighted on the risk register.

Question: What actions have been taken?

• Immediate review carried out to ensure safety across all areas.

• Trust wide task and finish group set up to review incidents and agree actions

• Insulin caseload scoped to understand challenges across localities

• Training needs analysis underway

• Trust wide programme being developed to ensure consistency of insulin delivery by skill

mix teams.

• Standard Operating Procedures (SOP) under review to ensure consistency of approach

and delivery: Aiming for sign off at next medicine management committee.

• Competency framework being reviewed and agreed for unregistered nurses.

• Implementation Plan for delivery within next 3 months

• Report into communities taskforce , TWGG, Clinical Advisory Group and Executive

Committees

Question: What are the priorities the board should seek assurance on?

• Assurance people are being managed safely

• See an improvement in 3 months’ time and actions delivered

Question: How will the board gain this assurance?

• Be aware that there is daily scrutiny of all datix incidents by Governance team and

identification of any potential issues

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• Escalation process to Area teams and DCN (Quality) in event of serious insulin issue and

immediate review carried out

• Insulin task and finish group is progressing actions - on track.

• Updated reports of Trust wide Governance Group and next Quality Improvement

Committee

b) EFFECTIVENESS

• A new process is in place to track compliance with actions as a result of audits and

this is expected to be reported on in quarter 2.this should provide better evidence of

sustained changes in practice, and greater assurance to the board.

• NICE Compliance - We have reviewed how NICE data is being managed via Datix and this has highlighted a need to revise the datix module to enable better data capture. This will enable a more relevant metric to be reported via the IPR/dashboard in next 3 months.

• The Quality Improvement Plan (QIP) plan is under review and being scoped with

priority leads. There is slippage in terms of some of the actions being commenced.

This will be reviewed in next quarter & enable a more robust review of delivery

against our plan at the Quality Improvement Committee.

c) CARING

• The Patient Experience Team are engaged in a series of ‘what matters to you’ events in all of the community hospitals. This involves talking to people about what they see as important and a report identifying trends will be discussed in the next TWGG in July 2018. This will be combined with findings from ‘sit and see’ observations that look more widely at all standards.

• The outcome of the analysis will enable new ‘always events’ to be considered which will involve local staff focusing on areas for quality improvement and enhanced patient experience. This is part of a national programme of work and will be important in determining our journey from good to great. More information will be available through the patient experience report.

• As highlighted in the IPR the Friends and family test methodology is under review.

The process of data capture for FFT requires an improved response in all areas to

achieve a more representative rating. A scoping exercise has been completed with a

view to improving the uptake across all services. A detailed paper on future options is

on the agenda for the next Senior Leadership Executive Committee (SLEC) meeting.

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It should be noted that SCFT remains in the top 15 of trusts submitting the most data

in terms of response numbers to FFT.

• For context, it should be noted that there were 562 compliments up to the end of

June 2018 which is a 14.7% increase from last year.

• In addition, the number of complaints received compared to our activity has been

reviewed and the average for the first quarter was 0.01% average complaint rate per

contact. More detail will be provided in the patient experience report to the Quality

Improvement Committee.

d) RESPONSIVENESS: Complaints and PALS activity

• Response times to complaints has improved significantly throughout the year,

resulting in 100% of complaints being responded to within he expected timescales

within April and May, and only 1 complaint over due by 4 days in June 2018.

• PALS enquiries have increased compared to last year and this is encouraging and

forms part of our patient experience strategy.

• The total numbers of complaints have reduced. This is the third year that there has

been a reduction in formal complaints.

e) WELL LED

Staffing is reported in detail via the safer staffing report and IPR, however there is a need to brief the board on a specific area related to the ward at Midhurst hospital.

The Midhurst Community Hospital has had a challenging time with recruiting sufficient nursing staff to keep our patients safe. Board members will be aware that we had reached an agreement to reduce the number of beds open to patients from a total of 17 beds down to 10 beds and then following further staffing shortages down to 8 beds. Despite efforts to attract staff to the unit, the Trust has continued to struggle to recruit and retain enough staff to care for patients safely. After exploring all options open to the Trust, we took the difficult decision to temporarily close the ward. We are working closely with our commissioners at NHS Coastal West Sussex Clinical Commissioning Group (CCG) to plan for how we meet the needs of the Midhurst community.

Conclusion/summary

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The quality report has highlighted areas of good practice and compliance, as well as articulates some current issues that require action from the organisation.

Board members are asked to note in particular the following key areas:

• Good oversight and management of top three incident categories i.e. falls, pressure ulcers and medication incidents

• Assurance regarding the spotlight on insulin incidents and current action being taken

• Assurance around proposals for friends and family test

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BOARD OF DIRECTORS 26 JULY 2018

Agenda Item: 11

Title: Serious Incident Quarterly Report

Purpose: Approval Assurance X Discussion X Briefing

Summary: The purpose of this paper is to provide the board with a summary of Serious Incidents reported since 01/04/18 to date. Current Serious Incident investigations status including the outcomes of recent CCG scrutiny panel activity. Examples of themes and actions being taken in response to serious incident investigations. The report concludes with a patient centred narrative around a recent Serious Incident investigation, the root cause analysis and learning to reduce risk of recurrence.

Recommendation:

• The Board is asked to note the report content and the process in place to investigate, identify lessons and escalate specific concerns to improve the quality of service delivery, patient safety and experience.

CQC Domains (Safe; Caring; Responsive; Effective; Well Led) indicate which are relevant below:

• Safe - The Trust is able to improve patient and staff safety through the monitoring and analysis of reported incidents.

• Caring - The Trust is able to improve the quality of care and patient experience provided through the reduction of avoidable incidents.

• Responsive - The Trust is able to respond to trends and themes in incident reporting, undertaking root cause analysis or deep dive to enable lessons to be identified.

• Effective - The Trust is able to monitor the outcome of patient safety initiatives through incident reporting.

• Well Led - The Trust is able to develop a culture of open reporting, focused on improving patient and staff safety and not blame.

Relevance to Strategic Goals:

• Ensuring safe treatment is provided to patients (strategic goal one).


• Assessment completed: 21/09/17

• Impact: No specific impact raised in this area

Prepared by (including job title): Tracy Allan, Patient Safety and Clinical Effectiveness Manager.

Presented by (including job title): Richard Quirk – Medical Director

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1.0 Serious Incidents Overview The Trust has continued to report all Serious Incidents (SIs) in line with the NHS England ‘Serious Incident Framework’. The Patient Safety Team continues to benchmark SCFT reporting standards both internally and externally. Increased triage and weekly incident review meetings are considered to be factors in promoting a more standardised approach to the recording of incident harm levels. Table one shows reporting trends by category in comparison to the previous years. Table one: Serious Incidents by category year on year:

Category 14/15 15/16 16/17 201718

2018/19

Staffing levels 0 0 1 0

Falls 12 24 18 11 2

Medication errors 1 1 2 5 1

Communications 3 0 2 0

Category 4 (C4) pressure damage 3 4 2 2

Category 3 (C3) Pressure damage 8 10 2 8 1

Unstageable pressure damage 0 1 1 0

Safeguarding 0 0 1 0

Sudden Unexpected Death (SUD) 4 1 0 6

Suicide /self harm 1 0 0 0 1

Delayed discharge 0 1 0 0

Unexpected deterioration 3

Delayed diagnosis 4 1 4 3 2

Delayed treatment 2 4 2 8 3

Infection Control 0 0 1 2

Infection outbreak 1 0 0 0

IT network failure 0 1 0 0 1

Information Governance 4 3 2 3

Missed Visit 1 0 0 0

Medical Device Failure 0 0 1 1

Missing property/theft 0 1 0 0

Information Technology 0 1 0 0

Clinical procedures 0 1 0 0

Wrong diagnosis 1 0 0 0

Reputational Damage 0 0 0 3

Never Events

Wrong site surgery (dental) 0 1 0 0

Dispensing Error (downgraded) 0 1 0 0

Total (Declared)

45 56 39 52 14

Please note the significant drop in falls with harm, which has been due to the continued drive to effectively manage patient’s falls risks, by review of the falls risk assessment, implementation of the co hort and enhanced nursing care, proactive care management by the ward staff and the implementation of safety huddles. The increase in pressure damage incidents that meet SI criteria has required a refocus on pressure damage training, review of the professionals’ framework for pressure damage prevention and a greater emphasis to staff that pressure area care is everybody’s business. A reduction in pressure damage is also part of this year’s quality improvement plan. Delays in treatment are primarily around the recognition of a deteriorating patient; this has been due to the lack of recognition of rising NEWs score or a delay in escalating raised NEWs to medical staff. Currently there is a baseline audit underway to look at how staff are

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completing the NEWs document and from this further actions including a review of the training currently being provided will be undertaken. Table two: Serious Incidents declared since April 2018 by area and theme.

Central Area East Area West Area

Total

Delay/Failure to Monitor 1 1

Diagnosis - Delay / Failure to diagnose fracture 1 1

Drug administration error 1 1

Fall - Found on Floor (unobserved) 1 1 2

Inadequate Monitoring 1 1

IT / Telecommunications failure / overload 1 1

Pressure Damage Cat 3 (developed under SCFT care)

1 1

Self Harm - Cuts/Ligature 1 1

Treatment/Procedure - Delay/Failure 1 1

Treatment/Procedure - Inappropriate / Wrong 1 1

Sudden Unexpected Deterioration 3 3

Total 5 1 8 14

3.0 Investigation process Following the declaration of a Serious Incident a lead investigator is identified to investigate the events. The investigation process is based upon principles of Root Cause Analysis. The lead investigator is usually a Quality and Safety Improvement Nurse (QPSIN) who work closely with the teams, services, the patient and families to establish the full details of events. SCFT is required to complete Serious Incident investigations within 60 working days as per the national guidelines. Once the investigation is complete the draft report is presented to the Deputy Area Director and the Area head of Nursing and Governance to confirm an appropriate investigation has occurred and to contribute to development of actions in response to findings. The signed off report is presented to the Serious Incident Review Group (SIRG) for scrutiny and approval. The approved version of the report is submitted to the CCG Scrutiny Panel (a panel of representatives from the Quality departments of our commissioning CCGs) for external review. The outcome of this can be:

• Agreed closure

• Conditional closure – minor clarity on detail requested with closure agreed without requirement for resubmission.

• Kept open – additional assurance requested by the CCG Scrutiny Panel, linked to report content and/or assurance regarding actions taken. Resubmission required.

• Downgrade – CCG Scrutiny Panel agreement that the incident did not meet serious incident thresholds or the investigation established the events were not linked to SCFT service provision. Table three summarises the current status of SI investigations that have been reviewed by the CCG since April 2018. (This data includes SI reports that were investigated in 2017/18)

Status Total West Central East Children

Number downgraded by CCG 4 2 1 1

Number currently Kept Open 3 2 1

Number Conditional Closure 1 1

Number closed by CCG in 2018/19 7 1 3 3

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The Quality and Patient Safety Improvement team submit responses for the conditional closures after a further review by the SIRG panel. Furthermore assurance is provided at the monthly Clinical Quality Review Meeting that is held with the CCG.

4 Investigation Outcomes The primary aim of incident reporting and investigation is to review and gain assurance that safe systems and process are in place, ascertain lessons are learnt and change has been implemented and establish any further requirements to ensure future mitigation of risk. Lessons identified from recent SIs investigations include:

• When patients have sustained an unwitnessed fall at home a set of clinical observations and full body check would ensure a thorough clinical assessment.

• Patients with long term conditions require their baseline NEWs scores to be recorded as part of their transfers of care.

• Risk assessments need to be completed and ongoing review throughout the patient’s admission to maintain patient safety.

• Patients with visual impairment require individualised plans of care to ensure the ward can

maintain their safety and independence

Lessons and recommendations are a key part of a SI investigation, these are primarily monitored by the service leads and the area heads of nursing and governance.

6.0 SI investigation summary: This serious incident relates to the deterioration and management of a category 2 pressure damage which initially occurred whilst the patient was in a nursing home. The wound deteriorated to category 3 between discharge from the nursing home and the initial assessment completed by the community nurse. The nursing home had not informed the community nursing services of the discharge and pressure relieving equipment was not in place in the patients home.

Background: The investigation established that the patient had a number of co-morbidities

that would impact on her wound healing. She also had a chest infection at the time of

admission to the caseload, secondary to chronic pulmonary embolism and a history of

asthma and heart failure.

Findings: All required actions in compliance with the Trust’s pressure damage framework were carried out by the clinical lead and a care plan was put in place for visits three times a week; to change the dressings and re-assess wound healing. Nursing visits were deferred over a period of seven days due to staffing pressures on the team, although the care plan clearly stated not to defer this patient’s visits. During this time the care agency who were visiting the patient three times a day had changed the dressings to the wound. In addition to this, there was a delay in ordering a cushion for the patients’ recliner chair which she preferred to sit in during the day. On 02.01.2018 the wound was viewed by the overnight nursing service. The wound was malodorous at this time and exuding brown exudate. On 03.01.2017 the carers called the paramedics and the patient was admitted to the acute

hospital. She required a course of intravenous antibiotics for a chest and wound infection.

Outcome The investigation concluded that the deferred visits a delay in provision of a cushion and the limited case management of the deteriorating pressure damage contributed to the worsening of the wound. Learning and Recommendations:

• Team refection on this patient’s experience of care.

• Assurance that all teams members are aware of their individual responsibilities to adhere to the pressure damage professional’s framework.

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• Team training analysis of attendance to SCFT Pressure Damage training.

• Quarterly audit to monitor accuracy in Purpose T risk assessment and appropriate care plans to risks identified.

• Introduction of pressure damage board to aid staff with the monitoring and management of pressure injuries on their caseloads

• Table top meeting with locality to discuss increasing incidents of pressure damage.

• Table top meeting regarding caseload management and the deferral process.

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Strategic Workforce

Board Report

July 2018

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

2017/18 16.1% 14.5% 14.2% 14.0% 12.5% 12.1% 11.7% 10.8% 10.9% 10.6% 10.5% 10.4% 14.0%

2018/19 9.6% 10.8% 11.3% 9.5%

2017/18 23 16 19 25 23 23 50 43 41 45 43 43 50

2018/19 52 49 53 45

2017/18 14.9% 14.9% 15.1% 14.5% 14.3% 13.9% 14.4% 14.4% 14.3% 14.0% 14.6% 14.4% 13.5%

2018/19 14.0% 14.4% 14.3% 13.5%

2017/18 61.5% 62.7% 62.4% 62.5% 63.8% 64.8% 67.3% 69.1% 70.8% 71.9% 73.6% 75.3% 80.0%

2018/19 76.6% 77.8% 77.4% 80.0%

2017/18 4.4% 4.2% 5.0% 4.3% 4.8% 5.2% 4.4% 3.2% 5.4% 4.9% 5.0% N/A

2018/19 5.6% 5.6% 5.2% N/A

2017/18 4.1% 3.8% 3.3% 3.7% 2.9% 2.8% 3.2% 2.5% 2.1% 1.9% 2.3% N/A

2018/19 3.1% 3.2% 3.8% N/A

2017/18 88.27% 89.29% 89.78% 89.90% 90.74% 89.54% 89.67% 90.84% 91.13% 90.79% 91.65% 92.24% 90.00%

2018/19 91.99% 92.17% 92.13% 95.00%

2017/18 59.55% 60.81% 60.78% 61.01% 62.02% 64.95% 67.26% 68.98% 69.17% 69.18% 71.58% 72.10% 90.00%

2018/19 74.93% 75.63% 76.61% 95.00%

2017/18 87.9% 89.1% 89.1% 89.7% 88.0% 87.1% 86.5% 86.3% 86.0% 87.6% 87.4% 87.7% 90.0%

2018/19 86.5% 86.0% 84.9% 90.0%

2017/18 3.73% 4.51% 4.29% 4.43% 4.88% 4.89% 4.95% 5.69% 4.87% 6.90% 6.92% 5.98% 4.00%

2018/19 5.14% 4.84% 4.00%

2017/18 50.04% 47.23% 49.83% 53.09% 54.26% 47.50% 45.90% 42.75% 39.60% 45.43% 56.08% 62.32% N/A

2018/19 58.16% 59.59% N/A

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B5 Retention after 2 years %

Time to Hire (Days)

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Turnover and Retention Data

Time to Hire Data

Statutory and Mandatory Training

Appraisal Data

Vacancy Rate %

Turnover Rate %

Racist Incidents

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2018/19 4 1 1 N/A

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Equality and Diversity

N/A14 15

2018/19 3 8 2Number of Raising Concerns

(witnesses)

2018/19 12 Number of Bullying and

Harassment Cases Raised

% of Sickness which is Long term

Temporary Workforce

Sickness Data

Employee Relation

Sickness Rate

Substantive

Appraisal Compliance Rate

Temporary Workforce

Bank % of Total Paybill

Agency % of Total Paybill

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Grade 2017 Q1 2018 Q2 2018 Q3 2018 Q4 2018

Band 8A 109 42

Band 7 4 25

Total Started 2017 Q1 2018 Q2 2018 Q3 2018 Q4 2018

Total 43 19

Apprenticeships

Leadership Masterclass

Starters and Leavers by Month

Absence Reasons (12 months FTE Lost) Absence Trending Analysis

New Starters and Leavers Comparison by Staff Group - last 12 months

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1. Exception report

a. Wellbeing

Wellbeing is now well established in the organisation with both Trust-wide and local initiatives happening throughout the year. The focus

now needs to be on reducing sickness absence which has been higher than in previous year. There were 57 ‘live’ long term cases (where

absence has been continuous over 28 days or more) in May representing 60% of all sickness absence. 8 of those cases were new.

Improved reporting, ensuring staff’s return to work is recorded in a timely way and the rollout of a case management approach should start

to show a reduction from the end of Q2.

b. Culture

There were 13 concerns raised by 13 people in Q1, up from the previous quarter when only 2 concerns were raised and up from the same

period the previous year (n.4). The trend shows the number of concerns raised is increasing which is a potential indicator of a positive

reporting culture. The most frequent theme for concerns recorded was ‘Behavioural / Relationship’ (n. 6) then followed by ‘Bullying /

Harassment’ (n. 5). This is a change from previous quarters where the most frequently occurring theme was ‘Patient Safety / Quality’.

There were no claims of victimisation made in this quarter from members of staff claiming to have suffered detriment as a result of having

raised a concern previously.

The same theme is emerging in the number of bullying & harassment complaints the HR team is dealing with. Most relate to people

experiencing difficult relationships with colleagues so there will be an increase in the number of staff trained to carry out facilitation and

mediation to resolve conflict in the workplace and support from the OD team is also being provided to teams.

There was one formal investigation commissioned in June. This was for a concern originally raised collectively in November 2017 by some

members of the Black, Asian and Minority Ethnic (BAME) Staff Network. There was a delay to the start of the investigation due to agreeing

the terms of reference for the review and identifying a suitable, senior and independent person to undertake the investigation. The

investigation is due for completion in July and its findings will be reported to the Executive Committee in August.

c. Leadership

The compliance with statutory and mandatory training for Bank workers improved again in June but remains below the target of 95%.

Letters were sent out at the end of June to all Bank workers who are out of date by 6 months or more to inform that they should book onto

the training by 16th July or they would be removed from the Bank register. This action is expected to have an impact on compliance by the

end of Q2 as workers attend the training during July, August and September.

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Statutory and mandatory training for permanent employees is below the new target of 95% but it is expected that the target will be

reached in year.

Appraisal rates are below target however changes to the Agenda for Change terms and conditions whereby appraisals will be conditional

to pay progression means that the rate is expected to increase again in year. A review of the process and documentation will also support

improved compliance.

d. Recruitment & Retention

There has been an increase in the vacancy rate which is due in part to adjustments to budgets at the end of Q1 and to a decrease in staff

in post of just under 50WTE. The number of vacant Band 5 nursing and a HealthCare Assistant posts has increased and some areas,

both community and inpatient, continue to have workforce challenges. The turnover for ancillary staff, Band 5 clinical staff and HealthCare

Assistants is of concern and local retention plans are trying to address those issues.

Time to hire increased in June with the number of days exceeding the target. Further work is ongoing to streamline the process for staff

moving roles within the organisation to reduce the internal time to hire and allow the recruitment team to spend more time on bringing new

staff onboard.

A dedicated campaign to recruit to Responsive Services across the Trust will be launched at the end of July and this will be followed by

campaigns to recruit in the areas with most needs.

Actions to improve retention have also been taken in Q1 including:

• New starter network created (using corporate induction attendees as cohorts) so new staff have a ‘ready-made’ pool of people they

can reach out to for ideas and support. Scoping having three and six month events to bring people in the network together.

• Retention workshops being run to identify key local themes affecting retention and potential actions to address.

• Re-introducing associate specialist grade to help support retention of specialty doctors as an alternative development / career

pathway to becoming a consultant

• Survey of staff with 20 years + NHS service identified and reflected / reinforced the themes from new starter surveys

• Staff benefits brochure launched and now being shared with new starters

• Trialling action learning sets in East and West

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e. Temporary workforce

There has been an increase in the use of agency workers in the first quarter of the year due to an increase in demand and additional

supply. This is an ongoing focus for the Trust and more detailed analysis of the data shows that some inpatient units continue to use high

levels of agency workers due to high vacancy rates (Midhurst, Kleinwort and the Crawley wards) and Responsive Services teams across

the Trust are also seeing higher levels of usage. The high sickness rate is also contributing to this picture. The use of medical locums has

significantly increased with some of the spend attributable to a locum consultant in a specialist service and this is expected to stop in

September when permanent staff come into post.

Bank workers can now book directly onto shifts using the HealthRoster portal which should have an impact on the fill rate for bank and see

a reduction in agency usage. Responsive Services in Central will be using HealthRoster from the end of July/beginning of August, which

should result in an increase in Bank usage. Staff Direct is also now the central point for booking locums, giving more control over prices

and usage.

f. Workforce transformation

The Therapies review is now in the final Design stage with a demand and capacity exercise being undertaken in each Area before the

Deliver stage can begin in Q3 which will see a change to the skill mix of some teams and more robust supervision and development for all

therapists across the organisation.

The Community Nursing review is nearing the end of the Design stage with extensive engagement having taken place in Q1 and ongoing

in Q2. The aim of the review is to establish the appropriate skill mix for teams taking into account national workforce challenges and a

change in demand and skills required in District and Community nursing.

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2. Spotlight on Inclusion

Our Trust is made up of a wide variety of services spread right across Sussex and the people that make up those teams come from

wonderfully diverse backgrounds. Every single person working at SCFT should feel that they belong, that they are understood and valued for

who they are. Getting that right that will allow compassion and innovation to flourish. We all want to work alongside people who learn from

different points of view, people that empower others, who demonstrate confidence in their colleagues and can hold them to account. Our

ambition is to be a truly inclusive organisation and I am proud to say we have made some very good progress.

Over the last 12 months we have seen the development of staff networks, through their members they are taking actions to improve the

experience of staff across the Trust.

BAME Network

The network held a celebration event on 12th July as part of NHS70

and to mark 100 years since World War One.

The event was an opportunity for staff and members of the

community to reflect on the cultural history of the NHS and to

celebrate the BAME members of staff who have contributed so

much to Brighton General Hospital and the wider NHS.

The event started with opening remarks from Peter Horn, who

highlighted the historical significance of the Brighton General site,

which was once used as a Kitchener Hospital for Sikh, Hindu and

Muslim soldiers wounded during World War One.

Founder of the Brighton and Hove Black History Project and MBE

Bert Williams shared his own personal story of travelling to

England with his Sisters as part of the Windrush generation. His

sisters joined the NHS as Nurses after a shortage of staff prompted

a recruitment drive in Jamaica after World War Two. He then gave a

talk about the rich cultural history in Brighton and Hove over the

last century.

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Around the room, there were exhibits highlighting the various elements of local history such as the Chattri Memorial on the South Downs.

Food and refreshments were provided by MommaCherri, a local soul-food chef who served a lunch including macaroni cheese balls, fish

cakes, sweet potato and Jerk chicken with corn bread.

There were also talks from Kate Parkin – Sussex Armed Forces Director who gave a presentation about the importance of BAME networks

within the Armed Forces and Tony Kalume, chairperson of Diversity Lewes who talked about prominent local BAME individuals throughout

history. Finally local Poet Terry Godwin presented the network with a framed copy of his poem ‘God Bless the NHS’.

The network has also been working on a number of other actions including:

• Posters have been cascaded across the Trust to outline the network’s mission and aims

• The network welcomed its first three non-BAME members at last month’s meeting and the Chair reiterated the message at the

Celebration event that the network is about inclusion, valuing individuality and creating a just culture where everyone is supported

equally to achieve their optimal potential.

• Training will commence soon for BAME staff to enable a BAME representative to be a member of interview panels for 8As and above

initially

• Following a successful initial session, Racial Conflict advice and support from a colleague in a neighbouring Trust has been sourced

and drop in sessions will be phased in

LGBT+ Network

The network continues to raise awareness and promote a culture

that values LGBT+ people. Pledges are coming in every day from

across the Trust from staff

Over 80 volunteers for the Brighton Pride Parade and on

Wednesday 11th July colleagues gathered to celebrate the launch

of this year's Brighton Pride car. Organised by Lindsey

Stevenson, Network Lead and members of the network, the car's

graphic livery is designed to celebrate the LGBT+ community and

70 years of the NHS. Celebrations were led by Richard Curtin,

Executive Sponsor of the network and Siobhan Melia and

supported by staff from right across the organisation.

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Disability Network

The Trust has set up a new network for disabled staff and their allies collaborating with the Trust to remove barriers and promote

independence and equality. The network prioritises the leadership of disabled people and anyone who shares that goal is welcome.

Religion & Belief Network

The Trust is in the process of creating the role of Lead Chaplain to build and provide strategic direction, leadership and management to a

multi-faith chaplaincy team, paid and voluntary, which includes non-religious members and serves patients, families, carers and staff; to assist

and guide the Trust in developing a culture of care that equals or exceeds best practice and embraces Religion and beliefs to promote

recovery and autonomy; and to engage with religion and belief groups, building confidence, challenging stigma and sharing knowledge on

behalf of the Trust.

The network now has a Chair and just over 30 members with plans to run an interfaith celebration in November during interfaith week.

The network has made links with a number of faith organisations including the Multifaith chaplain in a neighbouring Trust and the Chair has

met with the Bishop of Lewes on behalf of the Diocese of Chichester who is keen to work with the Trust to map out faith resources in the

various communities that we can publish/ make available to our Communities of Practice.

Gender Network (name under development)

The network will formally launch in the autumn with members invited to share information, experience and learning and with a view to work

with external speakers and organisations. The key issues already identified by the executive sponsor are flexible working, work life balance,

childcare and visibility.

Inclusion team

The inclusion team continues to lead actions to improve equality, diversity and inclusion throughout the Trust. Those are some of the actions

the teams took in Q1:

• Equality & Diversity training has been reintroduced the Statutory & Mandatory Training day rather than being delivered separately

• Improvements to the Stat&Mand. training day is taking place to ensure that staff with loss of hearing have access to the training

• 10 Equality and Human Rights Analyses (EHRA) have been reviewed by the Inclusion team

• The inclusion team have provided additional input into the Enhanced Care Collaborative improvement initiative and the Investing in

Volunteers Standard quality assessment

• The new interpreting, translation and communication support providers went live

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• Patient demographic assessment forms and guidance have been developed

• A programme of staff engagement with Operations to determine how best to support Area Management Teams (AMT) and other senior

teams to progress the inclusion agenda. Including attending AMT meetings, harm free care meetings, and the children’s integrated

clinical operations meeting.

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

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REPORT TO TRUST BOARD 26 JULY 2018

Agenda Item: 8

Title: Month 3 Financial Performance - June 2018

Purpose:

Approval Assurance X Discussion Briefing

Summary: The report sets out the Trust’s financial performance for the period to the end of June 2018. The Trust is reporting a surplus of £261k against a plan of £249k, a favourable variance of £12k.

Recommendations: The Board is asked to note the Financial Performance report for Month 3, June 2018.

CQC Domains (Safe; Caring; Responsive; Effective; Well Led)

• Delivery of the Trust’s financial plans are key to delivery of the well-led domain

Relevance to Strategic Goals: • Delivery of the Trust’s financial plans will support the ‘sustainable organisation’ Strategic

Goal


• Assessment completed: Report has been reviewed for equality and diversity impact

• Impact: No direct impact has been identified from this report.

Prepared by (including job title): Ed Rothery, Deputy Director of Finance

Presented by (including job title): Mike Jennings, Director of Finance and Estates

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Financial Performance Report Month 3 2018/19

Mike Jennings Director of Finance and Estates and Deputy CEO

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1. Financial Position at Month 3

• The NHSI agreed plan for 2018/19 is for a surplus of £3,144k, including £2,416k of Provider Sustainability Fund

(PSF) revenue. The planned surplus for Month 3 was £249k, the actual surplus reported for the month was £261k,

a favourable variance of £12k.

• The 2018/19 plan and Month 3 position assumes payment of 2.5% CQUIN on contractual income as well as

£362k of PSF revenue. Excluding the PSF, the Trust would be reporting a £101k deficit.

• Income was £99k (0.2%) lower than planned for the year to date. The income position improved in month with

increased income receipts across a number of clinical and corporate services. The income underperformance for

the first two months of the year reflected lower than planned activity in a number of clinical services, although

some of the underperformance is also reflected in lower than planned running costs. The Trust is providing

additional resource where appropriate to ensure that clinical service income is maximised.

• Overall pay costs were £332k higher than planned for the year to date. Agency costs, were £529k in June, an

increase of £87k on the previous month and the highest monthly spend since May 2017. Total agency costs for

the first three months of the year were £1,412k, this is still below the NHSI ceiling of £1,440k, reflecting the

significant reductions made by the Trust over the past two years. However costs are £393k higher than the

planned spend of £1,019k for three months. A review of agency spend and the options to control and reduce

spend is being undertaken by the executive team and senior managers. There are some areas where agency

spend is necessary for a period of time in order to stabilise services, or for income generation. However,

additional controls will be implemented to avoid unnecessary spend, more stringent management of agency

suppliers, particularly for medical and AHP agency staff will be implemented as well as ensuring we maximise the

support given for temporary staffing and more widely for the recruitment of permanent staff.

• Non pay costs are £391k lower than planned. £346k of the underspend results from the release of contingency

into the position in the first three months of the year.

• At the end of June the Trust held £3.1m of cash. The cash position is below plan due to the slower than expected

receipts of 2017/18 CQUIN income. This is now forecast for payment in July. The Trust has a capital plan of

£4.9m for the year that allows investment across its key priority areas, including further development of plans for

the Brighton General Hospital site and the continued roll out of our Digital Health Record system.

Executive Summary

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1. Key Performance Indicators

• The Trust remains on or above plan against most of its key financial indicators at Month 3. Although pay costs are

higher than planned, the overall surplus position is favourable to plan.

• The cash position remains behind plan, with slower than forecast receipts from 2017/18 CQUIN payments

• The efficiency programme performance is £167k behind plan at the end of M3. The lower than planned delivery has

been mitigated through use of by the Trust’s contingency.

• Agency spend has increased in the first quarter of the year as additional resource has been required to support a

number of clinical services. The Trust continues to look at all options for reducing spend, however its agency use of

resources indicator remains at ‘1’ – the highest rating - as spend is still below the NHSI agreed ceiling.

Indicator YTD Target YTD ActualYTD

Variance

Full Year

TargetFOT Actual

FOT

Variance

Performance against Control Total 249 261 12 3,144 3,144 0

Cash Balance (£000) 4,419 3,188 (1,231) 5,152 5,152 0

Capital Investment (£000) 967 821 146 4,909 4,909 0

Better Payment Practice Code Performance % 95% 94% -1% 95% 95% 0%

Efficiency Programme Delivery (£000) 1,869 1,702 (167) 8,923 8,923 0

Capital Service Cover rating 1 1 0 1 1 0

Liquidity rating 2 2 0 1 1 0

I&E Margin rating 2 2 0 1 1 0

I&E margin: distance from financial plan 1 1 0 1 1 0

Agency rating 1 1 0 1 1 0

Summary Financial Sustainability Risk Rating 1 1 0 1 1 0

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2. Income and Expenditure Summary

(£m)

The table above sets out the financial performance for the three months to the end of June. The reported surplus is £261k against

a plan of £249k, a favourable variance of £12k. Excluding PSF (STF) revenue, the deficit would be £101k which is also £12k better

than planned. Pay costs have increased by 3.7%, with income 1.3% higher and non pay costs 6.6% lower than for the same

period last year. Some of the switch between pay and non pay relates to the movement of Estates staff into the Trust in 2018/19.

By comparison to 2017/18, the Trust’s underlying position has improved by £25k. However, as this triggered the receipt of PSF, the

overall improvement is £129k between years.

2018/19 Full

Year2016/17

Plan Actual Var Plan Actual Var Plan ActualChange in

Year

Change in

Year

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 %

Income 19,002 19,139 136 57,431 57,332 (99) 230,310 56,577 755 1.3%

Pay (13,856) (13,970) (114) (41,543) (41,875) (332) (166,270) (40,327) (1,548) 3.7%

Non Pay excl dep'n, PDC & interest (4,591) (4,650) (59) (14,195) (13,805) 391 (54,832) (14,711) 907 -6.6%

EBITDA 555 518 (37) 1,692 1,653 (40) 9,208 1,539 114 6.9%

EBITDA Margin [EBITDA/ Income] 3.0% 3.0% -27.2% 3.0% 3.0% 40.4% 4.0% 2.7% 15.1%

EBITDA % [EBITDA Actual/ EBITDA Plan] 0% 0% 0% 0% 0% 0%

Investment Revenue 2 3 1 6 9 3 24 3 6 67.4%

Other Gains and Losses 0 0 0 0 2 2 0 8 (6) -316.6%

Finance Costs (11) (8) 3 (33) (31) 2 (133) (38) 7 -21.0%

Depreciation and Amortisation (385) (382) 3 (1,152) (1,146) 6 (4,901) (1,116) (30) 2.6%

PDC Dividend (92) (92) 0 (276) (276) 0 (1,104) (305) 29 -10.3%

TOTAL Non -Operating Expenses (486) (479) 7 (1,455) (1,442) 13 (6,114) (1,448) 5 -0.4%

Reported Financial Position: Surplus

(Deficit)69 39 (31) 237 210 (27) 3,094 91 119 6.5%

Net Margin [surplus(deficit) / Income] 0.5% 0.5% -22.4% 0.5% 0.5% 27.3% 1.3% 0.1% 15.8%

Adjustments

Donated/Government grant assets adj 4 22 18 12 51 39 50 41 10 19.4%

Control Total Surplus (Deficit) 73 61 (12) 249 261 12 3,144 132 129 49.5%

Impairments 0 0 0 0 0 0

Accounting surplus (deficit) 73 61 (12) 249 261 12 3,144 132 129 49.5%

Adjusted Margin [surplus(deficit) / Income] 0 0 -9.0% 0.5% 0.6% -12.1% 1.4% 0.2% 17.1%

STF Revenue in Position 120 120 0 362 362 0 2,416 258 104 28.7%

Position Excluding STF Revenue (47) (59) (12) (113) (101) 12 728 (126) 25

June YTD

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4. Balance Sheet Key Issues: • Receivables have increased by £4.1m in

total since the start of the year following significant reductions in February and March. Delays in the receipt of 17/18 CQUIN payments have been previously reported and the majority of this £1.9m debt is expected to be paid in July.

• The value of the Trust’s aged debt has

reduced substantially in the first quarter of the year as a result of an agreed payment plan between the Trust and NHS Property Services.

• Property, Plant and Equipment values

have fallen slightly in the first three months as depreciation costs outstripped additions.

Opening

Balance: 1st

April 2018

Statement of Financial Position Actual Actual Movement

£'000 £'000 £'000

NON-CURRENT ASSETS

Property Plant Equipment 43,605 43,313 (292)

Intangible Assets 6,563 6,562 (1)

Investment Property 0 0 0

Trade and Other Receivables NC 182 176 (5)

TOTAL NON-CURRENT ASSETS 50,350 50,052 (298)

CURRENT ASSETS:

Inventories 1,067 1,067 0

Trade and Other Receivables 16,872 21,018 4,146

Cash and Cash Equivalents 5,663 3,188 (2,475)

SUB TOTAL CURRENT ASSETS 23,602 25,273 1,671

Non-Current Assets Held for Sale 0 0 0

TOTAL CURRENT ASSETS 23,602 25,273 1,671

TOTAL ASSETS 73,952 75,325 1,373

CURRENT LIABILITIES

Trade and Other Payables (22,238) (23,565) (1,327)

Provisions for Liabilities and Charges (74) (74) 0

DH Working Capital Loan 0 0 0

TOTAL CURRENT LIABILITIES (23,897) (25,246) (1,349)

NET CURRENT ASSETS/(LIABILITIES) (295) 27 322

TOTAL ASSETS LESS CURRENT LIABILITIES 50,056 50,079 24

NON-CURRENT LIABILITIES

Trade and Other Payables NC 0 0 0

Borrowings NC (6,597) (6,421) 176

Other Financial Liabilities NC 0 0 0

TOTAL ASSETS EMPLOYED 42,656 42,866 210

FINANCED BY TAXPAYERS EQUITY

Public Dividend Capital 1,514 1,514 0

Income and expenditure reserve 40,162 40,372 210

Revaluation Reserve 12,583 12,583 0

Other Reserves (11,603) (11,603) 0

TOTAL TAXPAYERS EQUITY 42,656 42,866 210

Balance at end June 2018

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BOARD OF DIRECTORS – PUBLIC MEETING 26 JULY 2018

Agenda Item: 9

Title: Combined Q1 Corporate Objectives Progress Report and Board Assurance Framework (BAF)

Purpose:

Approval Assurance X Discussion X Briefing

Summary: The report contains an update on delivery of the 18/19 Corporate Objectives as at Q1, together with a summary of any risks to their delivery and an early year-end forecast. Where performance is below trajectory, a narrative explanation is provided, together with a summary of the actions being taken to return to trajectory. Progress on the strategic programmes and strategic enablers underpinning the Corporate Objectives will be reported separately through existing mechanisms as follows: Strategic Programmes: a. Our Community Way: Quality Improvement Committee, Executive Committee b. Community Hospitals and Alternatives to Admissions: Executive Committee, Delivery

Board c. Urgent Care: Executive Committee, Delivery Board d. Single Point of Access: Executive Committee, Delivery Board e. Service Line Reporting: Finance and Investment Committee, Executive Committee

Strategic Enablers: a. Digital Strategy: Finance and Investment Committee, Executive Committee, Informatics

Board, Capital Review Group b. Estates Strategy: Finance and Investment Committee, Executive Committee, Estates

Performance Meetings, Capital Review Group c. Workforce Strategy: Quality Improvement Committee, Workforce Committee, Executive

Committee d. Commercial Strategy: Finance and Investment Committee, Executive Committee

The Audit Committee will receive a more detailed version of the BAF at each meeting.

Recommendation: For the Board to review and discuss the report’s content.


• Well Led

Relevance to Strategic Goals: The Corporate Objectives support the delivery of the strategic goals. The BAF contains a risk assessment of threats to delivery of the Trust’s Corporate Objectives.


Q1

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• No impact.

Prepared by: Margaret Godfrey, Company Secretary

Presented by: Siobhan Melia, Chief Executive

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Combined Corporate Objectives Progress Report 18/19

1. Introduction

The report contains an update on delivery of the 18/19 Corporate Objectives as at Q1, together with a summary of any risks to their delivery and an early year-end forecast. 2. Quarterly Progress Report and BAF

Corporate Objectives 18/19 were developed to be measurable with quarterly trajectories towards their achievement set. Trajectories were developed so as not to be finite and/or based solely on numerical targets. Measuring progress against trajectories will provide a view of delivery per quarter and enable rapid action to be taken where objectives are identified as being off trajectory. Where performance is below trajectory and/or risks to delivery are scored at 12 or above, further information is provided at s.3 below.

Corporate Objective 1: Excellent Care: Improve the experience and outcomes for patients cared for in our inpatient areas, returning patients to their home as soon as possible, and reducing transfers to long-term residential care. Owner: COO

Q1 Progress (RAG + Summary Narrative) Real Risks to Delivery Summary of Controls/Mitigants

Assessment of Residual Risk (Likelihood x

Consequence) and Y/e Forecast

Q1: Q1 – Establishment of a change programme including but not limited to: creation of a Red2Green Framework for SCFT; review of the existing RedGreenDays recording and reporting; determination of the performance baseline for RedGreen days and potential targets; training needs analysis; assessment of information management requirements.

A Red2Green (R2G) Project Group has been formed to oversee the creation of the R2G framework. The framework objectives include:

• To reduce the number of red days and increase number of green days experienced during a patients stay and

• To reduce overall average length of stay (LoS)

• To reduce % of Delayed Transfers of Care (DToC)

• To reduce readmission rates

• Improve patient experience and outcomes Note: Targets being identified Baseline data collected to determine current performance of R2G days spent on each community hospital ward. Production of a R2G KPI Dashboard will be used to monitor ward performance, highlighting areas for improvement.

Lack of staff engagement. A comms and engagement plan is included in the project. All users of R2G visual management system will be required to attend mandatory training sessions. Members of the project group will assume a R2G Lead role to mitigate who will be members of the Clinical Operations Group.

6 – Moderate (2 x 3) 2 Y/E - Minor

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The Red2Green visual management system business case is completed and will be presented to the Planning & Development Group on 31st July 2018. However, the project has commenced and is progressing to the next development work stage, in line with Q1 requirements.

Q2: Implementation of the change programme.

Q3: Start of regular RedGreen reporting and monitoring.

Q4: Embedded use of RedGreen days leads to reduced Red days and increased Green Days. Start of scoping exercise to extend and apply the Red2Green SCFT Framework to our community services.

Corporate Objective 2: Well Being: We will improve the well – being and independence of adults with long term conditions, such as diabetes, coronary heart disease and chronic obstructive pulmonary disease. Owner: Chief Nurse



Consequence)

Q1: Identify project/ expert leads / QI project methodology Identify method of data collection, monitoring and governance. Establish baseline of active patients on the three LTC pathways identified.

This ties in with the national CQUIN requirements and the criteria has been identified as any patient referred onto the community nursing caseload with a long term condition, which will cover the three LTC identified. An initial Assessment of all patients referred to the community nursing caseload with a Long term condition (LTC) is currently taking place (between 9th July and 6th August 2018.) Reassessment of patients assessed in this time frame will then to take place 6 months post initial assessment in Feb/March 2019. If a patient is discharged from the patient caseload prior to the 6 months reassessment date these patient will be reassessed and scored. The ability to identify and score through system1 has been agreed and nursing teams will identify patients through the personalised care and supporting planning

Only being tested in one team in each locality area (two teams in Central) rather than across all teams currently and may need revising before wider roll out. Links closely to the personalisation objective so may be some overlap with other LTC. Difficult to get benchmark data currently.

Once pilot tested will have a better understanding of ability to roll out successfully or whether further refinement is required.

2x3 = 6 Currently risk is low as much of the preparation work has been completed and pilot on target for delivery. The risk will be the ability to roll out easily at scale.

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assessment, which is part of the nursing initial assessment care plan template. It will ask patients “how confident they feel in managing their own health condition”. It will also identify if a health planning support conversation has taken place. A care plan is generated which allows the staff member to confirm that the assessment has taken place, a review date is then set and the a six monthly review completed. The details of the care interventions and conversations can be recorded in the personalised care and support planning template. A guidance document has been requested by staff which will be developed.

Q2: Test methodology with a pilot patient cohort, revise as required Roll out initial patient activation questionnaire to ascertain level of knowledge, skill and confidence amongst patient cohort Identify baseline and percentage improvement target.

Q3: Roll out (implementation phase).

Q4: Improved patient activation scores for our patients. Map against other organisations who may be undertaking PAMs. Begin to identify Patient reported outcome measures for next year.

Corporate Objective 3: Joined-up Care: Improving patient experience and personalisation of care through the delivery of our Communities of Practice (CoP). Owner: DPI



Consequence)

Q1: Design of approach and methodology for capturing representative and meaningful patient feedback. Inaugurate the linkage

The organisation wants to further develop the Communities of Practice model ensuring that regular and representative feedback from patients, staff and partners is informing quality and service improvement. The design of the methodology in Quarter 1 has been

1.Availability of staff and stakeholders to take part in Focus Groups and Workshops

1. Arrange groups in consultation with key individuals to identify the most appropriate times and venues. Provide

2 x 3 (6) Moderate

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between feedback and Quality Improvement.

informed by a literature search and linking with national organisations such as the Patient Experience Network (PEN). Workshops have been held with other teams in the organisation currently capturing or working with patient experience information. These teams include, Quality Governance, Time to Talk, Research and Quality Improvement. As sustainability is a key outcome for this objective, the project will use QI methodology so that the resulting ways of capturing and using experience can be more easily taken on by services moving forward as greater numbers of staff become trained in QI methods. The project will include the following steps 1. A desk top analysis of relevant data related to the CoP teams to inform Focus Groups 2. Focus Groups to be carried out with staff in CoP teams 3. Patient Surveys to be carried out using questionnaires in a number of formats 4. Workshops to be put in place for external stakeholders 5. Capture project methodology as it is carried out to create a resource for the future RAG: GREEN

2. The project may produce a large amount of data which will need to be processed and analysed. There is currently no identified resource to do this work

clear explanations of the project in advance and why individuals are being asked to participate. Organise dates in advance to allow for planning. Adjust timescales as required following the pilot phase. 2.Discuss and problem solve with other teams involved in patient experience capture and put forward collaborative solutions as this will also be a risk to CoP experience capture moving forward.

3 x3 (9) High

Q2: Trial delivered to test methodology and process.

Q3: First run and reporting of full CoP feedback project.

Q4: Fully established methodology on continuous improvement for CoP through patient and staff feedback.

Corporate Objective 4: Sustainable: Ensuring the Trust continues to be a sustainable business by delivering within our financial budget. Owner: DoF



Consequence)

Q1: Delivery on plan Q1 outturn and forecast.

£261k surplus – exceeded plan by £12k • Achievement of full efficiency programmes

• Control of agency spend

• Ensuring full income plan achieved

• Retaining and securing new business

• Assurance of delivery of commercial and efficiency programmes through the Planning and Development Group

• Focus on controlling agency spend

3 * 4 = 12

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through workforce committee structure

• Robust contract management, and

oversight of CQUIN delivery

Q2: Figures for Q2 outturn and forecast.

Q3: Figures for Q3 outturn and forecast.

Q4: Delivery on plan for Q4 outturn and forecast.

Corporate Objective 5: Thriving Staff: The Trust will be an employer of choice and new recruits and newly qualified staff will get a structured support programme to ensure they have a positive working experience right from the start. Owner: Chief Nurse



Consequence)

Q1: Measure of progress will be: % of retention of Band 5 staff within the first two years. Establish way of amalgamating student numbers, new starters to the organisation and those starting in new roles within the organisation to establish a data base. Initiation of work programme including but not limited to Creation of New Starter Network. Development of Management and preceptor / mentor training. Revision of preceptorship training. programme and framework for delivery.

Progress has been good in the first quarter with a steady increase in the recruitment and retention of band 5 staff. Work is in train on development of a coordinated data base for all “new to role” staff. In the meantime the new starter network has started from those attending induction. Preceptorship training is in place and as part of the wider STP work this programme is being reviewed across the STP area to ensure a consistent approach for all areas of clinical supervision, preceptorship for new starts and mentoring. Practice facilitation is in place across the organisation but more is required to support the level of transformation and modelling work underway, especially to support the unregistered workforce.

Harnessing a coordinated approach across the STP

may hold back internal developments.

A programme “in house” could continue to be

developed and shared with the STP and could

be based on best practice seen during an amnesty of documents across organisations

reviewing what is currently in place and

based on best practice.

3x3=9 Currently the risk to

achieving this is medium due to expansion across

the STP of part of this objective.

Q2: Revision of a formal Mentorship programme Development of targeted Practice facilitator support. Commence roll out of training. Set target for improvement.

Q3: Commence formal

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programme at targeted groups of staff and commence measurement.

Q4: % of retention of Band 5 staff within their first two years – first milestone target achieved. Target improvement and stretch target developed for following year.

3. Risks etc

As at Q1, all objectives are on track to deliver by year-end, with Objective 4 being the highest risk.

The Board is asked to note the following new strategic risk:

Strategic Risk (NEW) ID 393 Delivery of Digital Transformation as part of the Digital Strategy

The Digital Strategy sets out the areas the Trust wants to focus on to exploit the benefits digital technology, data analytics and technology enabled care

services provide. There is currently insufficient capacity in the central Informatics team to support and deliver transformational analytical and digital IT

projects on a wider scale. In addition, capital funding is insufficient to replace the existing digital infrastructure on a regular basis and to introduce new

technology to enable better working conditions for staff and ultimately better health care outcomes for patients. This exposes the Trust to the risk of not

being able to deliver its objectives and to be commercially sustainable in the long-term.

Impact – 4

Likelihood 3

Overall score 12

Target score 9 (by 1/1/2020)

Next review date 2/11/18

The Director of Performance and Improvement can provide further detail of this new risk on request.

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BOARD OF DIRECTORS

26 JULY 2018

Agenda Item: 9

Title: Information Governance and Caldicott Annual Report 2017/2018

Purpose: Approval Assurance X Discussion Briefing

Please mark x as appropriate

Summary:

In 2017-2018:

• The Trust achieved an improved rating of 78% (Satisfactory) compliance in the Information Governance (IG) Toolkit.

• General Data Protection Regulations (GDPR) compliance in place and assured by the Information Governance Group on the 8th May 2018.

• The Trust achieved 96.4% compliance rate in IG Training for staff.

• The Trust reported 619 Information Governance Incidents, an increase from 450 reported in 2016-2017

• The Trust reported 3 serious incidents which were also reported to the Information Commissioners Office (ICO).

• 69% of all services had completed a health records standards audit.

• 934 staff completed mandatory for role health record keeping training.

• The Trust received 694 subject access requests, and 96.1% were responded to with the legal 40 day timescale

• The Trust received 234 requests for information under the Freedom of Information Act

Recommendation:

• The report documents the actions, developments and improvements which are planned for 2018-19. These will be monitored through the Information Governance Group.

CQC Domains (Safe; Caring; Responsive; Effective; Well Led) indicate which are relevant

below: Information Governance is relevant to each CQC domain.

Relevance to Strategic Goals: Ensuring we are led by excellent staff and providing confidential

care.

Equality and Diversity: Impact: No specific impact raised in this area

Prepared by (including job title):

Lindsay Wells – Information Governance Lead &

Data Protection Officer

Presented by (including job title):

Mike Jennings, Senior Information Risk Owner

Dr Richard Quirk, Caldicott Guardian

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Contents 1. Introduction ...................................................................................................................... 3

2. Achievement of Development Plans for 2017-2018 ............................................................ 3

3. Information Governance Toolkit ........................................................................................ 3

4. General Data Protection Regulations (GDPR) ...................................................................... 4

5. Information Governance Statutory Training ....................................................................... 7

6. Health Record Keeping Standards ...................................................................................... 8

7. Information Governance Incidents ..................................................................................... 9

8. Information Governance Serious Incidents ........................................................................ 11

9. Information Governance Project Support .......................................................................... 12

10. Subject Access Requests ................................................................................................... 12

11. Freedom of Information Requests ..................................................................................... 13

12. Corporate Records ............................................................................................................ 15

13. Action and Developments plans for 2018-2019 ................................................................. 16

Appendix A - Development plans for 2017-2018 ......................................................................... 17

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1. Introduction

The purpose of this report is to provide assurance that Sussex Community NHS Foundation Trust is

compliant with information governance (IG), including Caldicott statutory requirements, and where

necessary addressing information risks appropriately.

Compliance to IG is overseen by the Information Governance Group which is chaired by the Senior

Information Risk Owner (SIRO) and attended by the Caldicott Guardian, Information Governance

Lead, Head of IT and senior operational representatives.

Good Information Governance compliance supports the Trust in its achievement of its vision, values

and strategic objectives.

Governance of Records Leading to Clinical Outcomes

Confidentiality ➔ Trust

Integrity ➔ Safe Care (right decisions)

Availability ➔ Timely Care

2. Achievement of Development Plans for 2017-2018

In the 2017-2018 Information Governance and Caldicott Annual Report, 7 areas for development

were identified. Of these, 5 were achieved, 1 was partially achieved and 1 is being carried over to

2018-2019. Where these are not reported in full detail throughout the report, appendix A provides

an overview.

3. Information Governance Toolkit

The Information Governance Toolkit is the mechanism for NHS organisations and service providers

to demonstrate compliance to statutory IG requirements. The Trust is mandated to evidence

compliance against 39 requirements, score itself within each requirement from 0 to 3 and submit the

assessment annually by the 31st March.

Organisations are rated as

either satisfactory (green) or

non-satisfactory (red). To

achieve an overall

organisational rating of

satisfactory, each requirement

must be scored as level 2 or

above.

Following a significant

improvement in 2012/2013,

the Trust has seen a steady

improvement on their

compliance rates.

5459

7074 75 76 77 78

0

10

20

30

40

50

60

70

80

2010/2011 2011/2012 2012/2013 2013/2014 2014/2015 2015/2016 2016/2017 2017/2018

%Not Satisfactory Satisfactory

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For the 2017-2018 submission, the Trust achieved a satisfactory 78% compliance rating, a 1%

improvement on the previous year. Out of 39 requirements, 25 scored level 2 and 14 scored level

3.

Prior to final submission of the IG Toolkit, TIAA the Trust’s internal auditors undertook an audit

which provided an overall assurance assessment of Reasonable Assurance.

In 2018-2019 the IG Toolkit NHS Digital is changing to the Data Security and Protection Toolkit

(DSPT). This provides a more dynamic reporting tool which demonstrates compliance on an

ongoing basis rather than as a final end of March submission. It is however likely that a ‘snapshot’

with be required 3 times a year in line with the current baseline, mid-year and final submission.

The DSPT does not include levels and instead requires compliance with assertions and (mandatory)

evidence items. The assertions and evidence items are designed to be concise and unambiguous.

Documentary evidence is only requested where this adds value. NHS Digital have not yet released

any guidance on whether there is a requirement for independent audit.

The new toolkit will be reviewed and action plans developed. The audit requirement and action plan

will be presented to the Information Governance Group on 10th July for approval.

4. General Data Protection Regulations (GDPR)

The General Data Protection Regulations (GDPR) are the new legal framework in the European

Union (EU) and places new legal requirements on data controllers. As such, the Trust ensured that

a plan was in place to effectively transition to the new regulations by 25th May 2018.

A project implementation document was completed and signed off and a detailed action plan was

put into place and worked through key stakeholders within the Trust, including Human Resources

and the Contracting Teams. The Senior Information Risk Owner (SIRO) is in place as the Project

Sponsor and the project and actions are being monitored through the Information Governance

Group and on a 1-1 basis with the Senior Information Risk Owner.

In December 2017 a business case to support the implementation and ongoing requirements of the

GDPR was signed off at the Executive Committee. This included project support for GDPR, funding

for a robust Information Asset Management system, and resources for the changes to the

management of Subject Access Requests.

The status of the plan was presented at the Extraordinary Information Governance Meeting on the

8th May 2018. The Group was assured that the Trust had in place assurance in place to be

compliant to the requirements of GDPR. The following provides an update on the key areas of

focus for the Trust:

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Communication

• GDPR was been communicated to the Board, Wider Executive Committee, Area Management

Teams and through communications on the Pulse and Weekly Communications. A Board

Seminar was held in March around the requirements and challenges.

• In January 2018 a video was published on the Pulse as the start of wider communications to

Trust staff and further videos for staff and the public are planned to support the new

requirements around informing individuals of their use of data and the changes to the consent

model.

• Human Resources have reviewed current processes and staff contracts to ensure that there is

appropriate information for staff to inform then how we are processing their information.

• Privacy notices for patients and guidance for clinical staff using these, have been agreed and

will be printed an circulated to staff in time for the 25th May 2018

• Communications were made to staff running up to and after the 25th May 2018 with the Intranet

and Internet having updated pages.

Privacy Notices and Consent Processes

• Following numerous discussions on Consent for the use of patient information, it is clear that

this falls under the Common Law Duty of Confidentiality rather than GDPR. To meet GDPR,

clinical services need to ensure that patients are informed of the uses of their data. A ‘practical’

plan to achieve this, whilst limiting the impact of the primary priority to deliver patient care was

put into place and has been presented and approved by the Area Management Teams and the

Health Record Group.

• All corporate services who process data outside of usual staff management processes have

been contacted and where information is processed, action plans were put into place to ensure

the appropriate consent processes and privacy notices are in place.

Information Asset Management

• 99% of Clinical Services all completed their information asset management as part of the

Information Commissioner’s Improvement Plan in 2016-2017.

• The planned procurement of a centralised, dynamic Information Asset Management system will

be finalised by the end of April 2018 and implemented from the beginning of May 2018. This will

strengthen the current asset management processes in place; identify risks and mitigations

immediately to the information asset owner (IAOs); highlight actions in place; link into the IT

systems and applications to enable better planning for business continuity and disaster

recovery; and provide improved reporting to the Information Governance Team, Information

Asset Owners; Senior Managers and the Senior Information Risk Owner (SIRO).

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Information Breaches

• Robust Trust-wide incident management processes are already in place and meet the GDPR

requirements.

• Communications to staff on reporting in a timely manner will be included as part of the wider

GDPR communications.

• NHS Digital are currently updating the Incident Management Checklist and this will be

incorporated into the Trusts incident management processes.

Access to Information

• Communications have been sent out to staff regarding the change to the timescales for the

completion of Subject Access Requests (SARS) from 40 days to 30 days and that information

must be provided free of charge.

• The IG Team will be bringing the coordination of patient record SARs into the team to enable

better monitoring of SARs to ensure the new timescales are being met. An additional 0.5 WTE

Band 4 post has been recruited on an initial 15 month fixed term basis to support the likely

increase to requests as these will be free of charge, and the increased requirement to ensure

records are prepared within the shortened timescales.

• A transition process was introduced at the beginning of February 2018 where all requests are

notified to the IG Team when received (rather than when completed) to ensure the timescale are

adhered to. Any requests are reported to the Deputy Area Directors when over 21 days.

• Human Resources have updated their Policy and Procedure for access to staff information

which will be signed off through their governance structures and will link into the IG Team to

ensure these requests are logged and managed within the GDPR requirements.

Projects and contracting processes

• The Data Protection Impact Assessment has been reviewed and amended and embedded into

the Project Management Office and Commercial Development Team processes for any new

project, service or service redesign.

• A contracting checklist was developed to support the assessment of suppliers compliance to the

new regulations which is now in use with the procurement, contracting and commercial

development team.

• The contracting teams are working with the NHS frameworks to ensure all suppliers are

informed of the changes and their responsibilities for GDPR. The Trust is working with its

commissioners to provide assurance on the compliance to GDPR.

Information and Cyber Security

• The Trust is compliant to the Information Security requirements within the Information

Governance Toolkit and has been subject to a number of internal audits on various areas and

the recommendations have been complied to.

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• The Trust has completed the Cyber Essentials Assessment, which provides additional

assurance and links into the requirements of the new Data Security and Protection Toolkit. This

has been signed off by the Executive Committee and Senior Information Risk Owner (SIRO) and

submitted for review.

Data Protection Officer

The GDPR introduces a duty for public sector organisations to appoint a Data Protection Officer.

The role of the Data Protection Officer is to assist the Trust to monitor internal compliance, inform

and advise on your data protection obligations, provide advice regarding Data Protection Impact

Assessments (DPIAs) and act as a contact point for data subjects and the supervisory authority.

The Information Governance Lead is the nominated Data Protection Officer for the Trust and reports

to the Senior Information Risk Owner.

5. Information Governance Statutory Training

As at 31st March 2018 the Trust achieved 96.4% compliance rate of staff trained in line with the IG

Toolkit submission requirements.

In 2017-2018, Information Governance training was delivered through the Trust Statutory Training

(STAT) day.

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Following the Information Governance Group in October where it was highlighted and discussed

that training compliance was decreasing month on month it was agreed that although the IG

Training rates were published on Scholar (the Trust’s reporting dashboard), monthly reports of staff

not compliant to the IG Training would be sent to the Deputy Area Directors and General Managers

in order to achieve the 95% compliance rate.

These reports were also sent to Heads of Service,

Area Directors, Clinical Directors and the Chief

Operating Officer.

In 2018-2019, the IG Training will remain on the

Trust’s Statutory Training Day as this is well received

as shown from the STAT day evaluations and

feedback received:

NHS Digital have released a new online training tool

which is to be completed by all new starters. A small

presentation will be delivered at induction and these

staff will be followed up to ensure completion. This

training can also be completed by staff to supplement

the IG Training delivered as part of their STAT day.

This training will be recommended to staff and

services following an incident or as additional

staff training and development.

6. Health Record Keeping Standards

Health Record Keeping Policy

The Health Record Keeping Policy had a significant refresh to define the policy sections and the

procedural sections. This also included guidance on the use of loose sheets and clearer guidance

on reaching policy for access to own records.

Health Record Keeping Standards Audits

At the end of March 2018, 69% of all services had completed a health records standards audit or

were in the progress of completing, a 1% decrease on the previous year. This is reported quarterly

through the Health Record Group and escalated to the Information Governance Group. These

services are being followed up through the Service Managers and Area Nurses.

Any Trust wide learning is bought to the Health Record Group to ensure any required actions are

implemented, no significant health record keeping trends were identified and in most cases,

compliance to health record keeping standards were good. Services also report their findings and

any learning through their service governance groups.

In 2018-2018, the Quality Effectiveness Team will be reviewing the management of the Health

Record Audit in line with their clinical audits to ensure that there is a central collation of evidence

and there is an effective interaction with clinical documentation audits. This impacted the rates of

completion as adult services are awaiting the new audit tool to complete.

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National Independent Inquiry into Child Sexual Abuse (IICSA)

The IICSA is investigating whether public bodies and other non-state institutions in England and

Wales have taken seriously their responsibility to protect children from sexual abuse, and make

meaningful recommendations for change in the future.

Since the inquiry was instigated in April 2016, the Trust has ceased any disposal of health records

and relevant corporate records in accordance to the recommendations for health organisations set

out by chair of the inquiry.

The Safeguarding Steering Group is awaiting further recommendations to be released from the

inquiry in regard to the further retention of records.

Health Record Keeping Training

Health record keeping training is mandatory every 3 years for staff who use or administrate health

records. In 2017-2018, 22 face-to-face health record keeping training sessions were delivered,

capturing 342 staff and a further 592 completed the training using the health record keeping

workbook, totalling 934 staff trained.

The Health Record Keeping Training has a greater focus on SystmOne record keeping as service

implement the system and the IG Team work closely with the SystmOne projects and the Digital

Health Record Clinical Lead to ensure up to date knowledge of the system and its functionality.

Following the implementation of the updated Electronic Staff Record, better identification of staff

who require health record keeping training will support the reporting and uptake of staff to the

training.

One of the areas of development for 2017-2018 was to review compliance rates to Health Record

Keeping Training and ensure the Trust is meeting the requirements for 3 yearly training.

As the current education and training systems is not able to identify the staff who require the health

record keeping training, it has been difficult to accurately and effectively report on these figures.

With the implementation of the new ESR reporting system from the 1st April 2018, staff will be

assigned against competencies and therefore reporting on mandatory for role will be more effective

for 2018-2019.

7. Information Governance Incidents

The Trust operates a positive culture of reporting of incidents where staff are encouraged to report

information governance incidents.

All incidents are reviewed by the Information Governance Manager to ensure all relevant actions

are taken, provide support to staff in the management incidents, and identify any lessons learned.

This also ensures that the Trust is able to identify and mitigate against any potential serious

incidents.

Incident Trends are included in the Information Governance Team priorities, awareness campaigns

and training.

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In 2017-2018 the Trust reported 619 Information Governance Incidents, an increase from 450

reported in 2016-2017. This increase is in line with the overall incidents reported in the Trust.

Incidents reported in 2017-2018 were categorised as follows:

The highest reported IG incidents were related to patient information sent or received incorrectly/

inappropriately and Patient Documentation Lost or Misfiled. This follows the trend in 2016-2017.

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An analysis of these incidents shows the majority of the incidents were attributed to ‘human error’

and as such identified that awareness raising is key to minimising these incidents themes. Policies

and procedures are also reviewed to ensure these provide staff with clear information on their

responsibilities.

8. Information Governance Serious Incidents

In 2017-2018, the Trust raised three serious incidents, which were reported through the national

incident reporting system and to the Information Commissioner’s Office (ICO).

The first incident was reported in May 2017 and involved the loss of a single handover sheet which

contained personal confidential data on 15 inpatients.

The member of staff lost the handover sheet whilst giving emergency first aid outside Horsham

Hospital and the sheet has not been recovered. There was no evidence to suggest the information

has been used or accessed inappropriately.

On 8th August 2017, the ICO closed the investigation, stating that the incident did not fit the criteria

for formal enforcement action due to the mitigating circumstances leading to the handover sheet

being taken off site, the events leading to the subsequently loss and the actions taken following the

incident.

The second incident was reported in May 2017 and involves the inappropriate disposal of 5

handover sheets which contained personal confidential data on 31 inpatients. The sheets were

returned to the Unit by a member of the public. There was been no evidence to suggest the

information has been used or accessed inappropriately.

On 4th August 2017, the ICO responded to the incident to state that regulatory action is not required

due to the remedial action taken following the incident and because the risk of potential detriment or

distress to the patients is low.

The third incident was reported in February 2018 and involved the loss of a single sheet of paper

that was used as a work list/clinic list which contained personal confidential data on 8 patients from

the Heathfield Community Nursing Team. This incident met the serious incident criteria due to the

Trust having similar incidents within the last 12 months. There was no evidence to suggest the

information has been used or accessed inappropriately.

On 17th February 2018, the ICO responded to the incident to state that no further action by the ICO

is necessary for this incident and recommended completing a local Root Cause Analysis.

Following the first incident and continuing following the second incident, actions were taken by the

services involved and through the inpatient task force.

Actions included

• All inpatient staff at to be reminded of their obligations within the Trust’s Health Record Keeping

policy.

• Local processes to be set up to reminding staff to keep handover sheets secure and

confidentiality dispose of them at the end of shifts.

• Continued Trust-wide IG awareness raising regarding the security of handover sheets.

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• Review of the induction process for new starters in the inpatient units to ensure the Information

Governance workbook is completed within their induction period.

• All staff at Bailey Unit to be reminded of their obligations within the ‘Coastal West Sussex

Community Hospital Local Health Record Keeping Procedure’ during team meeting/s or local

staff training.

• The risk of ‘loose’ sheets is raised as part of general information governance awareness at the

Trust’s statutory training day and via the staff intranet.

• A poster has been created and shared with Inpatient wards reminding staff to confidentially

dispose of handover sheets.

9. Information Governance Project Support

Alongside general advice and guidance given to staff and services, the IG Team have provided

support to over 25 Trust projects to advise and assist on IG matters, including the completion of:

privacy impact assessments, information sharing agreements, quality governance toolkit, data

transfer agreements, business development tenders, IG Framework documents. Projects include:

• SystmOne Projects: Child Development Centres, Lymphoedema, Chailey, Podiatry Redesign,

• Sustainability and Transformation Plans (STP) and Local Digital Roadmap (LDR)

• Lymphoedema Service Mobilisation

• Child Protection Information Sharing Project (CP-IS)

• Diabetes Care For You

• Digital Health Sharing Programme (Docobo)

• Trust Public Wi-Fi

• Falls Pilot Data

• Cerebral Palsy Integrated Pathway Scotland [CPIPS]

• Learning Disabilities Mortality Review (LeDeR) Programme

• Horsham Hub

• Adult Social Care Outcomes Framework (ASCOF) for Short Term Services

• Frailty Project Coastal

• Infection Control Data Sharing

10. Subject Access Requests

In 2017-2018, The Trust significantly improved its response targets from the previous year. 694

subject access requests were received which equates to an average of 57.83 per month (an

increase of 191 request and an average of 15.92 per month from 2016-2017).

• 96.1% of requests were completed within the Data Protection Act requirement of 40 days, a

19.1% increase 2016-2017.

• 82% of requests were completed within the Department of Health guidelines of 21 days, a 39%

increase on 2016-2017

• 91.7% of requests were completed within the General Data Protection Regulations (GDPR)

requirements of 30 days (in force 25th May 2018)

• 3.9% of request exceeded the 40 day legal requirement, a 19.1% decrease on 2016-2017.

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The target is to achieve zero requests exceeding 40 days and 75% to be completed within 21 days.

Whilst the 40 day target was not met, there was a significant decrease on the previous year.

The Information Governance team escalate any requests passing 21 days to Deputy Area Directors

and General Managers on a weekly basis and to the Information Governance Group.

From the 25th May 2018, in line with the General Data Protection Regulations, the Trust will be

legally obliged to respond to requests without undue delay and at the latest within one month (30

days) and free of charge. From June 2018, the Information Governance Team will be fully

coordinating all subject access requests and work is in place to transition to this.

A business case was approved for additional resources to support this and the likely increase to

SARs due to them being free of change and the additional work required to meet the 30 day

timescale.

11. Freedom of Information Requests

On the 1st April 2017, the logging of Freedom of Information requests was transitioned from an excel

spreadsheet into Datix to align with Subject Access Requests.

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In 2017-2018 the Trust received 234 requests for information under the Freedom of Information Act,

an increase of 35 from 2016-2017. This equates to an average of 19.5 requests per month, an

increase of 3 per month from 2016-2017.

94% of requests received a response within the 20 working day response time, a decrease of 6%

from 2017-2018. Breaches of the timescale were attributed generally to compiling complex

responses across a number of services and request for significant amounts of information. The

team was also down on capacity between December 2017 and March 2018. These breaches are

escalated to service managers and reported through the Information Governance Group.

The majority of requests are received from Individuals, Commercial Organisations or researchers.

The majority of requests are regarding medical or clinical subjects, such as the provision of

services, or activity levels or the management of the Trust, for example commissioning, staff

numbers, organisational structures. In some cases a request may span a number of different

subject types, but Datix does not allow selection of multiple subjects and therefore the subject which

is the greater focus is selected.

Where requests may have impact on our ability to compete with other organisations in regard to

tenders and bids, these are discussed with the Deputy Director of Development and Partnerships.

All media requests are copied to the Head of Marketing and Communications. IG

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12. Corporate Records

A project commenced in In September 2017 to relocate the corporate records held in Brighton

General Hospital D-Block archive to the external offsite storage service Restore.

These records were originally stored in the Arundel Building basement and were moved to the D-

Block archive due to poor conditions caused by flooding and damp.

The boxes were largely unassigned and unmanaged and therefore work needed to be undertaken

to review the contents and ensure only relevant information was being kept, that the information

was identified and they had an appropriate retention schedule assigned.

456 boxes were archived in October 2018, and work commenced to recall batches of records in

order to review the contents, catalogue the information and establish suitable retention periods

and/or transfer ownership to the appropriate team.

The review of boxes has so far identified a mixture of records that are required to be stored for

longer and records that have passed their destruction dates; however records are on a temporary

suspension of destruction due to the independent Inquiry into Child Sexual Abuse (IISCA). It is

hoped there will be some clarification following hearings currently in progress.

The review has also identified that many of the boxes are disorganised and contain a mixture of

corporate information, small amounts of patient records or complaint files, and/or personnel files.

Due to the mixture of records and the legacy changes of the Trust, it is a time consuming exercise.

The work to recall the boxes is on-going and will continue into 2018-2019.

Following some estates work, a number of old records dating back to the 1940’s were discovered.

These were mainly old mortuary books and x-ray books. Owing to the historic interest of the NHS

and of Brighton General Hospital, the Head Logistics and Information Governance Lead met with

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the Archivist at the East Sussex Keep (National Archives local place of deposit) to discuss whether

these would be of historical value. It was agreed they were and following the discussion where

transferred to the Keep for permanent preservation.

13. Action and Developments plans for 2018-2019

1. Implement the General Data Protection Regulations (GDPR) by 25th May 2018.

2. Implement new centralised Information Asset Management system and processes.

3. Review clinical documentation to record the information sharing agreements.

4. Transition the coordination of Subject Access Request into the Information Governance Team.

5. Monitor compliance to the Health Record Keeping Audits through the Health Record Group to

achieve a 90% compliance rate for 2018/2019.

6. Review compliance rates to Health Record Keeping Training and ensure the Trust is meeting

the requirements for 3 yearly training.

7. Implement and complete the new Data Security and Protection Toolkit.

8. Review and management of corporate records moved from Arundel Basement to offsite storage

to index and ensure appropriate retention schedules are in place.

9. Develop processes to ensure the ‘20 year rule’ for records is in place, and staff are aware of the

criteria and management of records for permanent preservation.

10. Implementation of Information Sharing Processes as part of the Sustainability Transformation

Plan / Local Digital Roadmap in partnership across Sussex.

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Appendix A - Development plans for 2017-2018

The following provides an overview of the development plans documented in the 2017-2018 Information Governance and Caldicott Annual Report.

1. Implement the General Data Protection Regulations (GDPR) which will

apply in the UK from the 25th May 2018 and will replace the Data

Protection Act 1998, includes:

a. Scoping and implementing IT / Information Asset Management

System to have centralised data collation and reporting for timely

system and information management in line with GDPR

Requirements.

b. Mandating Privacy Impact Assessments across the Trust.

c. Change to consent requirements and processes.

d. Review processes for responding to subject access requests to

reduce the time taken.

Achieved - Assurance agreed at the Information Governance Group on

the 8th May 2018

2. Caldicott 3 / National Data Guardian recommendations

implementation.

Achieved - Linked into the General Data Protection Regulations (GDPR)

action plan.

3. Review health record keeping guidance and training in line with the

2016 Records Management Code of Practice for Health and Social

Care 2016 and following the work undertaken from the ICO

Improvement Plan.

Achieved - Health Record Keeping Policy updated and associated

procedural guidance added.

4. Review compliance rates to Health Record Keeping Training and

ensure the Trust is meeting the requirements for 3 yearly training.

Not achieved - Awareness raising has been completed for compliance to

health record keeping, however awaiting the new ESR training module to

be completed to be able to report on competencies to the training as not

all staff are applicable for training and was not easily reportable through

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current systems. Rolled into 2018-2019 actions

5. Redevelopment of Information Governance Compliance Reporting

Tools, including scoping Datix for use.

Achieved - IG Compliance databases are in place following the structure

changes. Datix is now being used for recording Freedom of Information

requests as well as Subject Access Requests.

6. Review requirements for Corporate Records Project Plan and

implement in 2017-2018 (carried forward from 2016-2017).

Partially Achieved - Work has been undertaken to review old corporate

records from the D:Block archive and also investigate the historical

relevance of old records found within Brighton General Hospital.

7. Development of Information Sharing Processes as part of the

Sustainability Transformation Plan / Local Digital Roadmap in

partnership across Sussex.

Achieved - The information sharing protocol has been developed and is

being signed up to by the organisations, including the GPs within the STP

Footprint (this is being managed by Carnall Farrar).

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Mortality Report Quarter 1 -2018 Dr. Vivek. Patil.

Acting Deputy Medical Director.

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Sussex Community NHS Foundation Trust – Mortality report Q1 2018.

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Reader Box

Description This is the summary of all the structured judgmental review o deaths in the inpatient units. Any learning from how we cared for the patient pre and post death is hared across trust.

Date published 5/7/2018

Date due for review None

Executive Lead Dr Richard Quirk.

Author Dr Vivek Patil.

Contact details [email protected]

Primary audience Trust Wide Clinical Governance Group


Executive Team, Trust Board and others.

Notes This is the summary of mortality reviews done in our inpatient units using structured judgmental forms. The aim is to identify if the trust could have improved the quality of care leading up to the death, identify any trends that would indicate that poor care had led to the death and to identify if there are any particular services where mortality is higher than expected and to take the necessary actions as need be. It is to be noted that this time we do have data set of mortality for community nursing teams. This gives us the overall number of deaths that are recorded as the discharge reason on SystmOne Community Nursing Units.

Table of Contents Heading 1 Introduction …………………………………………2 Heading 2 Results for Q1, analysis and findings………3

Heading 3 Learning ……………………………………………….. 7

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1. Introduction Sussex Community NHS Foundation trust (SCFT) has been using structured judgmental forms to review the period before a patient has died. This has been in practice since 2014. Reviewing deaths in this way has led to identify any trends that would indicate that a particular service has higher deaths than average which would lead to a more in-depth review of the care provided within that service. We have also introduced a buddy system where by neighboring inpatient units undertake the review for one another. This is in line with recommendation by NHSI.

This time we are also able to get the data set of mortality for community nursing teams. This gives us the overall number of deaths that are recorded as the discharge reason on SystmOne community nursing units. It is to be noted that our community nursing team involvement may be for a specific task completion such as dressing or administering a specific medication only and not involved in complete care of the patient. Majority of these patients will be still under general practitioner care. Although there are recommendations for sharing information and cross working in these cases, there is no coordination between primary care, acute and community trusts to undertake this work.

2. Results for Q1 2018 analysis :

2.1 Overall deaths during reporting period

Between 1st April 2018 to June 30 there were 23 reported deaths in our inpatient units. Of these 19 are reviewed using structured judgmental review forms in mortality review group. We aim to undertake review of all the deaths in inpatient units in a defined time line. But this is not always possible due to combination of heightened case load activity and the availability of senior staff to undertake the review. In this quarter we have also undertaken the review of 12 deaths from last quarter and learnings incorporated. Any deaths that have not been reviewed will be reviewed by the end of July by Acting deputy medical Director and report submitted to Trust Wide Clinical Governance Group and Mortality Group.

2.2 Deaths that have been reviewed using SJR process.

Age range is from 57 to 97 with mean age range of 85.05 for all the deaths reviewed using SJR forms.

SJR forms were completed by ward doctors, advanced nurse practitioners and ward sisters.

All admissions apart from one were before 20:00. One was at 2100 but this did not have any relation to outcome of death.

Main causes of death were old age and frailty, chest infection cancer and CVA.

From review of cases it is noted that 3 had malignancy and one had distal metastasis

Increasing comorbidity is seen in the form of respiratory, cardiovascular and metabolic (diabetes) pathology.

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2.3 Involvement of coroner.

1 case was discussed and referred to coroner. However there was no hospital post mortem on any of the cases. This demonstrates that clinicians are actively reporting to Coroner and seeking advice in cases where diagnosis may not be clear.

2.4 Medical oversight of patients who have died.

First clinical review of patients took place within arrival to within one working day as in line with standard operating procedure for our inpatient units. 4 patients were seen after 12 hours by a clinician ( doctor / ANP) as they were admitted late in the evening or over weekend. This however has no correlation to the cause of death.

It has been recorded that in all reviews there was evidence of clear management plans within one working day and there were no omission in the initial management plans.

2.5 Transfer between wards and hospitals.

All patients were admitted to the appropriate ward in the first instance. There were no patient transfers between our inpatient wards themselves. Two patients were transferred to acute hospitals and were returned with an appropriate management plan.

2.6 Medical staff reviews.

It has been documented that patients were seen on regular basis in accordance with the standard operating procedure and documentation was noted to be of good medical standards. In one notes it is documented that quality of the notes could be improved and this has been discussed with the relevant clinician. It is worth noting that some of our units are Nurse led units and if there is a sudden change in patients clinical condition, doctor input is sought accordingly. This has no correlation with the cause of any deaths.

2.7 Care preceding death.

6 patients sustained a fall during the length of their stay. One of them sustained a small laceration to the scalp area with minor head injury. On review of these falls it is noted that these patients did have previous falls. Most of the falls occurred when staffing was at its minimal level. This was established after discussion with the ward sisters / matrons and this is not captured through mortality questions. One patient was transferred to acute hospital and returned with appropriate management plan. None of the falls had direct correlation to death.

4 patients were noted to have pressure damage which were present before admission to our inpatient units. None developed pressure damage while under our care.

Fluid balance has been documented as adequate in all cases.

National early Warning Score (NEWS) was recorded as appropriate in all cases and in majority of cases this was discontinued as patients approached end of life.

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None of the patients had raised troponin, abrupt drop in hemoglobin or hypoglycemia or raised INR.

5 patients had urinary catheter in situ and review suggest that these were inserted for appropriate clinical reasons i.e. acute urinary retention and end of life care. It is to be noted that none of them developed any post insertion infection. This demonstrates good catheter care provided in our inpatient units.

Reviews of structured judgmental review (SJR) forms suggest that 3 people had lower respiratory tract infection. They were all treated with appropriate antibiotics. Chest physiotherapy was considered as inappropriate as they were approaching end of life care. It is worthwhile to note that these patients have several comorbidities and also immunocompromised which makes them more susceptible to hospital acquired infections.

There is no documentation of never events.

In all cases a decision to limit the treatment was made. Resuscitation status was documented in all cases. All patients were seen before the death by a clinician.

Palliative care team was involved in three cases. From the review it is felt that patients received optimal care in preferred place. All patients’ relatives and carers were involved in discussion about preferred place of death.

In overall review it is felt that there was no delay in making diagnosis and there was good communication between teams. All deaths were explainable. From the review it is felt that there were no avoidable deaths.

2.8 Evidence of Good standard of care.

Highlights of good aspect were communication between teams, documentation, keeping families and carers involved care given by the staff themselves.

The standard of documentation is noted to be good in most and average in some and improvements can be made in this area.

2.9 Deaths occurring in community teams.

The chart below shows the number of patient discharges with death recorded as the discharge reason on SystmOne community nursing units. The data set compares the data from 2016 till march 2018.

Total reported by week

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This data set shows that on an average there are around 100 recorded deaths per week. However our community teams may be going in only for a simple task completion rather than complete management of patients. Majority of these patients will be under general practitioner care. One interesting observation is that we do see a high number of deaths in winter period which could be due to respiratory associated infections which are more prevalent during this time.

Average weekly deaths by unit

Community Nursing –

Unit Average

Community Nursing Arun West SCFT Arun West 5.4

Community Nursing Bognor SCFT Bognor 7.8

Community Nursing Chanctonbury SCFT Chanctonbury 3.0

Community Nursing Chichester Central SCFT

Chichester Central 4.7

Community Nursing Chichester South SCFT Chichester South 6.1

Community Nursing Lancing SCFT Lancing 3.1

Community Nursing Littlehampton East SCFT

Littlehampton East 3.5

Community Nursing Littlehampton West SCFT

Littlehampton West 5.1

Community Nursing Rural SCFT Rural 4.1

Community Nursing Shoreham SCFT Shoreham 2.9

Community Nursing Worthing Central SCFT Worthing Central 4.8

Community Nursing Worthing East SCFT Worthing East 6.4

Community Nursing Worthing West SCFT Worthing West 3.1

CoP Burgess Hill SCFT Burgess Hill 1.4

CoP Haywards Heath SCFT Haywards Heath 1.9

CoP Crawley West SCFT Crawley West 2.9

CoP East Grinstead SCFT East Grinstead 1.6

CoP Horsham South SCFT Horsham South 1.0

CoP Horsham North SCFT Horsham North 2.1

CoP Crawley East SCFT Crawley East 1.2

IPCT Brighton & Hove SCFT IPCT 9.1

Community Nursing HWLH SCFT HWLH 5.0

CN TOTAL 86.4

Other services

Unit Average

Bladder and Bowel Service SCFT Bladder and Bowel 7.1

Responsive Services Crawley SCFT Responsive Services 0.2

Tissue Viability SCFT Tissue Viability 1.5

IV Nurses North SCFT IV Nurses 0.4

COPD SCFT COPD 0.7

Midhurst Macmillan Specialist Palliative Care Midhurst 0.7

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It is to be noted that this data set needs a meaningful evaluation. Some of the services may have higher number of deaths like bladder and bowel services where patient may have had a catheter inserted or continence pads ordered as a part of end of life care. End of life care patients are usually referred to bowel and bladder services more often than any other service. This data set can only be useful if we have a close collaboration between primary care, secondary care and ourselves.

3. Learning Documentation - It is to be noted that end of life care documentation is rated as average to good. In patient units are specifically asked to improve on the documentation of care plans with clear management and communication plans.

Data analysis – Although we can pull out the data out of SystmOne for Community Teams ,it does not provide us with the necessary intelligence to evaluate the data. Systm One needs to be configured in a way that it does not capture the double counting of number of deaths.

Although the communication between the teams is good it can be further improved by involvement if families and carers more often to provide a better care.

One of our aims is to get the review done on time which can be at times challenging given the case load each unit has to manage with the current staffing challenges.

We are getting involved in Kent Surry & Sussex wide mortality review project and see how we can improve on our reviews and share some of our experiences across the other health care providers.

SCFT Macmillan

Responsive Services Mid Sussex and Horsham SCFT

Responsive Service 0.4

Heart Failure SCFT Heart Failure 0.3

Venous Leg Ulcer SCFT Venous Leg Ulcer 0.0

Diabetes North SCFT Diabetes 0.4

Other TOTAL 9.4

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Title of Meeting

Board of Directors

Date of Meeting

26 July 2018

Report Title

Revised Standing Orders, Standing Financial Instructions and Scheme of Delegation for SCT FT

Author

SOs – Margaret Godfrey, Company Secretary SFIs and SoD – Ed Rothery, Deputy Director of Finance

Responsible Executive

Mike Jennings, Director of Finance and Estates

Purpose of Report (e.g. for decision, information) For the Board to approve revised SOs, SFIs and SoD. The Audit Committee reviewed these documents initially in February 18 and again on 3 July and feedback from those meetings have been incorporated into the final versions. The Audit Committee recommends the final documents to the Board for approval. Copies of the full documents have been put onto VBR, in the Board Shared Documents section, or can be requested in hard copy from the Company Secretary.

Summary The Trust’s SOs, SFIs and SoD required updating following its authorisation as a FT. They were due for review again in 2018. This review reflects changes in the Executive Director structure brought in since 2016 and other minor changes and feedback received at the February and July meetings of the Audit Committee. Amendments are shown in the final documents using Track Changes.

Paper Previously Reviewed By Audit Committee.

Strategic Impact N/A

Risk Evaluation N/A

Impact on Care Quality Commission Registration and/or Clinical Quality Factors into Well-led Domain requirements.

Governance Implications (legal, clinical, equality and diversity or other): The Trust is required to have up-to-date, relevant SOs, SFIs and SoD in place at all times.

Financial Implications N/A

Freedom of Information Implications – can the report be published?

Not until approved by the Board.

Recommendations a) To approve revised SOs, SFIs and SoD.

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Revised Standing Orders, Standing Financial Instructions and Scheme of Delegation

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Sussex Community NHS Foundation Trust – Name of report title

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Reader Box

Description

Date published

Date due for review

Executive Lead

Author

Contact details

Primary audience


Notes

Table of Contents Heading 1 .......................................................................................................................... 2

Heading 2 ........................................................................................ Error! Bookmark not defined.

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Scheme of Delegation Summary of Proposed Changes – July 2018

• The updated SFIs and Scheme of Delegation are attached for review by the Committee. All documents show proposed updates, as highlighted at the February 2018 Audit Committee as tracked changes from the previously approved SFIs.

• In addition there have been a number of changes to the scheme of delegation following a subsequent review. The table below sets out the changes in the scheme of delegation from the 2016 approved SFIs. The changes below are not shown as tracked changes in the document, to try to improve the ease of review.

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Document Page Section Change Proposed

Section d – reservation and delegation of powers - scheme of reservation and delegation (decisions reserved to the board)

2/19 THE BOARD

Approve proposals on individual contracts (other than NHS contracts) of a capital or revenue nature amounting to, or likely to amount to over £1 million in any given year

Previously: Approve proposals on individual contracts (other than NHS contracts) of a capital or revenue nature amounting to, or likely to amount to over £250k over a 3 year period, or the period of the contract if longer


2/19 THE COUNCIL OF GOVERNORS

Approve the appointment (and where necessary dismissal) of External Auditors

Previously: Approve the appointment (and where necessary dismissal) of External Auditors and advise the audit commission of the appointment


3/19 THE BOARD Approval of external auditors’ arrangements for the separate independent examination of funds held on trust

Previously: Approval of external auditors’ arrangements for the separate audit of funds held on trust

Section d – reservation and delegation of powers - scheme of delegation derived from the accounting officer memorandum

4/19 CHIEF EXECUTIVE Sign a statement in the annual report and accounts outlining responsibilities as the Accounting Officer.

Previously: Sign a statement in the annual accounts outlining responsibilities as the Accounting Officer.

Detailed scheme of delegation

2/13 Non Pay Revenue and Capital The following limits apply to all non-pay revenue expenditure, authorisation of new contracts and also to approval of service developments which may have revenue implications as well as

expenditure (previously no distinction was made between contract signature and non-pay revenue spend and no mention was made of service developments) The stated amounts relate to expenditure incurred in any given year All requisitions up to £50,000 – Budget Holders (previously was Heads of Service) All requisitions from £50,000 to £250,000 – Directors (no change) Requisitions £250,000 to £500,000 – Executive Committee (previously Board) Requisitions £500,000 to £1 million – Finance and Investment

Committee (previously Board) Requisitions over £1 million – Trust Board

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3/13 Capital Schemes

Capital Schemes The Trust’s investment policy gives further detail on the criteria to be applied for approval of capital schemes and the delegated limits. The amounts quoted below apply both to approval of

business cases and approval of capital contracts. Up to £250,000 £250,000 to £500,000 £500,000 to £1 million Over £1 million (previously this was not identified separately – now aligns with proposed investment policy)


4/13 Quotation, Tendering & Contract Procedures

Compliance with legislative requirements including OJEU - Chief Executive or Director of Finance and Estates Previously not mentioned


5/13 Expenditure on Charitable and endowment funds

Up to £1,000 - Authorised Signatories (Previously up to - £100) From £1,000 to £5,000 - Director of Finance and Estates (Previously £100 - £1,000)

Over £5,000 – Charitable Funds Committee (Previously over £1,000) Over £100,000 Trust Board


6/13 Losses, Write-off & Compensation

All categories of losses and special payments, cash due to theft, fraud, overpayment and overpayment – Below £25,000 Director of Finance and Estates – Above £25,000 Finance and Investment Committee


7/13 Losses, Write-off & Compensation

Write off of irrecoverable debtors Up to £25,000 - Director of Finance and Estates (previously up to £1,000)

Between £25,000 and £250,000 Director of Finance and Estates and Executive Committee Over £250,000 - Finance and Investment Committee and Director of Finance and Estates (previously reserved to the Board over £5,000)


13/13 Virement Policy Remove from Scheme of Delegation and include in separate Virement Policy

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Agenda Item: 14

Title: Digital Strategy 2018-2021

Purpose: Approval x Assurance Discussion Briefing

Summary: A review of the current IT strategy has been requested by the Board with the focus on making its remit broader and to add wider digital aspects. The document presents our first Digital Strategy. It sets out what digital means and why it is such an important enabler to achieve our vision of excellent care in the heart of the community. Our Digital Strategy shows that digital is a way of thinking and working differently, using data, digital technology and technology enabled care for the benefit of the patient. We all have a role to play in becoming an organisation that thinks ‘digital’ with health care professionals being the key driver for this. The key focus of this strategy is on creating a digital culture across our workforce whilst we ensure important digital housekeeping rules are in place to keep personal data safe and secure and IT systems working. Key deliverables that can be expected are listed under the eight key digital priorities and principles. The IT team has started to populate the list of digital improvements they are going to deliver this year. We will encourage staff to list and share the items they are going to do digitally to improve outcomes for patients and/ or working conditions for staff.

Recommendation: The Board is asked to

• approve the Digital Strategy 2018-2021

CQC Domains (Safe; Caring; Responsive; Effective; Well Led) The Digital Strategy is a strategic enabler and therefore relevant to all domains. Its primary focus is well-led to enable high quality care through the efficient and effective use of digital ways of working.

Relevance to Strategic Goals: The Digital Strategy is a strategic enabler and therefore relevant to the delivery of all corporate objectives.



• Outcome: The outcome of the EHRA is to continue the work. Amendments of the draft document have been made to include explicitly the importance of considering the impact of any digital project on patients with protected characteristics. Digital technology provides many opportunities to improve access and availability of services and information, however, the strategy emphasises that digital technology needs to consider different needs or the availability of digital infrastructure in order to benefit all patients.

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Prepared by: Anuschka Muller, Director of Performance and Improvement

Presented by: Anuschka Muller, Director of Performance and Improvement

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Digital Strategy 2018-2021

Improving our patients’ health and well-being and their care experience through the effective use of data, digital technology and technology-enabled care

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Sussex Community NHS Foundation Trust – Digital Strategy - DRAFT

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Table of Contents 2018-2021 ................................................................................................................................................. 1

Summary .............................................................................................................................. 3

Introduction and Context ...................................................................................................... 4 The importance of a Digital Strategy ........................................................................................................ 4 What does ‘digital’ mean? ........................................................................................................................ 5 What are the benefits of ‘digital’ for our patients and health care professionals? ................................. 6 The Digital Strategy – one of our key enabling strategies ........................................................................ 6 Local Health & Social Care Economy ........................................................................................................ 7 National Context and Vision ..................................................................................................................... 8 Regional Digital Agenda ............................................................................................................................ 9

Our digital Story so far ........................................................................................................ 10 Key achievements using digital ways of working .................................................................................... 10

The future – what we will focus on ...................................................................................... 12 Outcomes enabled by the Digital Strategy ............................................................................................. 12 Digital Guiding Principles and Priorities – our digital building blocks..................................................... 13

What will be different in the future ..................................................................................... 14

The plan – how we will do this ............................................................................................ 17 Delivering the Strategy over the next three years .................................................................................. 17 Key challenges ......................................................................................................................................... 30 Oversight of Delivery – Governance structure ....................................................................................... 31

References .......................................................................................................................... 32

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Summary This is our first Digital Strategy. It sets out what digital means and why it is such an important enabler to achieve our vision of excellent care in the heart of the community.

Our Digital Strategy shows that digital is a way of thinking and working differently, using data, digital technology and technology enabled care for the benefit of the patient. We all have a role to play in becoming an organisation that thinks ‘digital’ with health care professionals being the key driver for this. Their ideas, innovations and vision for what digital can achieve for patients based on their in-depth knowledge from day to day interactions with patients need to guide our design and development of digital solutions – not the other way round. We could install the best systems but without the knowledge and passion from the front-line we could not reap the benefits of digital.

At national and local level, challenges in the health and care systems need to be addressed, such as a growing older population with increasing complex needs while social care budgets are being cut and NHS budgets are being stretched by increasing demand on acute hospital care; two areas are being nationally promoted as the solution to better and more efficient and sustainable health care through various initiatives and publications: Community Services and Digital.

We are combining the two, being the Community Services provider across Sussex and Brighton & Hove and having the foundations and ambitions to transform our services through the use of data, digital technology and technology enabled care services.

We have identified four key outcomes which our Digital Strategy will focus on:

• Enabling patients to manage their health more independently

• Enabling staff to provide excellent and relevant care in the most appropriate location

• Enabling an efficient and effective delivery of community health services

• Enabling better working together across the local health system

These outcomes will be supported through specific deliverables that are aligned to a set of digital building blocks – our Digital Principles and Priorities. The majority is applicable to all staff in all services areas and only a small proportion is actually ‘techie’ stuff that needs to be delivered by IT professionals. Principles will allow us to develop digital solutions without being driven by the central Informatics team whilst ensuring we adhere to good practice and use resources sustainably.

The key focus of this strategy is on creating a digital culture across our workforce whilst we ensure important digital housekeeping rules are in place to keep personal data safe and secure and IT systems working.

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Introduction and Context The importance of a Digital Strategy Digital technology is becoming increasingly a part of our everyday lives. Digital solutions and processes have the ability to transform the way in which we interact with patients and other public services such as other health providers and social care, sustaining, reshaping and improving our health and care services for the future.

The opportunities data, digital technology and technology enabled care provide to improve health and care outcomes are vast and expectations of the public will be growing with artificial intelligence, virtual consultations, and instant access to people becoming more and more the norm. Digital solutions will be central in improving health and wellbeing for our population and will be crucial in addressing the challenges and realising the opportunities we face in health and social care in the future to achieve tailored, person-centred high quality care and improve outcomes for all.

Information and technology offers us a chance to not only meet the increased demand set out in the Five Year Forward View, but to provide our patients with higher quality care and a choice of services which are more convenient and faster to access.

Our Digital Strategy sets out our key priorities in achieving this ambition, what we are going to focus on over the next years and our intended collaborative work in delivering those objectives.

We are not starting from scratch; we are lucky to have not only good digital foundations with regards to a central informatics function but also – and more importantly - a workforce that is keen to use digital technology and is already embracing and actively bringing in digital solutions to improve health and well-being outcomes for people – staff and patients alike.

This strategy is describing the next steps and how we can all contribute and benefit from using digital technology to monitor, review and improve the quality of care we provide, to communicate and engage better and easier with each other and to empower patients by having access to their own health records and plans and using digital solutions to be more in control of their own health.

“Digital technology has the potential to shift the balance of power between clinicians providing care to patients receiving care” (Prof. Darzi, 2018)

But is it not only patients and our staff we have in mind, digital solutions also open doors to volunteers and the wider community which are key for making the connection between health and social care, patient’s family life and support network in the community. We have seen great examples of how volunteers visit patients in our community hospitals and use tablets to explore and discuss available help in the community for when the patient is going back home. This has had a massive impact on patient’s confidence as returning home with limited physical abilities can be a frightening prospect. This strategy is aimed at encouraging, driving and enabling more of new digital applications that can make a massive difference to our patients.

It is an ambitious journey that will require a lot of skills, engagement and determination; it is an ambition that is supported and driven by our Board and Senior Teams to enable our workforce to deliver excellent care in the community.

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What does ‘digital’ mean? Organisations today all want to become more digital. But what does digital really mean? And are we not already digital as we use computers, emails, internet, social media, smartphones, online appointments and online health records?

It is tempting to look for simple definitions, but to be meaningful and sustainable, we believe that digital should be seen less as a thing and more a way of doing things across the organisation and with others. To help make this definition more concrete, we have broken it down into three attributes1:

Developing foundational capabilities that support the entire structure. This is about the technological and organisational processes that allow our organisation to be agile and effective. This foundation is made up of three elements:

Mind-sets. Being digital is about using data to make better and faster decisions, devolving decision making to teams closer to the patient, and developing much more iterative and rapid ways of doing things. Thinking in this way should not be limited to just a handful of functions within the central informatics team. It should incorporate our entire workforce, including creatively partnering with external companies and the academia to extend necessary capabilities. A digital mind-set provides the basis for cross-functional collaboration, flattens hierarchies, and builds environments to encourage the generation of new ideas. This is essential to unlock the second attribute:

Creating value in new areas. Being digital requires being open to re-examining our entire way of doing business and understanding where we could add value to the wider community within the health and care system. This is closely linked to our commercial strategy and digital solutions are key for providing excellent and cost-effective services.

Creating value in the processes. Digital thinking is required to transform existing processes into more efficient digital processes. For example, providing a scanned form on our webpage that needs to be printed and filled in by hand before sending it (re-scanned) via email will not create additional value to anyone – it will cost even more. So, when we want to use a digital solution to replace a physical process we need to rethink the processes around the task and focus on the outcome in order to make the most of a digital innovation.

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What are the benefits of ‘digital’ for our patients and health care professionals? We have good in house examples that describe the benefits of various digital projects (see further below – Key achievements). As our work progresses, the patient experience will become more personalised, with advice, support and care uniquely tailored to each person. Services will appear more joined up, and patients will not just understand how to navigate between them, but will be smoothly guided through one clear relationship to get to the care they need.

Some of the benefits that digital transformation can generally deliver are listed below:

• Provides patients with a smooth health and care experience without having to tell their health story to every new health care professional

• Increases a patient’s health journey experience without the need to use digital technology themselves if they do not wish or do not have the means.

• Give patients more control over their health and well-being

• Give patients and health care professionals the facilities to connect easily with each other

• Empower carers, i.e. those who look after people when they are not well

• Empower the wider patient’s community e.g. friends, neighbours, family

• Provide evidence against set standards of care driving high quality of care and better patient experience

• Reduce the administrative burden for care professionals

• Support better working together across care professionals through appropriate information sharing

• Support the development of new medicines and treatments

The Digital Strategy – one of our key enabling strategies We have set out our direction for community services in our Clinical Care Strategy2. The Clinical Care Strategy describes the vision for our organisation – Excellent Care at the Heart of the Community – and the strategic goals that will contribute to achieving the vision underpinned by a set of strong values. The Clinical Pathway Design describes what patients can expect from us: people are seen, assessed, investigated, treated, signposted / referred and cared for at the right time, in the right place by the right people. Over the last years, we have used data and digital technology to support this and we have seen the positive difference it can make.

While data and digital services/technologies will play a key enabling role for us to deliver and further improve our clinical and operational vision over the next years, the Digital Strategy will also strongly influence and be dependent on our other enabling strategies: Workforce Strategy, Estate Strategy, Patient Experience and Commercial Strategy.

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The Digital Strategy is our guidance to ensure we make the most of digital when we design, deliver, review and improve services.

Local Health & Social Care Economy Over the last 10 years, the population of those aged 65 and above in the South East has grown in rates never seen before and it will continue to increase. It is estimated that in 2035, our elderly population (65+) across West Sussex, East Sussex and Brighton & Hove, will have increased by 48%3. That is 178,400 more people over the age of 65. This equals the size of the combined population of Horsham and Crawley.

At the same time, the working population will only have increased by 37,800 (4%). This provides a huge challenge as we need to look after more people but will have fewer people to do so.

With a growing elderly population come unique challenges for the health and social care system that require a different, more integrated and community based approach on health and social care delivery due to people living longer but also experiencing more years living with life limiting conditions that are usually complex and require a variety of interventions. Digital Technology will play a vital role in ensuring we increase population health for young and old people whilst using resources efficiently and fairly. There is an urgent need to accelerate the implementation of new technologically-enabled models of care as the South East experiences challenges in a number of areas: staff recruitment and retention in health and social care services, increasing health

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care costs based on the traditional health care model and growing expectations of the public for instant access to health care and a seamless experience across health and social care.

National Context and Vision

Our Digital Strategy sits within a wider national context set out by the Five Year Forward View for the NHS (2014), the Health and Social Care Act 2012, the Department of Health’s Digital Strategy (Leading the Culture Change in Health and Social Care, 2012) and the latest Government Digital Strategy (2017) and the NHS Digital Roadmap (2018).

Specific reports on the role of digital technology on improving care in the NHS have been published to assess and address the challenges and opportunities of digital information technology (Wachter, 2016; National Information Board, 2014) and how it can be used to transform the outcomes of care for patients through patient-centred, personalised care.

All reports emphasise the unique opportunity digital technology provides and the importance of embedding digital ways of working to transform and improve health and social care services in the next years to address increasing health and social care demand whilst resources are limited. However, digital maturity – people’ skills in using digital technology, the sophistication of technology in place and the connectivity and interoperability of information technology across health and social care providers – is showing that there is still a long way to go to harness the benefits of digital technology for a wider population and across the health and social care system and that this has to be driven locally based on national best practice guidance.

A particular national focus is now set on the goal to deliver paper-free care at the point of access by 2020 (The Forward View Into Action: Paper-free at the Point of Care, 2016)

The SCFT Digital Strategy provides the framework to enable SCFT to deliver excellent care in the community exploiting the benefits of digital technology for all patients, staff and across partners. Digital technology will be a key enabler in strengthening community services and supporting people in their community to achieve better health care outcomes following national guidance and supporting local digital roadmaps.

The importance of Community Services and its future role has been recently highlighted by the King’s Fund Report Reimagining Community Services ( 2018) and NHS Providers’ publication NHS Community Services: Taking Centre Stage (2018).

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Regional Digital Agenda Our Digital Strategy forms a key part of a wider geographical digital agenda that spans the Sussex and East Surrey Sustainability and Transformation Partnership (STP) and includes health and social care providers.

The Local Digital Roadmap is the digital strategy for the STP and sets out how we will develop paperless working for the NHS and social care across Sussex and East Surrey by 2020. It also describes how we will enable the development of additional services through the use of digital technologies.

The local digital roadmap recognises the importance of collaborating across organisations and in particular of taking the workforce on the journey of using digital technology and designing new models of care with digital technology in order to transform services and to realise the benefits of digital.

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Our digital Story so far Key achievements using digital ways of working As an organisation we have always invested in digital technology and in addition to the traditional delivery of hardware (e.g. PCs, laptops) and software (e.g. patient management systems, email) we have been at the forefront of using digital to innovate – supporting enthusiastic staff to make their ideas happen. Here are some examples of these:

Time To Talk – using a combination of face to face and online consultations has offered patients the option of a safe online consultation to talk for those who prefer it. Patients are given the option to use an online consultation after an in-depth assessment thus ensuring the right options for each patient. This has resulted in outstanding results for patients with more patients being able to access the service at the same time.

Guest Wi-Fi – All our patients and their families, carers, friends and visitors have access to free Wi-Fi to stay connected with friends, their community, news etc. Of course, Wi-Fi is also accessible to everyone else who visits us in our buildings which has also been taken up by volunteers who offer advice and support to our community hospital patients supporting them for the time after hospital by using information on the internet about social care providers, community groups or even online shopping!

Reducing Delayed Transfers of care - We did not have a system to manage our community hospital beds and patients so we created one ourselves! It proved to be absolutely vital in demanding times such as winter to enable clinicians to manage patient flow with other health and care providers. In combination with our business intelligence Platform we are providing real-time access to patient data across our 11 community hospitals which supports better demand and capacity planning.

Enabling better caseload management for community nurses – Our business intelligence platform links to our electronic health care system and can therefore provide operational data in one place that enables community nursing teams to manage their workload and ensures patients are seen on time.

Docobo – Using this technology enabled care service to reach out to care homes which enables them to reduce admissions to acute hospitals and helps patients to stay in their preferred place of care.

Joined up workforce management processes – with an electronic roster system in place, allocating health care professionals to the relevant shifts has become accessible at the click of (a few) buttons. Our staff can also access their wage slips, personal information etc. securely online which helps reducing postal costs and increases data accuracy.

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Flexible working – we have enabled flexible and remote working for our staff through the provision of laptops, an easy to access secure VPN connection to our documents and a flexible workforce policy. This is a key focus of the digital strategy and plans are in place to make flexible working as smooth and easy as possible.

Engagement via social media – our communication and engagement team uses social media extensively to keep in touch with the public but also with our staff.

Keeping our digital infrastructure and patient’s data safe against cyber security attacks – our dedicated and knowledgeable in house IT team ensures personal data is kept safe and secure by diligently looking after our IT systems and IT security applications.

Digital Health Record – an ambitious programme that has already delivered the electronic health record management system to many teams across the organisation. It has already provided many benefits and is certainly one of the key foundations to deliver this strategy. The roll-out continues!

Text messaging for dental appointments for autistic children and their parents/carers – designed based on feedback from parents and carers, we trialled a text messaging service that would send a message when the dentist was ready to see the child – eliminating waiting times in a stressful waiting room environment and enabling autistic children to wait outside or in the car where they felt more comfortable.

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The future – what we will focus on Outcomes enabled by the Digital Strategy Digital has become part of everyone’s lives and it has changed the way we use and access information, how we connect with each other, how we do shopping, learn and understand the world.

Digital technology will continue to accelerate information analysis and create new opportunities for making people’s lives richer, easier but also more complex. The digital world is not black and white and offers so many options that sometimes it is difficult to decide what to change or invest in. It is therefore important to be clear about the focus of using digital technology and defining what we mean by digital ways of working.

With endless options available which could require considerable funding, we wanted to ensure that we make digital investments and changes wisely and build on existing capabilities, ideas and evidence ultimately contributing to improved patients’ lives.

We listened to patients, we engaged with our health and care professionals, our corporate support staff, technology professionals, operational managers, commissioners and our board members. We also reviewed what is already being used by other healthcare providers and what their experiences are. We used learning from the NHS Digital Academy and will continue to use all of the channels to further shape and monitor the delivery of the Digital Strategy.

The outcome has been clear, ‘Digital ways of working’ will always be an enabler; in itself digital cannot deliver excellent care. But it is important to have a workforce which understands what digital ways of working can mean – this is key to release the ideas and commitment from almost 5,000 staff. Digital is something we all can do, use, change and implement. We will therefore focus on these four Digital Outcomes supporting and enabling each other:

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Digital Guiding Principles and Priorities – our digital building blocks In order to achieve the four outcomes set out in the previous chapter, we need to put in place the underpinning cultural, architectural and information guiding principles and priorities for the effective use of data, innovative digital technology and technology enabled care services.

These will form our building blocks for embedding digital ways of working and its benefits across the organisation. Some of these building blocks will require specific technical expertise and knowledge which can be delivered by the Informatics department but the majority of our building blocks are relevant to every member of staff, whether they work at the front line with patients, manage operational services or work within our supporting services.

Our Digital Guiding Principles and Priorities can be used by every member of staff to identify current gaps and future opportunities within their services. This is a huge journey we have to make and we can only truly release the benefits of what the digital age offers us if everyone becomes a digital champion in the work and care space.

Digital Guiding Principles and Priorities Our Digital Building Blocks

We work digitally as an organisation

We use data intelligently

to design, deliver and review our services

Patient information is

electronically available anywhere, anytime

Personal and care information is up to date,

accurate and kept safe and secure

We enhance digital ways of working and maximise the use of

data and digital technology available to

us to create an excellent care and working

environment

Business intelligence supports operational and

strategic decision-making in a timely manner and where

possible, in real- time

Real-time date and information from health

and care records is available to those who

need it, when they need it, wherever they are, in a

secure and safe way

We will keep personal information and related

care information up to date and accurate which is

important for good patient care planning

We embed technology enabled care services

(TECs) wherever possible

We use digital resources

wisely

We will maximise in-house digital expertise

Our digital strategy

supports the wider STP Digital Roadmap

Using TECS we provide patients with more independence and

increase their ability to manage their health

conditions whilst TECS support continuous care

improvement

We develop and use good digital

housekeeping rules for procuring and

maintaining digital technology to maximise the benefits at minimal

costs

We provide in-house analytical, digital and

technological expertise to minimise reliance and

dependency on external providers

We engage and work in partnership with

commissioners and health & social care providers

across the STP to shape and deliver the Local

Digital Roadmap.

In the next chapter, we provide details on what these principles and priorities mean and what activities we have already identified to deliver against them.

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What will be different in the future For patients

There are numerous benefits of using data, digital technology and technology enabled care services. Some benefits are not related to directly using digital technology, so it is not all about internet, apps and smartphones.

With the emphasis on empowering all of our staff to be innovative with digital solutions, we expect a multitude of health care and patient experience improvements; some will be very specific for specific conditions or patient groups with particular needs. We therefore have concentrated on generic benefits to all patients in our graphic below to show some examples of what it can look and feel as a patient in five years.

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For our staff Our staff were quite modest when we asked what a day would look like with digital being part of everything. Key messages were being able to work remotely and flexibly with access to better communication tools and to relevant data for decision-making. We thought they need more than that and have added some of the outputs from our deliverables into the graphic below:

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Benefits for patients and staff Better digital communication across our workforce and between patients and staff across the health system is wide-reaching and will have a positive impact on all sorts of occasions. The graphic below shows some of the multitude of situations that will be addressed through better digital communication, engagement and interaction.

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The plan – how we will do this Delivering the Strategy over the next three years Over the next chapters we have described against each of our eight digital priorities and principles what they mean to us in the context of the services we deliver. Following this, we have listed some of the deliverables that will ensure we are achieving our ambition. A number of activities will develop over time but they will all need to align to our digital priorities and principles so that we can funnel precious resources and work towards a common goal.

(1) We work digitally as an organisation

We work digitally as an organisation

We embrace digital ways of working and maximise the use of data and digital technology available to us to create an excellent care and

working environment.

What this means

We recognise that ‘digital and data’ has often been seen as the domain of the Informatics team – and this inhibited ownership of the digital agenda across the organisation. Our Digital Strategy now empowers and encourages everyone in our organisation to step forward and to make the most of data, digital technologies and technology enabled care services.

We will focus in particular on building our workforce capability and strengthening clinical leadership in thinking digital as we recognise that leadership and workforce development in digital skills and capability will underpin the successful design, uptake and use of digital technology. Even with the right technology in place, we need to collectively drive the use of data in day-to-day and strategic decision-making, intelligently redesign processes to gain advantages from digital capabilities and pro-actively seek new digital solutions to make this strategy a success.

Due to digital technology, communication and engagement with each other has completely changed and we need to make use of this technology to support our workforce and the interactions between patients and health care professionals. Remote and lone working is very common in our services, with the majority of our health care professionals visiting patients in their homes or in community settings spread across Sussex and Brighton & Hove most of their time. In addition, we work closely with other health and care providers for example in our Communities of practice, to provide a seamless patient experience across services. They all have a need for better digital communication channels and ensuring the patient experiences health and care services as one, being delivered on time and at high quality.

Electronic prescribing and electronic pharmacy services are in use widely across the health care system and our patients and staff should benefit from its advantages. Electronic pharmacy and prescribing supports the ordering, prescribing, dispensing and administration of medicines. With formulary management and automatic recording of prescription it is an artificial intelligence that will support our clinicians to prescribe the right medicines in the right doses and in the right combination. It will also provide better auditing mechanism which can be used in training and research.

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Facilitating better digital communications across our workforce and between patients and staff across the health system is important for a number of reasons, it also enables our Clinical Care Strategy aim of ensuring that care is delivered by the right person at the right time, that we communicate with people about their care and we plan our visits around the person’s needs. We will provide a named staff member as point of contact and we will ensure our care is coordinated in partnership with the person and their carer.”

A key deliverable will be to provide staff with the ability to connect easily via phone, text, IM or video with each other.

In addition, providing patients with access to their electronic health care record empowers them to have a more informed conversation with their health care professionals to shape their health care plan (see also next chapter on ‘Patient information is electronically available anywhere, anytime’).

We will achieve this by

• Strengthening the flexible and remote working facilities and functions for our workforce, including

o The replacement of 1,000 mobile phones with smartphones

o The introduction of virtual desktop infrastructure (VDI) technology and the replacement of desktop PCs with ThinClient devices to allow for fast log in / log off for clinical staff when using the same computer

o Trialling out Skype for Business for video and conference calls and IM

o Supporting volunteers in our in bed units with tablets to support patients in their life planning

• Developing and implementing a Communication and Engagement strategy that embraces digital in all aspects to ensure patients and staff feel informed and have the ability to engage in a meaningful way and can contribute to service improvement.

• Considering the impact every digital project may have on those with protected characteristics to ensure we enhance quality of life and provide suitable alternatives or amendments if patients do not have the ability or digital infrastructure available to use digital technology.

• Making access to our services straight forward by introducing a single point of access system so that referrals to all our services will be managed electronically through this single point of access.

• Creating the functionality to integrate systems with each other across the trust to enable a better view of a patient’s journey for clinicians and for service improvement activities.

• Using technology in innovative ways to improve operational productivity, e.g. patients receive telephone or virtual follow ups; automated appointment reminders; paper-free environment, using Artificial Intelligence to support travel and appointment planning in the community

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• Developing and implementing a mobile device policy that moves us towards a smarter way of using mobile devices including an approved app centre.

• Encouraging and supporting clinical staff to develop digital trials with academic or commercial research partners.

• Developing a roadmap for becoming a paper-free organisation

• Forecasting and modelling demand and capacity for operational planning

• Using all functionalities of our electronic staff record system (ESR) to maximise accessibility, user-friendliness, compliance and to contribute to the paper-free goal

• Demand and capacity – waiting lists

• Server updates, what is currently on the roadmap (thinclient, VDI, mobile devices)

• Pictures on phones from patients straight to s1

• Using artificial intelligence (AI) to support staff with complex tasks that are based on algorithms that need a large amount of data, for example, electronic travel planner to maximise efficient route planning or the use of digital technology to scan wounds and make suggestions for appropriate wound dressings and long-term care procedures

• Implementing electronic prescribing and electronic pharmacy services to increase patient safety and optimal use of pharmaceutical resources

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(2) We use data intelligently to design, deliver and review our services

We use data intelligently to design, deliver and review our services.

Business Intelligence supports operational and strategic decision-marking in a timely manner and where possible in real-time.

What this means

We are data-rich and insight-poor. Most organisations face this dilemma in the digital age and so do we. We are all collecting huge amounts of data, we are having access to even more external data and yet, decision-makers find it difficult to understand what the data is telling them. The current NHS system that emphasises market choice of providers requires strict contract management by Commissioners. As a consequence, lists of so called Key Performance Indicators (KPIs) have been created to monitor the delivery of the contract – a process that consumes large amounts of human and technical resources but has – so far – only delivered limited insights into what good service delivery means. It also does not support clinicians and operational health care staff with insights on waiting lists, caseloads, patient cohorts, barriers to good patient flow through the health system and quality standards.

There is a huge opportunity in a data-rich world for analytics professionals to influence business and society and to improve impact and value of services. We will use this opportunity and make a big step towards using a different approach to traditional performance monitoring and instead will embed a data-storytelling approach that brings the messages that lie within our data to life, for our teams at the front line and for those who manage our services strategically.

There are two objectives for collecting and using data, one is to support individual health care planning and monitoring and the second is the continuous improvement of service delivery. Both objectives are covered in this strategy. The latter will require our in-house team to become the ‘voice of the patient’, advocating high quality, efficiency and effectiveness of our services and pro-actively identifying areas of improvement. This will require a new operating model for our performance and business intelligence team, different analytical skills, and a new contract management approach with Commissioners. Our architectural housekeeping rules (see below) will be crucial to enable this transformation.


• Creating a demand and capacity function that supports effective waiting list management, caseload management and minimises delayed transfers of care within our in bed units and in our community services

• Providing easy and comprehensive access to operational information with the ability to drill down, creating one version for operational and strategic use.

• Making operational data available in real time.

• Development of ‘ImpactChallenge’ projects – using data and patient pathway mapping to understand the patient’s experience and service productivity.

• Creating an Insight and Performance team based on operational and strategic needs that supports decision-making and drives service improvement for the patient.

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• Changing the linkage of operational activity data from cost centres to operational teams to enable better performance management.

• Continuing to report on data quality to increase the focus on improving our data.

• Integrating all our patient management systems to create the patient pathway story across services including the development of a data model.

• Working pro-actively with Commissioners to design contract management arrangements that focus on monitoring of patient pathways and patient outcome information instead of monitoring pure activity data.

• Establishing close working and training arrangements with CCG performance analysts.

• Establishing a Data Analytical Network to enable better knowledge exchange and personal support between the central analytical team and analytical support staff based in the services.

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(3) Patient information is electronically available anywhere, anytime

Patient information is electronically available

anywhere, anytime

Real-time data and information from health and care records is available to those who need it, when they need it, wherever they

are, in a secure and safe way.

What this means

A fully integrated Digital Health Record ensures that all information relating to the care of an individual is accessible by those needing to care for that person. This is in many cases the foundation for enabling other aspects of the Digital Strategy and for developing personalised care services within our organisation and with other health and care service providers.

The components of an electronic record include:

• Summary Record

• Access to Order Communications and diagnostics reporting

• Scheduling and referral management

• e-prescribing

• electronic document management

• Electronic health records support remote care.

A digital health record will enable us to become paper-free at the point of care as set out by NHS England in The Forward View into action: Paper-free at the point of care.


• Continuing the roll-out of the Digital Health Record Programme and making the most of this information management resource for improving health care delivery.

• Enabling the patient to access their health care record and their health care plans electronically (personal health care record).

• Establishing e-prescribing and e-pharmacy systems to improve quality and efficiency of medicine management.

• Investigating the options for providing patients with digital devices such as wristbands that can contain their electronic health record, medicine management, appointments with health and care providers etc.

• Establishing a Single Point of Access for referrals to our services.

• Maximising the use of mobile devices and introducing ThinClient devices to provide staff with flexible access to health records while out in the community or working flexibly from health settings.

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(4) We embed technology enabled care services (TECS) wherever possible

We embed technology enable care services

(TECS) wherever possible

Using TECS provide patients with more indepence and increase their ability to manage their health conditions whilst TECS support

continuous care improvement

What this means

Technology Enabled Care Services (TECS). TECS involve the use of technology to enhance care by capturing and sharing information in new ways. TECS aim to deliver better outcomes for patients by maximising the value of technologies that enable better communication between the patient, their carers and their care team – this includes health and social care teams. These technologies include:

We are already using TECS in various services and patients have provided very positive feedback as have our health care professionals. We want to make more use of TECS and will encourage our clinicians to investigate where this can be introduced.


• Working with our health and care partners, our clinicians will identify new opportunities for TECS application in our services to improve care quality and care experience.

• Creating a Digital Forum and actively sharing good examples of current or planned use of TECS in our services or to learn from others.

• Encouraging patients to make use of NHS approved health care apps to support prevention and self-management (if appropriate).

• Establishing good digital housekeeping rules to ensure TECS and the information

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gathered are used appropriately.

• Working closely with social care services to explore opportunities for joint use of TECS where people have social and health care needs.

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(5) We keep personal and care information up to date, accurate, safe and secure.

Personal and care information is up to date, accurate and kept safe

and secure

We will keep personal information and related care information up to date and accurate which is important for good patient care planning.

What this means:

Personal and health care information is one of the key foundation stones for high quality care. Patients expect that data relevant to them is being captured and maintained at a high standard so that their needs are being addressed appropriately. This becomes particularly important when care is carried out over a period of time or when several services are involved in the patient’s health care.

High data quality is also crucial for evidence based decision-making, whether this is to prioritise patients or to review and evaluate the service provision. Therefore data is one of our most important assets for planning and delivering the right care at the right time. If data is of poor quality, decisions will be poor as well which can have a negative impact on patient experience and patient care, staff workload and on the health of the organisation as a whole. 4

We have good processes in place to capture patient and operational data electronically; we will now focus on entering data right first time and ensure data is complete, consistent, accurate, valid and captured in a timely manner.

We already have good procedures and policies in place to ensure data and information is kept secure, e.g. Information Governance and Cyber Security, however, some areas are not so well covered and will need to be addressed.


• Developing and implementing a Data Quality Policy

• Developing and implementing an Information Governance Strategy

• Eliminating processes that have led to maintenance of spreadsheets and other databases that are not acknowledged as the digital health record for the service

• Establishing an Information and IT Asset Register to manage information and IT assets centrally – operationally and financially

• Identification and maintenance of Information, IT and Cyber Security Risks

• Board level leadership on Cyber Security

• Development of ongoing Data & Cyber Security awareness training

• Creation of a Cyber and Data Security role to establish strong data and cyber security protection processes and to lead and implement the above deliverables on cyber

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security.

• Ensuring unsupported systems are being replaced or upgraded or measures are being put in place to ensure our cyber security measures are not compromised by unsupported systems

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(6) We use digital resources wisely

We use digital resources wisely

We develop and use good digital housekeeping rules for procuring and maintaining digital technology to maximise the benefits at

minimal costs

What this means:

Digital Technology is expensive and it is important that relevant costs are matched by excellent outcomes for patients. There is a danger to become technology-obsessed and to aim for the latest releases and innovations. We must therefore ensure we assess any digital needs appropriately and seek best practice and comparisons from other organisations and aim for collaboration before procuring new digital technology.

Once digital technology is in place, it needs to be customised, used, connected and maintained appropriately. This relates to how we enter, store, share, archive and delete data to ensure we make our data useful, accessible and safe.

We must also not assume that information technology consists of endless capacity, capability and resilience. Sensible use of storage and requests to system changes will prolong the lifetime of our information technology.


• Establishing an IT Asset Register and centralising IT related budgets ensuring that we have a long-term view of IT assets’ performance and replacement cycle manage

• Identification and monitoring of IT and Cyber Security Risks

• Leading from Executive Director level on Cyber Security

• Development of ongoing Data & Cyber Security awareness training

• Development of procurement principles for large and/or complex digital platforms or contracts

• Developing and implementing a set of ‘good digital housekeeping rules’, including

o Archiving and Retention Policy

o Records Management Policy

o IT System Change and Customisation Policy

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(7) We will maximise in-house digital expertise

We will maximise in-house digital expertise.

We provide in-house analytical, digital and technological expertise to minimise reliance and dependency on external providers.

What this means

With digital thinking promoted across the organisation in our first principle ‘We work digitally across the organisation’, it is imperative to rely on all staff when it comes to innovative ideas for using and working with data and technology. However, we will need specialist technical expertise. Over the last decade, public services have gone through various models of providing a digital function for their organisation. Outsourcing the IT function has been seen by many as the solution to the ever increasing infrastructure costs but outsourcing has often been paid with restricted abilities to innovate, customise or to produce cheaper, bespoke solutions.

We have established an excellent IT function over the last years that has provided the organisation with the ability to support staff with day to day IT issues, develop and implement long-term solutions. Our internal Informatics function has also established an in-house delivery team for the implementation of the electronic health record system thus saving the organisation considerable costs on external consultancy.

The provision of an in-house Informatics function (IT and Analytics) will increase our ability to embed digital thinking while making us independent on market dominating providers and their support.


• Encouraging in particular clinical staff to develop and use digital knowledge and skills through appraisals and personal development objectives.

• Creating a Digital Forum four times a year, a conference type knowledge and idea sharing forum for all staff to share in-house practical digital examples, new developments and ideas for future service improvements as well as hearing from external experts and clinicians.

• Strengthening the in-house IT function; bringing the remaining outsourced IT Support team in house to have a 360° IT systems and maintenance support.

• Developing and maintaining a strategic IT Roadmap for the Trust to act as a common asset for all staff to contribute to thus enabling networking and sharing of learning around any digital projects, small and big.

• Creation of a Data Analytical Network.

• Development and publication of an IT training course catalogue with training provided by our in-house IT training team and available, approved external training.

• Providing support for local digital projects in our services through access to central IT and analytical advice.

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(8) Our Digital Strategy supports the wider STP Digital Roadmap.

Our Digital Strategy supports the wider STP

Digital Roadmap

We engage and work in partnership with Commisioners and health & social care providers across the STP to shape and deliver the

Local Digital Roadmap.

What this means

We do not work in isolation. The tools and systems we use in one organisation will need to link with those being used in other organisations in health and social care. This is often referred to as interoperability. Our patients and staff span care boundaries. Illness does not recognise borders and care boundaries. To combat it, we need to work beyond the borders of our estate by collaborating with others.

Our Digital Strategy forms a key part of the Local Digital Roadmap for the wider health and social care system in Sussex and East Surrey matching the local Sustainability and Transformation Partnership (STP) geography.

The programme is structured into five domains which are (a) Exploiting Existing Technology, (b) Shared Health and Care Information, (c) Analytics, (d) Service Redesign and Citizen.

The local digital roadmap recognises the importance of collaborating across organisations and in particular of taking the workforce on the journey of using digital technology and designing new models of care with digital technology in order to transform services and to realise the benefits of digital.

The priorities set out in our Digital Strategy are directly supporting the five domains as set out in the Local Digital Roadmap. They will also enable a better system-wide management of patient journeys and a better understanding of overall service demand and capacity through the effective and intelligent use of data which will be central for managing demanding times such as winter.

There are clear benefits for us as an organisation as for the wider health and care system to work towards data and system interoperability and access to data for analysis and planning. Community Service providers have recently been described as the key solution to the health care crisis on a national level5,6. It is therefore paramount that we influence and shape the overarching STP Digital Programme going forward.


• We will focus on good partnership working to enable and support the achievement of outcomes that are beyond individual organisation’s control. It will also be important to use evidence and keep a clear focus on overarching outcomes.

• We will actively engage in and influence the STP Digital Programme design and delivery to focus on better outcomes for the whole health and care system.

• We will champion the investment of system-wide funding to benefit all people in the area.

• We will pro-actively use our evidence to discuss and shape system-wide outcomes with

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Commissioners.

• We will support nursing and residential homes to become a more integrated part of the health and social care community Our current electronic health record system is also available to Nursing and residential homes at no charge, where homes do not chose to deploy the system in full, we will encourage them to use a minimised version of it that enables the viewing of the record.

Key challenges We are aware that such wide variety of changes will face challenges. However, the key risk for us as an organisation would be not to progress with our digital ambitions and just sticking to a traditional way of IT delivery.

The key challenges we face in delivering our Digital Strategy are

Challenge Mitigations

Engagement of staff in the

ownership of the digital

agenda

Using digital champions in the organisation

Creation of digital forum and other networks

Better access to meaningful data and insights, training

Access to central IT support for local digital projects

Funding limitations Accessing central government funds and STP wide project funds for

digital projects

Technical system barriers Agile system design for future interoperability assurance

In-house IT function to provide expertise on technical systems

In-house ability to develop IT systems for specific needs or for trials to

minimise the reliance on external IT providers and their IT support

Adhering to standardised use of external IT systems to minimise

customisations that have a high degree of support reliance

Alignment with STP wide system development

Skills and human resource

limitations

Accessing the wider public sector and higher education sector to learn

from others or to use external skills that work not for profit

Holding low cost ‘hack days’ to develop own bespoke solutions with

external specialist expertise

Foster partnership working with other analytical teams in the STP

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Oversight of Delivery – Governance structure The oversight of progress made against the Digital Strategy’s principles and priorities will happen on various levels to ensure operational and strategic scrutiny and assurance but ultimately will be presented to our Board and scrutinised by the Finance & Investment Committee

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References

1 Dorner, Karl and Edelman, David (2015) – What ‘digital’ really means. McKinsey publications online.

2 Clinical Care Strategy 2014-19. Excellent Care at the Heart of the Community (2014) – Sussex Community NHS Foundation Trust. Online publication https://www.sussexcommunity.nhs.uk/downloads/about-us/trust-reports/strategies/2015/clinical-care-strategy.pdf

3 POPPI and PANSI Population projections, www.poppi.org.uk, www.pansi.org.uk

4 Redman, Thomas C. (December 2013). Data Driven: Profiting from Your Most Important Business Asset. Harvard Business Press. ISBN 978-1-4221-6364-1.

5 NHS Providers (2018): NHS Community Services: taking centre stage. Online publication http://nhsproviders.org/state-of-the-provider-sector-05-18

6 The King’s Fund (2018): Reimagining community services. Making the most of our assets. Online publication https://www.kingsfund.org.uk/publications/community-services-assets

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Digital Strategy Team Contribution – Informatics Team 3 key improvements we will deliver this year to enable digital ways of working across the organisation. Our Digital Strategy shows that digital is a way of thinking and working differently, using data, digital technology and technology enabled care for the benefit of the patient. We all have a role to play in becoming an organisation that thinks ‘digital’.

As the in house IT team we focus on providing the digital infrastructure for our Trust. This year we will be doing a lot in the background to keep us safe against cyber-crime and to ensure our servers are not running out of space or stopping to work.

We have also exciting projects coming that will see staff being more mobile, better connected and able to access relevant information more quickly electronically.

Here are our three highlights:

Mobile Phones

We will replace around 1,000 out of date mobile phones for frontline community staff.

Fast PCs

We will replace desktop PCs in key clinical areas with a lean version, called ThinClient,that will massively reduce log on times and will run much faster. Which means several members of staff in your team can quickly log in and out of the same PC!

Digital Health Record

More services will move over to SystmOne and will be able to use one digital health record across different services.

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Digital Strategy – We want to hear from all staff! Our Digital Strategy shows that digital is a way of thinking and working differently, using

data, digital technology and technology enabled care for the benefit of the patient. ‘Digital

ways of working’ will always be an enabler; in itself digital cannot deliver excellent care.

Digital is something we all can do, use, change and implement. Our Digital Strategy focuses

on these four Digital Outcomes to ultimately improve patients’ health and well-being and

their care experience.

Share your team’s initiatives, ideas and projects that are using data or digital technology or

technology enabled care services that link into the above outcomes here:

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Agenda Item: 15

Report Title: Annual Health and Safety Report 2017/2018

Purpose:

Approval Assurance ✓ Discussion Briefing

Summary: This report outlines the Trust’s health and safety performance during 2017/18 and improvements planned for 2018/19. The key points from the report include:

• An increase in health and safety incident reporting (from 1109 in 2016-17 to 1247), can be attributed to an increase in ‘low’ and ‘no-harm’ incidents, indicating improved reporting. While the number of incidents with ‘moderate’ or higher levels of harm have reduced from 30 to 15. The improved levels of reporting can be attributed to the triaging of incidents to ensure that the levels of harm are accurate, and raising awareness of incident reporting on the annual statutory training.

• Benchmarking the number of incidents reported under RIDDOR with other healthcare organisations, has shown pro-rota for the number of staff in SCFT there are less reportable accidents lower than other organisations.

• The report identified several areas of priority and actions for the Health and Safety Committee. These areas include verbal and physical abuse, moving and handling, ‘Slips, trips and falls’, and unsafe environments.

• Planned improvements for 2018/19 include: o Reviewing the current use of lone worker devices and investigate future

options/devices available on the marketplace. o Working with Education & Training, to book new starters at each Induction

day onto mandatory training courses. o Providing dual moving and handling, and resuscitation training courses in

each Area, every month, to improve training compliance. o Monitoring the outcomes from local health and safety inspections to identify

and escalate any issues before they become risks.

Previously reviewed by: The report has been approved by the Health and Safety Committee

Recommendation: The board is asked to acknowledge the work undertaken to improve health and safety management, and to endorse the recommendations for further improvement.


• Safe – Good health and safety practice supporting a safe working environment for our staff and patients.

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• Well led – Understanding of health and safety requirements is an important part of

effective leadership.

Relevance to Trust’s Strategic Goals: We will provide excellent care every time to reinforce wellbeing and independence.

Equality and Diversity (Has an equality impact assessment been carried out on the report

contents and is it considered that there may be E&D implications?):


• Impact: No adverse impact on equality and diversity has been identified

Report author: Mark Plows Safety & Risk Lead

Report owner (lead Executive Director): Susan Marshall Executive Chief Nurse

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Sussex Community NHS Foundation Trust – Annual Health and Safety Report 2017/18

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Annual Health and Safety Report 2017/2018

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Reader Box

Description Report on the Trust’s health and safety performance over the fiscal year 2017/2018. Detailing: any significant changes in the management of health and safety; comparing incidents and training data with previous years; and setting out plans for 2018/19.

Date published July 2018

Date due for review July 2019

Executive Lead Susan Marshall, Executive Chief Nurse

Author Mark Plows, Safety & Risk Manager Steve Tancock, Head of Fire & Security

Contact details Brighton General Hospital, Elm Grove, Brighton, BN2 3EW.

Primary audience Trust Board


Senior managers

Notes Each quarter reports on the Trust’s performance are submitted and reviewed by the Health and Safety Committee. The data and outcomes from the quarterly reports have been pulled together for this annual report.

Table of Contents 1. Introduction ................................................................................................................. 3

1.1 Scope of the report .............................................................................................................. 3

2. Report Summary .......................................................................................................... 4 2.1 Health and safety performance in 2017/18 ........................................................................... 4 2.2 Changes to legislation .......................................................................................................... 6

3. Management of Health and Safety................................................................................ 7 3.1 Quality Governance ............................................................................................................. 7 4. Estates Department ................................................................................................................. 8 4.1 Governance Structure .......................................................................................................... 8

5. Current Compliance ...................................................................................................... 9 5.1 Monitoring compliance and effectiveness ............................................................................. 9 5.2 Monitoring accident and incident data ............................................................................... 10 5.3 Reporting of Injuries Diseases and Dangerous Occurrences Regulations .............................. 21 5.4 Training ............................................................................................................................. 22

6. Next steps .................................................................................................................. 28

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1. Introduction The purpose of this report is to provide assurance to the Board with an overview of the Trust’s activities relating to health and safety compliance. The Trust is committed to the prevention of injury and ill health to all staff, patients and visitors, by promoting a safe environment and developing a positive pro-active culture by achieving the following objectives.

• Internal reporting mechanisms; incident investigations, health and safety groups/committees, audits, and inspections identify opportunities to develop and improve the management of health and safety.

• The continuous monitoring and review of risk assessments to ensure they remain relevant, improve and are freely available to those who require them.

• Information, instruction and training on risks and control measures in the workplace is provided to all our employees.

• The Trust provides and maintains suitable environments and facilities for staff, patients and visitors.

• Compliance with health and safety legislation and Trust policy.

1.1 Scope of the report This report describes the Trust's actions and achievements relating to the management of health and safety and is primarily concerned with non-clinical health and safety issues that affect staff, patients and visitors. Clinical related patient incidents are reported separately to the Trust Wide Governance Group (TWGG) with assurance provided to the Quality Committee.

This report details the Trust's health and safety performance throughout 2017/18, in order to comply with the Health and Safety at Work Act 1974 and associated statutory regulations, with particular reference to:

• Health and Safety

• Fire Safety

• Ionising Radiation

• Moving and Handling

• Occupational Health

• Staff Security

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2. Report Summary 2.1 Health and safety performance in 2017/18 During 2017/18 there were 1247 health and safety related incidents reported on Datix, compared to 1109 incidents in 2016/17, 835 in 2015/16, and 864 in 2014/15. The Health and Safety Committee continue to monitor incident reporting and the current increases have been attributed to the introduction of Datix on 5th July 2016, which is easier for reporters to use, highlights specific data for investigation and is simpler for managers to interpret incident data for trend analysis and assurance reporting. This upward increase in incident reporting continues an upward trend, which was noted in the previous annual report, and is an indicator of good reporting levels. During the reporting period there were a total of 15 incidents reported to the Health and Safety Executive (HSE) under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR). This is less than the previous year (17 in 2016/17) and consistent with other years (14 in 2015/16 and 16 in 2014/15). There are no obvious trends and details of every reported incident are reported at the quarterly Health and Safety Committee meetings.

2.1.1 Improvement initiatives during 2017/18

• Fire: Identified correct fire compartmentation throughout Sussex Community NHS Foundation Trust (SCFT) owned premises via a capital project; working with other agencies to improve the fire safety measures in accommodation leased or rented as an occupier.

• Security: Improvements included upgrading the CCTV systems at Central Clinic Worthing and Portslade Health Centre. Access control systems were also updated at Central Clinic Worthing and 3rd Floor J Block

• Sharps safety: In conjunction with infection control a sharps supplier event was organised at Horsham Hospital to instruct and train new community staff on the safe use of safer sharp devices. The event was opened up to other teams/services and was positively received by the staff who attended. The Health & Safety (H&S) team continue to work with Procurement to review any new purchase requests to ensure that the Trusts continues to remain complaint with the associated Sharps regulations.

• Risk Assessments: Following the introduction of the ‘Procedure for the Management and Transfer of Patients Experiencing Mental Health Crisis’ the H&S team have liaised with the Area Nurses and Minor Injury Units (MIU)/ Urgent Treatment Centres (UTC) to provide training and support on undertaking ligature risk assessments, so that if/when mental health patients present themselves at SCFT services, the Trust is protecting staff and patient safety.

• Bariatric inpatients: in conjunction with Fire Safety and the Area Nurses the processes for caring for and managing bariatric patients in in-patient services were reviewed and a range of measures implemented to ensure appropriate handling and emergency evacuation equipment is available when and where required.

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• Ionising radiation: the Trust re-registered all the services using x-ray equipment, with the HSE, when new ionising radiation regulations were introduced in January 2018.

• Medical Gas Training: working with Medicines Management and Education & Training, the H&S team assessed the requirements for medical gas training, ensuring that sufficient courses are provide, in the right areas, across 2018/19 to ensure compliance.

• Patient handling training: in April 2018 a specific paper went to the Health and Safety Committee, analysing the Trust’s compliance levels and setting out a pathway to the Trust’s 90% target. In 2018/19 the H&S team will be liaising with Education to implement the recommendations.

The H&S team’s work during 2017/18 to address staff training compliance has included:

o Contacting all managers, with staff who are out of date with their training, to advise of upcoming training.

o Reviewing the number of staff who will require training (up to 6 months ahead), to ensure the location and number of courses can adapt to meet demand.

o Forward planning of future courses, up to 16 months in-advance, so that staff can book onto courses before their training lapses

o Providing bespoke training courses for remote sites (e.g. Midhurst Hospital) and departments (e.g. Chailey Clinical Services, Podiatry and Child Development Centres),

o Liaising with Services, so that where roles have changed and individuals no longer require training, the performance team is updated to ensure accurate compliance reporting.

• Moving and handling inpatient support: To support inpatient services during winter months (2017), the Lead for moving and handling spent time on each of the in-patient wards in the Trust to provide: hands-on advice, instruction and guidance to staff on safe handling techniques and practices.

2.1.2 Planned improvements for 2018/19

Based on the previous planned improvements and health and safety performance for 2017/18, the following improvements are planned for 2018/19.

• Fire risk assessment process is being reviewed and improvements explored via IT solutions, allowing assessments to be carried out on site with the use of the latest tablet technology and web based programs. A number of products are being considered including, end product and usability which will allow for better graphical evidence and final reports, will be key items for consideration.

• Promotional material to reduce verbal abuse and violence aggression in the trust working environment.

• Monitor staff engagement with health and safety, including where staff/services are based on isolated or remote sites, by checking samples of local inspections from all the sites/premises where SCFT staff are based. This will provide assurance that local hazards are being reported or escalated appropriately.

• Support the development of moving & handling link trainers, where appropriate for the local services’ needs, to support training compliance.

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• Support the Medical Device Group with the Project to centralise the medical device inventory and maintenance provider, into one inventory and one provider.

• Monitor the Trust’s medical gas safety training and review the Medical Gas Group’s training risk assessment to provide assurance to the organisation.

• Liaising with Education & Training so that staff can book onto mandatory training during Induction days, speeding up the compliance rate for new starters.

• Planning future mandatory training with resuscitation, so that dual patient handling and resuscitation training days are scheduled in each Area.

• To increase staff awareness of Managing H&S training and encourage attendance the H&S team is looking to contact previous attendees who are due refresher training, following up with staff that did not attend training and promote training with area management teams.

Following the approval of this Annual Report, the Health and Safety Committee will focus on the key findings from this report and incorporate them into the Group’s work plan for 2018/19.

2.2 Changes to legislation During the previous year there have been one minor legislation changes affecting the Trust, and two significant events (i.e. Grenfell Tower and Brexit), which have the potential to affect future legislation.

2.2.1 Ionising Radiation

New Ionising Radiation Regulations came into force on 1st January 2018, replacing the previous 1999 regulations. The legislation affected SCFT services operating x-ray equipment and DEXA scanners. The new regulations required SCFT to re-register with the Health and Safety Executive (HSE). The legislation was reviewed by the Radiation Protection Group, with competent advice and support from the Trust’s appointed Radiation Protection Advisers, and documentation reviewed/updated to reflect the legislative change.

SCFT services with ionising radiation were re-registered on 15th January 2018, ahead of the 5th February 2018 deadline, and the Trust is fully complaint with the new legislation.

2.2.2 Fire Safety

The Grenfell Tower inquiry has put a spot light on a number of fire safety issues however mainly focusing on the quality of fire retardant products used during construction and or refurbishment; changes to legislation will (if implemented) be carefully considered and embraced through the Capital Projects and Estates maintenance and electrical teams. One of the immediate concerns following the fire, was around external cladding and how quickly cladding can cause a fire to spread. Following the Grenfell Tower fire the Trust’s Fire Safety Team checked all SCFT premises for cladding and have confirmed that no SCFT owned or managed sites have external cladding. And that, on sites containing SCFT services, which are managed by other organisations, only Crawley Hospital has external cladding and this is limited to a roof plant room. The roof plant room cladding at Crawley Hospital poses no risk to staff or patient safety, due to it’s location, and the location of the cladding has been highlighted to the landlord/responsible body, NHS Property Services.

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2.2.3 Effects of Brexit on H&S legislation and the healthcare sector

Many of the current health and safety regulations in the United Kingdom (UK) originate from European Union (EU) directives and regulations. In many cases the UK government had input into these EU directives (e.g. EU Sharps Directive) and they have either been transposed directly into UK legislation or are wholly/partly covered by existing legislation. In the UK health and safety legislation is underpinned by the Health and Safety at Work etc Act 1974, which had no input from the EU and legal responsibilities will remain unaffected by Brexit.

One applicable area where Brexit may affect the healthcare sector is the supply of medical devices. Currently most forms of equipment are issued with a Conformité Européene (CE) mark to demonstrate that they meet established safety standards. In the UK CE marks for medical devices are issued via the Medicines and Healthcare Products Regulatory Authority (MHRA). If the UK leaves the EU, this may have an impact on UK manufacturers being able to gain CE certification. The Medical Device Team is monitoring the effects of Brexit and will advise the Trust if there is a direct impact.

3. Management of Health and Safety Responsibilities for the management and implementation of the health and safety arrangements are detailed within the Health and Safety Policy, and associated procedures. The Trust’s health and safety arrangements are supported by the Quality Governance Service and Estates Department, who have specialist leads providing competent advice, training and report on assurance within the governance structure.

3.1 Quality Governance

3.1.1 Health & Safety team (including Moving & Handling)

The Health & Safety (H&S) team is managed by the Safety & Risk Manager, and includes: a Lead, Facilitator, and Moving & Handling Trainer. The team fulfils the role of competent person under the Management of Health and Safety at Work Regulations and provides moving and handling advice and training for staff. The team work alongside Risk, Resuscitation and Medical Devices within the Quality Governance Service. The team provides a range of functions including the following.

• Advice to staff and managers.

• Statutory training for all staff.

• Mandatory training for managers and representatives (e.g. patient handling, health and safety for managers).

• Additional training for staff (e.g. stress management, Display Screen Equipment (DSE), and load handling).

• Undertaking accident investigations.

• Internal health and safety audits.

• Provide reports and analysis on incident figures/trends.

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• Horizon scanning.

• Providing advice and guidance on handling techniques.

4. Estates Department Security (Accredited Security Management Specialists) and Fire Safety functions are integrated with the Estates and Facilities department, reporting to Director of Finance, Estates and Facilities. Security and Fire Safety staff liaise with the H&S team regarding any safety issues affecting Trust employees, patients or visitors.

4.1 Governance Structure

Figure 1. Health and safety governance structure

Figure 1 outlines the governance structure for health and safety within the Trust and below are the key details about the reporting groups.

• The Health and Safety Committee is chaired by the Chief Nurse and meets quarterly. In 2017/18 there were three groups reporting into the Health and Safety Group.

o The Radiation Protection Group is chaired by a Consultant from Special Care Dentistry and meets every six months.

o The Medical Device and Decontamination Group (MDDG) meets every quarter and is chaired by the Medical Director.

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o The Medical Gases Group, a sub-group of the ‘Medicines Safety and Governance Group’, jointly reports to the Health and Safety Committee. The Medical Gas Group is held every 6 months and chaired by the Chief Pharmacist.

Estates related subjects, such as Water Safety and Asbestos, are managed through separate governance arrangements within the Estates and Facilities Division. The Leads from Health & Safety and Medical Devices are invited to these meetings to advise and liaise between different governance groups/committees.

5. Current Compliance 5.1 Monitoring compliance and effectiveness At a local team level, health and safety arrangements are monitored through workplace inspections and compliance is monitored by the H&S team.

The H&S team regularly carry out internal audits, to measure health and safety performance, and ensure the following arrangements are in place.

• Teams and services have the correct documentation in place.

• Significant risks have been appropriately assessed.

• Performance is measured against previous audits.

• Actions from inspections, risk assessments (e.g. DSE, sharps) and previous audits have been successfully completed.

The current three yearly audit schedule started on 1st April 2017 and is on track to finish on 31st March 2020, covering all services and divisions within SCFT. During 2017/18 54 internal audits were completed, including.

• Children and Wellbeing Services.

• Adult services in each Area (i.e. West, East and Central), including:

o Inpatient and outpatient services (including Allied Health Professions)

o Minor Injury Units and Crawley Urgent Treatment Centre

o Responsive and community nursing

• Corporate services.

Following each audit, services are provided with an action plan, guidance and instructions on any recommendations. Where applicable, staff are provided with bespoke training, in addition to the 'Managing Health and Safety’ training courses.

At the end of each audit, teams are scored on their health and safety performance and this is used by the H&S team to identify any services, who may require more frequent audits or follow up visits to support them. During 2017/18:

• 5 teams scored less than 80%.

• 14 teams scored between 80 to 90%.

• 35 teams scored over 90%.

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Where teams scored less than 80%, they are re-visited by the H&S team, to provide additional training and guidance on implementing the audit’s findings.

Any trends from internal audits are reported to the Health and Safety Committee and actions agreed as part of the groups work plan. The following points outline the key areas affecting low scoring teams.

• Regular health and safety inspections of staff and patient areas, to identify hazards and document actions taken.

• Reviews of risk assessments and documentation, to ensure they are kept up to date and remain relevant.

These points typically tend to occur in teams with high staff turnover or where managers are on long term sick leave. In these cases the H&S team use informal visits and communication to keep in contact and provide support.

5.2 Monitoring accident and incident data The Trust uses an online system for reporting and recording incidents, called Datix.

For this report, only the incidents relating to health and safety have been included (e.g. slips & trips, manual handling, sharps, violence). Incidents relating to patient falls have been excluded from this report, as these are reported separately by the Falls Group, who report to the Total Care Steering Group.

Figure 2. Reported health and safety incidents

Each incident is investigated by the applicable line manager and their findings are recorded on Datix.

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When incidents are identified as potentially reportable under the RIDDOR the H&S team carry out additional investigations to verify whether the incident requires further reporting, provide support to the service/team and to identify any corrective or preventative actions.

Figure 2 shows the number of health and safety related incidents reported each month, over the previous three years. During 2017/18 the number of incidents each month has varied. There are no underlying causes for these differences and there is no trend with previous years data.

When compared against the Trust’s vacancy rate (i.e. the percentage of unfilled posts) in Figure 3, there is no apparent collation between the number of incidents and unfilled posts. Over the previous year the vacancy rate has typically declined, while the number of incidents has fluctuated. The vacancy rate was downloaded from the Trust’s information management system ‘Scholar’ on 25th April 2018.

Figure 3. Health and safety incidents compared against vacancy rates

5.2.1 Level of harm

The incident reporting system allows the reporter to rate the level of harm and this gives an indication around the severity of the incident.

In 2017/18 there were:

• 849 ‘No Harm’ incidents (901 in 2016/17 and 614 in 2015/16);

• 396 ‘Low’ harm incidents (178 in 2016/17 and 192 in 2015/16);

• 14 ‘Moderate’ harm incidents (28 in 2016/17 and 25 in 2015/16); and

• 1 ‘Severe’ harm incidents (2 in 2016/17 and 4 in 2015/16).

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Figure 4. The level of harm reported on health and safety incidents

The overall increase in incidents is attributed to improved reporting, where staff are reporting on actual harm, rather than probable harm and this can be seen in the incident data (see Figure 4). The number of Low harm incidents has increased and the number of Moderate incidents decreased. Part of this change has been due to increased triaging of incidents by the Quality Governance Service, checking that the levels of harm assigned to incidents by staff, match the guidance provided in the Trust’s Risk Management Policy.

One ‘Severe’ harm incident was reported under the ‘Abuse, disruptive, aggressive behavior’ following an abuse incident outside of SCFT’s care.

5.2.2 Incident categories

When reporting an incident, the report selects an appropriate category and these are used to determine trends and ensure any/all applicable services or specialist leads are automatically notified. The types of categories selected for health and safety related incidents are displayed in Figure 5. The main causes of health and safety related incidents (e.g. those with more than 50 incidents reported within the year) are shown in Table 1 and compared with the two previous years. The top three causes of incidents remain consistent with previous years (i.e. verbal and physical abuse, and manual handling).

When compared to last year, the number of verbal abuse incidents has increased, while the number of physical abuse incidents has decreased. Part of this change is attributed to incidents being initially incorrectly categorised as physical abuse, when no contact has occurred, and the category being corrected when triaged.

The number of ‘Unsafe environment incidents’ have significantly increased, when compared to other types of accidents. This does not include ‘Unsafe clinical environment’ which is a new category created on Datix and accounted for 37 incidents in 2017/18. This increase can be attributed to anti-social behavior in the area surrounding Tarners Child Development Centre in Morley Street, Brighton, where staff have been documenting incidents affect staff and patients visiting their centre in weekly incident reports (21 incidents reported in 2017/18).

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Figure 5. Graph of the different categories selected for health and safety incidents

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Incident categories 2017/18 2016/17 2015/16

Verbal Abuse - various categories 363 278 190

Physical Abuse - various categories 128 161 67

Moving And Handling - various categories 107 107 120

Unsafe / inappropriate environment 105 66 52

Fall - staff various categories 74 69 74

Medical sharps incidents - various categories 73 89 96

Table 1. Top 6 categories of reported health and safety incidents

5.2.3 Verbal and physical abuse incidents

The verbal and physical abuse incidents are spilt into further categories, according to whom the abuse originated from and who the abuse was directed at (e.g. staff, member of public, patient).

Overall the numbers of incidents being reported by staff have increased and the number of incidents of staff receiving abuse from patients or members of the public, have significantly increased (see figure 6). This is attributed to an increase in incident reporting from bedded units, where individual patients with dementia or other cognitive impairments, can account for several incidents until additional measures are put in place. The range of measures can include a change in medication, supplying additional clinical or security staff. In other areas the security team support staff by issuing warning letters to patients or family members regarding their behavior and provide advice on lone working. The Security Management Teams are continuously scrutinising the incident data to identify any trends and themes, and liaise with managers at different levels to mitigate any risks. Where appropriate, findings are shared with staff and managers. Any themes or lessons learnt from incidents or investigations are incorporated into the Trust’s statutory and mandatory training.

Figure 6. Verbal abuse incidents

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The main types of reported verbal abuse incidents are Patient on Staff (175) and Member of Public on Staff (132) (see Figure 6). Although, the main cause of physical abuse (see Figure 7) has been abuse from patients on staff (88), the number of incidents has reduced from 128 in 2016/17. The decrease has been attributed to improvements in the triaging of incidents.

In order for incidents to be considered as ‘physical abuse’ they should meet the following definition:

“The intentional application of force to the person of another without lawful justification, resulting in physical harm or personal discomfort”

Any incidents incorrectly categorised are triaged and in most cases re-categorised as ‘verbal abuse’ incidents.

Part of the increase in physical and verbal abuse incidents is attributed to an increase in challenging patients; particularly in the Trust’s inpatient services. A Dementia Lead has been appointed and they work closely with the Security Management Team and Estates department to ensure that our inpatient environments are conducive for patients with cognitive difficulties. In services where mental health patients may present themselves (e.g. Minor Injury Units, Urgent Treatment Centres), the H&S team and Area Nurses have been supporting services to ensure suitable risk assessments and protocols for staff to follow are in place.

Figure 7. Physical abuse incidents

The Trust’s Security Management Team follow up each abuse incident to provide support to staff, provide guidance and carry out investigations. The Trust provides and displays NHS Protect posters, titled ‘Your Choice of Treatment’, in waiting room areas to warn against aggression. In cases of physical abuse against SCFT staff; where staff choose to raise charges against a member of the public or patient, they are supported by the Security Management Team.

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The Security Management Team report on abuse incidents to the Health and Safety Committee, providing in-depth incident analysis, horizon scanning and advice on actions or recommendations. The team incorporates any applicable lessons learnt from incidents, into the mandatory and statutory training courses.

Measures in place to protect staff include policies on managing violence and aggression, lone working and general security. The Trust also has a security strategy that the security team produces. Training is also provided in the form of conflict resolution, assault avoidance and disengagement. The team also manages the Skyguard lone working devices that are provided to staff across the county as well as providing the training for the devices.

5.2.4 Moving and handling incidents

Figure 8. Moving and handling incidents

The moving and handling incidents reported on Datix are broken down into further categories (see Figure 8). This shows a reduction in patient injuries from moving & handling activities (from 31 to 24) and a slight increase from staff injuries (from 63 to 70). Part of the decrease in patient injuries can be attributed to the introduction of a separate category, in 2016, for inappropriate handling techniques. This new category has typically been used by staff to report unsafe techniques outside of our care.

During 2017/18 the number of non-patient moving and handling courses was increased to meet the demand from office based, facilities and estates staff. In departments where significant non-patient moving and handling takes place (e.g. estates and facilities) the H&S team have worked with staff to ensure tasks are fully risk assessed and information/training is provided to staff. No correlation from these incidents and staff training compliance has been identified and the same number of non-patient moving and handling courses have been planned for 2018/19.

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Previously increases in moving and handling incidents have been attributed to improved reporting with the introduction of Datix and the Trust taking on addition staff in HWLH during 2016/17. Improved reporting is a continuing theme (across various categories of incident reporting) and these increases are generally in the no or low harm categories (see section 4.2.1).

The Trust has an internal Occupational Health (OH) department with physiotherapy support to enable staff with Musculoskeletal disorders (MSK) to either stay at work or return to work. Referrals to OH are monitored and reported to both the Workforce, and Health and Safety Committees.

5.2.5 Medical sharp incidents

The requirements to protect staff, and others, from sharp injuries, and potential blood borne viruses, are implemented across the Trust through a range of control measures. These include the following.

• A Sharp Safety procedure. First implemented in 2010 and continually reviewed and updated, using input from services, specialists, incident trends, etc.

• Individual teams and services implementing local sharp risk assessments (which are checked during both infection control and health & safety audits).

• Maintaining a Standard List of safer sharp devices.

• Restricting non-compliant sharp devices from the online NHS Supply Chain Catalogue, so that services can only order non-compliant items once assurance has been provided that a suitable and sufficient risk assessment is in place (and reviewed by the H&S team).

• Information on sharp safety and needlestick injury advice on the Statutory training days.

• The risk of not complying with the EU sharps directive was on the Risk Register and the register entry is regularly reviewed by the Health & Safety and Medical Device and Decontamination Leads. Actions and mitigation have been implemented and these have reduced the risk to a low level.

• Training and demonstrations organised with safer sharp suppliers.

During 2017/18 two services were authorised to purchase non-compliant devices (e.g. those without safety guards or retractable needles); following the completion of suitable and sufficient risk assessments. These included:

• the MATT department at Bognor Regis War Memorial Hospital who required spinal needles for pain relieve treatment and no safer sharp alternatives were available; and

• the Immunisation Service in West Sussex who required fine gauge needles for immunising neonates and school children.

The restrictions on ordering sharps from NHS Supply Chain have been in place for three years and whenever services attempt to order any sharp device outside of the standard list Procurement department have flagged the request to the H&S team to review.

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These control measures are monitored by the Health and Safety Committee to ensure that they continue to be effective.

Sharp injuries are reported to the Trust’s Sharp Injury Hotline, which directly connects members of staff with the Occupational Health Department. Each case is assessed by Occupational Health, who advise on blood samples, vaccinations and provide advice to staff and managers. The figures for sharp injuries below are taken from the quarterly Occupational Health reports, who report on any trends and actions to the Health and Safety Committee.

The number of sharp injuries in 2017/18, reported to the Sharp Injury hotline, has decreased from 71 in the previous year to 58 incidents (see Figure 9). A significant part of this decrease is attributed to the introduction of safer devices in dental and podiatry (e.g. scalpel blades). The decrease is also attributed to the range of other measures the Trust has implemented to protect staff.

Figure 9. Types of sharp injuries

The decrease in sharps injuries is spread across most professional groups (see Figure 10). The largest frontline professional group in SCFT are trained nurses and they account of 36 of the 58 sharps injuries.

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Figure 10. Sharp injuries by profession

These injuries have been reviewed each quarter by the Health and Safety Committee and following underlying causes have been attributed to the increase in needlestick injuries.

• Staff using patients’ own insulin pens.

• Sharp bins being overfilled and/or devices protruding from the top of the bins.

• Patients moving expectantly/suddenly.

To put these incidents into perspective in the West Area, during May 2018, 7168 patient visits to administer insulin were completed. An Insulin Task and Finish Group has been established to review and define Standard Operating Procedures, role and responsibilities for administration of insulin, and staff training. Each incident is investigated by a manager and their findings and actions are recorded on Datix (e.g. requesting safer sharp devices from GPs, ordering replacement or larger sharps bins, liaising with other services involved in patients’ care). The H&S team are liaising with the Procurement department when new devices become available or existing devices change.

Training on compliance with the Sharps Directive is included on the annual statutory training and information posters on what to do in the event of an injury are displayed in all SCFT clinical areas.

5.2.6 Staff fall incidents

Incidents involving staff falls, mainly consist of ‘slips, trips & falls’ and occur on a wide range of premises where staff may be at work (see Figure 11). These include NHS hospitals, healthcare centres, schools, family centres, local authority buildings and in the community visiting patients. Where incidents occur on premises under the Trust’s control, the incident is assessed by the H&S team and if there are any underlying actions (e.g. uneven paving) the team liaises with the Estates Department to ensure corrective action is taken.

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Patient falls are excluded from this report, as these are reported on separately and reviewed by the Falls Steering Group, who report to TWGG. With the exception of 2 incidents, all 71 non-patient falls incidents were low or no harm. There were three slip, trip or fall incidents which resulted in fractured or broken bones and were reported to the HSE (see section 4.3). In each case actions were implemented to avoid a re-occurrence. The only trend in the incidents, was in the inpatient ward at Uckfield Hospital, where two reportable incidents occurred. The underlying causes in both of these incidents were slippery floors after the floors had been cleaned by housekeeping. At Uckfield Hospital the housekeeping is managed by another organisation and SCFT staff liaised with the housekeeping staff to overcome the issues identified by the incidents. This included additional training and assessment and contract review meetings

Figure 11. Staff fall incidents

5.2.7 Unsafe environment incidents

The number of unsafe environment incidents has increased from 66 to 105 in 2017/18. A significant part of this increase is attributed to 21 incidents from Tarner Child Development Centre, in Morley Street Brighton, regularly reporting anti-social behavior in the surround area affect staff and patients accessing the centre.

This category is used to identify a wide range of different types of incidents. Other themes in this category include; temperature control in medicines or clinical areas, parking, and leaks/floods in premises. The reported temperature control issues have typically been during warm weather conditions and have been on sites where other organisations are responsible for the building maintenance. In these cases the incidents have evidenced that staff have liaised with medicines management to ensure drugs and feeds are unaffected and

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rehabilitation activities have been adjusted appropriately to the patients’. The parking incidents have occurred across a range of sites and there are no specific common causes.

5.3 Reporting of Injuries Diseases and Dangerous Occurrences Regulations

The Reporting of Injuries Diseases and Dangerous Occurrence Regulations (RIDDOR) require every employer to report certain types of incidents to the Health and Safety Executive (HSE) and for registered healthcare organisations, the Care Quality Commission (CQC), so that inspectors can target their visits and inspections.

During 2017/18, 15 incidents were reported, under the RIDDOR requirements, compared to 17 incidents in 2016/17, and 14 in 2015/16 (see figure 12). The main cause of reportable incidents is slips, trips and falls (9 staff and 1 patient incidents). These incidents were spread across different sites and the only recurring theme was at Uckfield and Crowborough Hospitals. In these cases, floors were sufficiently wet after cleaning (as identified above). After liaison with the services involved, additional training and actions were implemented to address the root causes. Since these incidents, SCFT Facilities have completed checks on the provision of housekeeping services and have received assurances that onsite housekeeping staff have adequate training and refresher training in place. All RIDDOR incidents are reported in further detail to the Health and Safety Committee each quarter, to ensure incidents are appropriately managed, control measures implemented, and to provide assurance to the Executive Committee.

Figure 12. Causes of RIDDOR incidents

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5.3.1 Benchmarking reportable incidents Type of organisation Average

staff Head-count

Staff Over 7 day injuries

Staff

Specified injuries

Patient reportable incidents

Visitor reportable incidents

TOTAL Incident rate per 100,00 employees

SCFT 4978 11 2 1 0 261

Community NHS Trust

5460 12 7 0 2 385

Hospices & community staff

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Community Care 550 3 0 1 0 727

Table 2. SCFT RIDDOR data benchmarked with other organisations

In order to provide a point of comparison on the number of reportable incidents, information from comparable organisations has been obtained through the Healthcare Risk Management Group (HRMG), a networking group for healthcare providers in the southeast of England.

In Table 2 we have displayed SCFT’s RIDDOR incident rate (e.g. the number of reported incidents per 100 000 employees) alongside those from other healthcare organisations.

The Trust’s incident rate, per 100 000 employees, has decreased from 350 to 261, due to less staff. The incident rate for SCFT is lower than the other comparable organisations and is attributed to slightly fewer reportable accidents and a higher headcount in 2017/18.

5.4 Training Health and safety training is provided at different levels, throughout the trust, according to individuals' roles and responsibilities. Within SCFT some types of training are described as Statutory, where all staff (including agency and bank) must attend, or Mandatory, where only specific roles (e.g. managers, clinical staff) have to attend.

5.4.1 Statutory health and safety training

The annual statutory training provided to all staff includes a range of topics relevant to ensuring the health, safety and welfare of staff, patients and other persons. The training includes information on typical workplace risks, relevant control measures, applicable Trust policies, how to seek additional information or advice, and includes sessions on:

• Fire Safety (incl. Medical Gases) & Security

• Infection Control (incl. Sharp Safety)

• Health and Safety, (incl. Back Awareness and Medical Devices)

The level of training compliance for substantive staff is at 92.24%, which is an increase over the level in 2016/17 (87.27%) and the Trusts target of 90%. Although the level of training compliance for Bank staff has increased to 72.10%, it is below the current target of 90% and is an area of focus for the Trust. There is a risk on the risk register to continually review the Trust’s compliance levels and mitigation measures.

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The training figures are analysed by the Education and Training department, who report on training compliance to the Developing our Talent Group who provide assurance to the Workforce Committee on actions being taken.

5.4.2 Managing health and safety training

The Trust provides in-house training for Managers, so that they can manage health and safety within their areas and understand their responsibilities. The half-day mandatory course is run by the H&S team.

The course is valid for two years and the course content is regularly reviewed and updated, to ensure the course content is up to date with Trust policies, good practice and legal requirements.

Figure 13 Managing Health and Safety Training attendance

A number of teams and services have changed and merged within the Trust (e.g. ‘Communities of Practice’, new children services contracts) and so the baseline target for training managers and representatives has been amended according. Based on the current organizational structures the current baseline target is training 139 staff every two years. In the last two years 178 staff have attended the training and the trust is exceeding this target (see figure 13).

5.4.3 Patient handling training

The compliance figures for patient handling training were showing at 77% at the end of March (see Figure 14; source: Scholar 06/06/2018). Although, this figure is down from the 78.5% compliance at the end April 2018 the figure had increased to 79.2%. During 2016/17 the team delivered additional training sessions specifically for Staff Direct, to improve Bank staff compliance, and between April 2017 to March 2018 Bank staff compliance increased from 44.1% to 59.7%.

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Figure 14. Percentage of substantive staff compliance with patient handing training

Since December a decrease in attendance (see Figure 15) has been attributed to staffing pressures during winter months and several courses have had to be cancelled due to low attendance. Staff compliance with training is an area of risk and is being reviewed through the risk register. Since the start of April 2017 there has been anecdotal feedback from course trainers that the patient handling courses have been fully booked and the level of compliance is expected to increase as a result. The Patient Handling training includes practical exercises, which require a minimum of two staff (with the trainer observing) in order to run the course safely.

The number of substantive and bank staff identified on Scholar as requiring Patient Handling training as mandatory for their role in 2017/18 is 2443. During 2017/18 there were 212 courses and each course can take up to 12 staff. Staff have to attend training, to refresh their competency, every two years. The current number of courses is sufficient to accommodate the numbers of staff, who require training (see Figure 15).

During 2017/18 additional measures have been implemented to support patient handling in the Trust:

• 6 additional courses were put on during winter months

• The Moving & Handling Lead visited all the Trust’s inpatient departments to support guidance and advice on the ‘shop floor’.

• 4 courses bespoke for bank staff were set up.

• Bespoke training sessions for podiatry services were held, where staff required training, but whom didn’t use hoists and slings.

And in 2018/19 additional bespoke courses for children services and Chailey Clinical Services have been scheduled, to provide training tailored to the needs/requirements of children.

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Figure 15. Attendance on schedule patient handling courses.

The Patient Handling courses are held at different training venues across the Trust, which have been equipped with patient handling equipment (e.g. hoists, slings, slide sheets). Currently there are four training venues across the Trust.

• Crawley Hospital, PCT Training Room

• Bognor Regis War Memorial Hospital, Marion Restaurant

• Brighton General Hospital, Moving and Handling Training Room

• The Quadrant in Lancing, Conference Room

In addition to the Patient Handling courses the Moving & Handling Team provide training to non-clinical staff, via the ‘DSE and Load Handling’ courses. In 2017/18 the team provided 24 ‘DSE & Load handling’ courses and a similar level of training is planned for 2018/19.

5.4.4 Conflict resolution training

The Conflict Resolution courses are currently managed by the Security Management Team in liaison with the Education and Training department.

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The training is mandatory for all frontline staff and is available to staff who communicate with patients over the telephone. Staff attending this course receive additional information on Lone Working and Telephone conflict, these staff are required to re-attend this course every three years.

The internal target for ensuring Conflict Resolution compliance is to train 1280 staff each year and this is based on the number of frontline staff divided by three (e.g. training valid for three years before refresher training is required). During 2017/18 1335 staff were trained; exceeding the internal target.

Other measures put into place by the Trust, such as introducing the Skyguard lone worker devices, presentations with the Wider Executive Leadership Team, will have indirectly increased awareness of training and its importance.

5.4.5 Stress management training

Since 2013 Occupational Health and H&S team jointly developed and ran an in-house course for Managers on how to manage stress and each year the course content is reviewed and updated. During 2017/18 a workbook was developed as an alternative form of training and additional resources and communications have been distributed to all staff, promoting the range of wellbeing services available across the Trust. The training and guidance follows the HSE's ‘Stress Management Standards’ and includes team and individual methods of risk assessment, so that managers can take both proactive and reactive approaches.

In addition to local risk assessments and the Trust’s in-house Occupation Health department, the following measures are in place to manage the health risks associated with managing workplace stress.

• All staff received a basic awareness of stress as part of their annual Health and Safety Statutory training.

• The ‘Workforce Health, Wellbeing and Engagement Group’ reviews and sets objectives for promoting staff wellbeing and has been working on actions plans linked to the Trust’s ‘Commissioning for Quality and Innovation national (CQUIN)’ goals;

• Occupational Health have in-house Clinical Psychologists, who provide individual support and facilitate group workshops; and

• Occupational Health monitor and report on any stress related referrals to the Health and Safety Committee.

5.4.6 First aid training

The Trust has a Basic Life Support Trainer who delivers first aid training. The Trust provides the one-day Emergency First Aid at Work course, which is suitable for the majority of office work environments and the three day First Aider qualification, which is suitable for sites with increased hazards or tasks, such as wheelchair workshops or estates maintenance tasks.

As part of the Trust’s First Aid Procedure, individual teams assess their first aid arrangements, using a simple checklist, at the local level and on premises with inpatients or multiple services the H&S team undertake overarching assessments. These overarching assessments allow the H&S team to advise managers on local arrangements and provide assurance to the Trust. These assessments are reviewed every two years and take into

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account: SCFT activities on site, availability of emergency services, previous first aid incidents and the availability of registered medical professionals.

First aid arrangements are monitored as part of the planned health and safety audits across the Trust and the audit findings are reported to the Health and Safety Committee and help influence planning for the number and location of future first aid courses.

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6. Next steps The main causes of health and safety incidents in 2017/18 and the areas of priority will be:

• Verbal and physical abuse;

• Moving and handling;

• ‘Slips, trips and falls’

• Unsafe environments

The Trust provides mandatory conflict resolution training to all frontline staff and physical intervention training for those teams that have identified through risk assessments the need for that training. Warning letters are sent to patients and family members, when it is deemed acceptable, regarding their behavior and the Managing Violence and Aggression Policy identifies a three step process in relation to dealing with violent patients and / or family members

The Security Management Team will be continually monitoring the use of the Trust’s Skyguard lone working devices and reviewing other lone working options/devices available on the market place, to ensure the Trust continues to manage staff safety effectively.

Patient handling training will continue to be main focus for the H&S team and following a paper to the Health and Safety Committee in May 2018, analysing the compliance levels, the team will be liaising with Education & Development to ensure training is targeted at the staff showing as out of date (incl. new starters) and existing staff before their training lapses, including additional provision before winter months when pressures on staff are higher.

Several of the reportable slips and trip accidents were caused by wet floors on inpatient wards. In these incidents, actions were put into place to prevent re-occurrence and suitable risk assessment and audit systems were in place. In order to provide further assurance that housekeeping of floor services are suitably managed the H&S team will carry out unannounced on safety visits to observe facilities/housekeeping cleaning tasks across the Trust’s inpatient departments.

The incident category ‘unsafe environments’ is used to cover the range of local operational hazards, and while it is important that these are reported, staff responsibility to escalate risks is important to prevent re-occurrence. During 2018/19 the H&S team will be requesting samples of local health and safety inspections from all sites, where SCFT services are based, to ensure staff/services are flagged up any issues and actions are being implemented.

These actions will help to provide focus for the Health and Safety Committee to work on for 2018/19 and will be incorporated into the Committee’s work plan.

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TRUST BOARD – PUBLIC MEETING

26 July 2018

Agenda Item: 16

Title: Duty of Candour (DoC) Briefing

Purpose:

Approval Assurance Discussion Briefing X

Summary: Duty of Candour (DoC) became a legal requirement in November 2014 with the requirement for all organisations registered with the Care Quality Commission (CQC) to comply. This report provides the Board with assurance of the actions the Trust has taken to promote an open and transparent culture and ongoing plans to enhance compliance with its Being Open and DoC Policy.

Recommendations: • Note the content of this report.

CQC Domains (Safe; Caring; Responsive; Effective; Well Led) indicate which are relevant below: • Safe – Involvement of patients and their families in incident investigations.

• Responsive – Promoting an open and transparent environment

• Caring – Reflecting patient’s experience in lessons identified .

• Effective – Ensuring mechanisms for monitoring the effectiveness of services from a patients perspective

• Well Lead – Promoting an Open and transparent culture.

Relevance to Strategic Goals: • We will provide excellent care every time to reinforce wellbeing and independence.

• Working with our partners we will personalise services for the individual.

• We will be a strong sustainable business, grounded in our communities and led by excellent staff.

Equality and Diversity: • No specific Equality and Diversity issues arise by reason of the matters covered in the Report.

Prepared by : Colin Edwards Head of Quality Governance

Presented by: Dr Richard Quirk Executive Medical Director

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Introduction Sussex Community NHS Foundation Trust (SCFT) is committed to promoting an open and transparent culture and this includes open communication with patients and/or family members/carers when a patient is involved in an incident, which causes harm. This is now a statutory requirement as part of Duty of Candour responsibilities. This report provides the Board with assurance of the actions the Trust has taken over the last year to ensure compliance with its being open and DoC Policy. Background Duty of Candour (DoC) became a legal requirement in November 2014 with the requirement for all organisations registered with the Care Quality Commission (CQC) to comply. Since 2014 there have been various independent reviews into levels of family involvement in investigations (Mazaar Report December 2015, Carolan Report October 2016 etc.). More recently these have particularly focused upon how Trusts engage with families in investigations following the death of a patient. The findings of such reviews are being used to inform SCFTs ongoing systems of openness and candour. SCFT Being Open and Duty of Candour Systems SCFT has many systems in place that aim to promote an open and transparent culture. These include;

• Patients being proactively informed about all elements of their treatment and care from the point of referral.

• Provision of service leaflets and involvement of patients in their treatment/care planning processes.

• Incident reporting policy and systems to ensure staff are able to report all incidents and near miss events enabling both local and corporate overview of potential risks to patient safety.

• Being open and duty of candour policy.

• Offering meetings with patients, families and carers to discuss concerns, agree actions and agree timeframes for reporting actions back.

• Maintaining a record of all DoC communications locally by the service area.

• Maintaining a central overview of DoC application on Datix (Risk management system), and in the case of all serious incidents ensuring a brief summary of DoC communications and plans within final investigation reports.

Duty of Candour process If a patient safety incident occurring under SCFT care causes moderate or more severe harm, it is expected that DoC processes will be applied. The specific requirements of these processes can be summarised as:

• Incident identification,

• Incident reporting,

• Escalation to senior management (moderate harm and above)

• Agreement of a lead to verbally inform patient/family of events,

• Provision of verbal apology and disclosure (followed up with written notification – 10 days’ timeframe),

• Investigation of events,

• Written outcome and apology,

• Feedback opportunity

• Actions plans

• Communication of learning.

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Although SCFT has many systems in place as listed above to promote DoC and the stepped process appears very clear, full implementation of the requirements in practice can prove very challenging. These challenges are not specific to SCFT and are being experienced across all sectors of healthcare. Examples of the challenges include patients being transferred out of SCFT care following an incident, which affects the ability to maintain face to face communications with patients/families; challenges accessing information regarding the ongoing care needs/outcomes for the patient following transfer out of SCFT; differing opinions/expectations of family members; duplication of discussions; and complexities with recording patients ‘next of kin’ details. Individualised approach

Reviewing moderate harm or higher there is an expectation that our services commence the duty of candour process. A duty of candour audit completed in 2017 did not provide assurance that this was the case (see audit section p.4). The patient safety team have devised a 72 hour reporting form for moderate or higher harm to assist in the determination whether an incident meets SI criteria. The form does provide a prompt that if moderate or above harm has occurred within SCFT the duty of candour process does apply. All SI investigations the Quality and Patient Safety Improvement Nurses offer advice and support to the teams to deliver duty of candour.

Staff support

As part of the SI process all staff involved in the incident are asked to provide a reflective recall of the events. These are normally shared with the ward manager/ matron and will be used by the investigator within the report. The Quality and Patient Safety Improvement nurses always ensure that staffs are made aware that the investigation is not about blame and will not be used as part of a HR process. The aim of the investigation is to look at system and process issues and to ensure learning and change occurs. The staffs involved are also asked to contribute to the investigation report and will be asked to review the final version.

Monitoring Policy Compliance

SCFTs Serious Incident Review Group (SIRG) scrutinise assurance of DoC standards in Serious Incidents. Quarterly risk and incident reports to TWCGG include reference to DoC application. The outcomes and learning from all investigations are shared via SCFTs governance committee structures. These governance processes incorporate the monitoring of action plan delivery. The Datix incident module includes a specific section for the central recording of DoC details in the event of all moderate or above harm level incidents that have occurred under SCFT care. Annual Record Keeping Audit includes monitoring standards of Patient /Carer involvement Informal evidence of application of DoC processes include managerial spot checks of service records, health records review, one to one discussions and anecdotal conversations with patients and their families.

Duty of Candour confirmation is part of the SI investigation report and assurance of its completion is provided by the most senior nurse/ team lead for the service. Initial Disclosure and Verbal apology by a member of the service/ clinical team involved directly with the patient's care should confirm to the patient/relative/carer that an incident has occurred and that this will be investigated after recognition of the patient safety incident and must be within 10

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working days of the incident occurrence. A verbal apology for any distress or harm should be offered at this point as well as written notification confirming the disclosure. If the incident was an SI and closed by the CCG it is the service/ teams responsibility to follow up with a third contact – this is normally via a meeting to discuss the report findings or by letter. This final part of the process is not regularly monitored by patient safety; however duty of candour data is pulled each month and provided to Area Management Teams. This will include those harms that are moderate or higher but not declared an SI.

Audit In 2017 an audit was implemented to provide assurance that services were compliant with the duty of candour process. Duty of Candour workshops was completed across the organisation in Quarter 2. 2017. A review of a sample number of patient health care records associated to Serious Incidents or internal investigations were examined between Jan – July 2017 to audit the use of the duty of candour letter’s (initial letter of disclosure and post investigation letter/ meeting to share learning) - a data pull from Datix was completed. Audit Results: The duty of candour training took place in Q2 2017 across adult and children’s services, 83 staff attended this training. Each area was requested to review 5 sets of patient records that had experienced moderate or higher harm whilst in SCFT care. Data provided from each area identified that the process was not always followed or adhered to national guidance. The data from Datix identified 37 cases of moderate or higher harm and 20 of these incidents had completed the full process of duty of candour. The overall results did not provide adequate assurance. The following recommendations were made:

1. Development of a staff poster on the duty of candour and this to be shared with all clinical services – agreed has been circulated to community and inpatient taskforce.

2. Development of a patient/ staff leaflet that can be given at the time of an incident – leaflet is prepared and going to PEG this week for their view if they agree, Clinical Effectiveness Lead to take to TWGG (2nd August 2018) and then organise printing – see next steps section.

3. Further training of the meaning of duty of candour and the process – planned for Q. 3 to be facilitated by Clinical Effectiveness Lead.

4. Spot check data pull from Datix to review adherence to policy – will be completed in Q.3. 5. Further audit in 2018 to provide a greater assurance – on audit plan for Q.4.

DoC Workshop

Further DOC workshops are planned for Q3.

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Actions Taken

The following recommendations and actions were taken forward in response to the DoC audit and workshop outcomes.

RECOMMENDATION ACTION TAKEN

Ensure centralised record of duty of candour application is recorded on all moderate and above under SCFT care incidents.

a) Ensure Datix DoC fields linked to all moderate and above reported incidents under SCFT care reflect SCFT policy – Completed.

b) Ensure incident ‘Sign off’ managers are advised of their responsibility to undertake DoC – Completed.

c) Escalating any concerns to Senior Area Nurse or a member if the patient safety and risk team - Ongoing.

d) Monitor compliance to DoC policy via weekly incident review meetings - Through Area Management Slides.

e) Make above fields mandatory for sign off managers to complete – Completed.

f) Confirm the offer of inclusions of patients, family, carers in all SI investigation reports (patient involvement section) – Completed.

Enhance Trust wide awareness of DoC principles.

a) Incorporate specific reference to DoC in Governance section of Trust Induction - Trust induction day structure was altered to include a discussion on DoC.

b) Make DoC training slides and support documents accessible on PULSE – Outstanding - Expected completion date 30/09/2018.

c) Produce quick guide of process including details of where support can be accessed - Completed

Next Steps

As well as embedding the above on an ongoing basis the following actions are in progress/planned for 2018/19, this work will be integrated into the Patient Experience Workstream.

RECOMMENDATION ACTIONS IN PROGRESS/PLANNED 2018/19

Increase opportunities to discuss any challenges to DoC communication with families and carers and advocates.

a) Update policy and PULSE (Intranet page) to reflect recent national publications and provide more explicit guidance on expected process – Outstanding - Expected completion date 30/09/2018.

b) Plan webinar/teleconference to discuss frontline Q&As regarding DoC communications aim to include patient/public representation - Outstanding - Expected completion date 30/11/2018.

Increase opportunities for Carers /Family involvement in investigations/ongoing opportunities to promote open culture.

a) Increase reference to DoC in service & PALS communications, leaflets & posters etc. – Outstanding - DOC leaflet and poster needs to be agreed by August 2018 – (See Attached). b) Ensure Patients forum/feedback mechanisms are used to inform ongoing openness and candour review processes – Outstanding - Once poster and leaflet agreed these will be forwarded to Health Watch/ CCGs/ PEGs/ Council of Governors in September/ October 2018.

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Utilise staff feedback opportunities to support ongoing promotion of open culture.

a) Ensure staff feedback /surveys on openness and candour are also used to inform use findings - Recent staff survey reflects the culture of openness.

Formal monitoring of DoC Policy application.

a) Undertake repeat DoC audit in accordance with clinical audit schedule 2017/18 - Planned for Q4.

Consider patient advocates attendance to SIRG

An opportunity to reflect the Trusts openness and transparency to be reviewed and considered by SIRG, by 31/08/2018.

Duty of Candour leaflet devised by KSS Patient Safety Collaboration which SCFT participates with and DOC poster for staff devised by Patient Safety and Clinical Effectiveness. References/supporting documents: A promise to learn a commitment to act, Prof Don Berwick 2013 Building a culture of candour; a review of the threshold for the duty of Candour and of the incentives for care organisations to be candid David Dalton/ Prof Norman Williams March 2014 NHS Serious Incident Framework NHS England March 2015 Independent review of deaths of people with a Learning Disability or mental Health problem in contact with Southern Health Foundation Trust between April 2011 – March 2015 ( Mazaars report December 2015) A review of family involvement in investigations conducted following a death at Southern Health NHS foundation Trust S Carolan October 2016 Providing a safe space in healthcare safety investigations consultation Department of Health October 2016 Learning candour and accountability; a review of the way NHS trusts review and investigate deaths of patients in England Care Quality Commission December 2016 Colin Edwards Head of Quality Governance

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Board Schedule June 2018 onwards

Date Type of Meeting/Event Approx. Duration Venue/location Agenda Items/Information Requirements

28 June 2018 Directors’ Meeting + seminar/development time

9.30 a.m. start – allow full day

All BGH currently. Digital Strategy Finance Report IPR Dashboard CEO Report – update on key risks and issues Clinical Care Strategy refresh Annual R&D Report Any time critical business to be transacted

12 July Remove from diaries N/A N/A N/A

26 July Public Board + any Part 2 business required

10.00 a.m. – 1.00 p.m. (Public) 1.30 – 2.30 p.m. (Part 2) Seminar – 2.45 - ??? (t.b.c.)

Quality Report (inc. Serious Incidents) Strategic Workforce Report Finance Report IPR Quarterly Reports (Q1) – “must do’s” are Mortality, GoSW, BAF/Corporate Objectives (internal driver, not regulatory) Duty of Candour Annual Compliance Report Annual Health and Safety Report Revised Standing Orders (SOs), Standing Financial Instructions (SFIs) and Scheme of Delegation (SoD) Seminar – interactive session on fundraising strategy – MJ/Jean Barclay/JN FTSU Self-assessment toolkit – Part 2

NOTE: AMM/CoG 19 September

13 September Board/CoG Away Day All day, 9.30 a.m. start

Clinical Care Strategy refresh engagement exercise

27 September Public Board + any Part 2 business required

10.00 a.m. – 12.30 p.m. (Public) 1.00 – 2.00 p.m. (Part 2)

Quality Report (inc. Serious Incidents) Strategic Workforce Report Finance Report IPR Medical Revalidation Annual Report

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IG Toolkit & Caldicott Guardian Annual Report Annual Infection Prevention and Control Report Equality and Diversity Annual Report Emergency Planning Annual Report Care without Carbon Annual Report Seminar/Part 2 – Board Risk Appetite session – RQ BGH Redevelopment OBC (Part 2) SPV Project decision (Part 2)

25 October Directors’ Meeting + seminar/development time

9.30 a.m. start – allow full day

Finance Report IPR Dashboard CEO Report – update on key risks and issues Any time critical business to be transacted Second phase of Board Development work – inc. review against NHSI Board Well-led Framework Committee Chairs’ Reports LTFM assumptions + down/upside modelling – Seminar session Draft Corporate Objectives 19/20 (Part 2) (or Nov)

29 November Public Board + any Part 2 business required


Quality Report (inc. Serious Incidents) Strategic Workforce Report Finance Report IPR 6-monthly Safer Staffing Report Quarterly Reports (Q2) – “must do’s” are Mortality, GoSW, BAF/Corporate Objectives (internal driver, not regulatory) Update on Dementia Strategy – referred from Quality Committee

13 December Held for seminar – keep for Op Plan sign-off if necessary

9.30 a.m. start – allow half-day

Operational Plan 19/21 6-month Review of new Board meetings schedule (put in place June 18)

31 January 2019 Public Board 10.00 a.m. – 1.00 Quality Report (inc. Serious Incidents)

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+ any Part 2 business required p.m. (Public) 1.30 – 2.00 p.m. (Part 2)

Strategic Workforce Report Finance Report IPR Quarterly Reports (Q3) – “must do’s” are Mortality, GoSW, BAF/Corporate Objectives (internal driver, not regulatory) Charitable Funds Annual Accounts FTSU Guardian Annual Report

28 February Directors’ Meeting + seminar time


Finance Report IPR Dashboard CEO Report – update on key risks and issues Committee Chairs’ Reports Any time critical business to be transacted

14 March Seminar/development time All day Use as Annual Board Away Day?

28 March Public Board + any Part 2 business required


Quality Report (inc. Serious Incidents) Strategic Workforce Report Finance Report IPR Draft Plan and Budgets 19/20 (Part 2) Draft IPR 19/20 (Part 2)

25 April Directors’ Meeting + seminar/development time


Going Concern Assessment Board Committee Annual Reports Finance Report IPR Dashboard CEO Report – update on key risks and issues Committee Chairs’ Reports Any time critical business to be transacted

23 May Public Board + any Part 2 business required


Quality Report (inc. Serious Incidents) Strategic Workforce Report Finance Report IPR 6-monthly Safer Staffing Report Quarterly Reports (Q4) – Mortality

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Corporate Objectives Annual Review 17/18 Committee Chairs’ Reports Annual Report & Accounts and Quality Report (delegated to Audit Committee) NHSI Self-Certifications 1, 2, 3, 4, 5 and 6 BAF 18/19 Annual Aggregated GoSW Board Report Annual Review of Risk Management Strategy

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