board of directors meeting held in public to be held on ......d3 rtt year end position rj note d3 10...

Board of Directors Meeting Held in Public To be held on Tuesday 19 May 2020 at 09:30

in the Boardroom, Doncaster Royal Infirmary & Teleconferencing

AGENDA

LEAD ACTION TIME / ENC

TIME/MINS

A MEETING BUSINESS 09:30

A1 Apologies for absence SBE Note Verbal

5

A2 Declarations of Interest

SBE Note Verbal

Members of the Board and others present are reminded that they are required to declare any pecuniary or other interests which they have in relation to any business under consideration at the meeting and to withdraw at the appropriate time. Such a declaration may be made under this item or at such time when the interest becomes known. A3 Actions from previous meeting

SBE Review A3

B PRESENTATION

No Presentation

C STRATEGY

09:35

C1 ICS Update

RP Note C1 5

D QUALITY, PERFORMANCE AND SAFETY

09:40

D1 COVID-19 Update RJ Note Verbal

15

D2 Quality and Performance Report RJ Note D2

15

D3 RTT Year End Position RJ Note D3 10

E CAPACITY AND CAPABILITY

No Items

F FINANCE AND CONTRACT MATTERS

10:20

F1 Finance Report – April 2020

JS Note F1 15

G GOVERNANCE AND RISK 10:35

G1 Use of Trust Seal

FD Note G2 5

G2 Chairs Assurance Logs for Board Committees: Finance and Performance Committee – 21 April 2020

ND Note G3 5

G3 Infection Prevention and Control Board Assurance Framework

DP Note G4 10

G4 Appointment to the Post of Director of Learning Opportunities and Skills (DCS)

RP Note Verbal 5

G5 Caldicott Guardian

RP Note Verbal 5

H INFORMATION ITEMS (To be taken as read)

11:05

H1 Minutes of the Finance and Performance Committee – 31 March 2020

NR Note H1 5

H2 Letter of Thanks from the Yorkshire Organ Donation Services Team

PD Note H2

H3 Board Work Plan

SBE Note H3

H4 Minutes of the Council of Governors – 30 October 2019 and 30 January 2020

SBE Note H4

H5 Minutes of the Management Board – 18 November 2019, 20 January 2020, 10 February 2020, 9 March 2020 and 20 April 2020

RP Note H5

I OTHER ITEMS

11:10

I1 Minutes of the meeting held on 21 April 2020 (pre-approved by the Board of Directors)

SBE Note I1

I2 Any other business (to be agreed with the Chair prior to the meeting)

SBE Note

Verbal

I3 Governor questions regarding the business of the meeting (10 minutes)*

SBE Note Verbal 10

I4 Date and time of next meeting: Date: Tuesday 16 June 2020 Time: TBC Venue: Boardroom, DRI / StarLeaf Videoconferencing

SBE Note

Verbal

I5 Withdrawal of Press and Public

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

SBE Note Verbal

J MEETING CLOSE

11:20

*Governor Questions The Board of Directors meetings are held in public but they are not ‘public meetings’ and, as such the meetings, will be conducted strictly in line with the above agenda. For Governors in attendance, the agenda provides the opportunity for questions to be received at an appointed time. Due to the anticipated number of governors attending the virtual meeting, Hazel Brand, as Lead Governor will be able to make a point or ask a question on governors’ behalf. If any governor wants Hazel to raise a matter at the Board meeting relating to the papers being presented on the day, they should contact Hazel directly prior to the meeting to express this. All other queries from governors arising from the papers or other matters should be emailed to Fiona Dunn for a written response. In respect of this agenda item, the following guidance is provided:

Questions at the meeting must relate to papers being presented on the day.

Questions must be submitted in advance to Hazel Brand, Lead Governor.

Questions will be asked by Hazel Brand, Lead Governor at the meeting.

If questions are not answered at the meeting Fiona Dunn will coordinate a response to all Governors.

Members of the public and Governors are welcome to raise questions at any other time, on any other matter, either verbally or in writing through the Trust Board Office, or through any other Trust contact point.

Suzy Brain England, OBE

Chair of the Board

Action notes prepared by: Katie Shepherd Updated: 21 April 2020

Action Log

Meeting: Public Board of Directors

Date of latest meeting: 21 April 2020

KEY

Completed On Track

In progress, some issues Issues causing progress to stall/stop

No. Minute No. Action Lead Target Date

Update

1. P19/7/19 Virtual Meetings - The potential to improve the Trust’s systems for streaming and conference calling meetings between the Trust’s three sites would be examined.

KA October 2019

December 2019 March 2020

July 2020

Update 21/04/20: Progress had been made on this action due to many meetings taking place virtually throughout the Covid-19 period.

2. P19/12/E1 Workforce Plan - Information on how the local community was involved in workforce planning and recruitment would be provided to future updates for the Board.

KB July 2020

3. P20/01/B1 Council Motion on Climate and Biodiversity Emergency - A Board workshop would be planned to further explore Climate Change and Biodiversity – looking at what could be done immediately and what could be done in the future.

KEJ May 2020 July 2020

A3

Action notes prepared by: Katie Shepherd Updated: 21 April 2020

4. P20/03/E1 Freedom to Speak Up Report - Further investigation would be undertaken into the reasons for escalation of hygiene issues to the FTSU guardian.

KB/KEJ July 2020

5. P20/03/H1-H4

Board Level Meetings - Suzy Brain England would liaise with the Trust Board Office to ensure that a clear message was circulated regarding the temporary changes to Board and Board Committee meetings.

SBE March 2020

July 2020

Close.

6. P20/04/A1 Thank you to Team DBTH – The Board of Directors collectively wanted to extend their thanks to Team DBTH in response to Covid-19, and thanked them for their continued efforts in getting DBTH as well prepared as possible for, and in response to the pandemic. This message would be added to the Team Brief.

ES April 2020 Close. This message was included in the Team Brief

7. P20/04/I3 Governor Activity - Governors would be informed of a timetable of meetings once they have been agreed. Once normal business resumes.

FD July 2020 Progress: A decision has been taken to deliver all types of meetings by Star Leaf for the foreseeable future. Fiona Dunn was working on a timetable of Governor meetings.

8. P20/04/I3 Virtual Meetings Capacity - Jon Sargeant would liaise with Ken Anderson to identify if it would be possible for a large number of people to dial into one meeting for the Council of Governors meetings.

JS April 2020 Close. The system will allow up to 100 attendees. There are protocols that can be called in to place to control who speaks to make even a large meeting manageable by Star Leaf.

1

CHIEF EXECUTIVE REPORT

May 2020

Author(s) Andrew Cash, Chief Executive Officer

Sponsor

Is your report for Approval / Consideration / Noting

For noting and discussion

Links to the STP (please tick)

Reduce

inequalitiesJoin up health

and care

Invest and grow

primary and

community care

Treat the whole

person, mental

and physical

Standardise

acute hospital

care

Simplify urgent

and emergency

care

Develop our

workforce

Use the best

technology

Create financial

sustainability

Work with

patients and the

public to do

Are there any resource implications (including Financial, Staffing etc)?

N/A

Summary of key issues

This monthly paper from the Chief Executive of the South Yorkshire and Bassetlaw Integrated Care System (SYB ICS) provides a summary update on the work of the SYB ICS for the month of April 2020.

Recommendations

The SYB ICS Health Executive Group (HEG) partners are asked to note the update and Chief Executives and Accountable Officers are asked to share the paper with their individual Boards, Governing Bodies and Committees.

C1

2

South Yorkshire and Bassetlaw Integrated Care System

CHIEF EXECUTIVE REPORT

May 2020 1. Purpose

This paper from the South Yorkshire and Bassetlaw Integrated Care System Chief Executive provides an update on the work of the South Yorkshire and Bassetlaw Integrated Care System for the month of April 2020. 2. Summary update for activity during April 2020 2.1 Coronavirus (Covid-19): The South Yorkshire and Bassetlaw position There is increasing evidence, both nationally and regionally, that the first peak of Covid-19 has now passed. The numbers of patients needing critical care facilities across the hospitals in South Yorkshire and Bassetlaw (SYB) appear to have now plateaued. There is consensus among partners that the immediate Phase One response to Covid-19 is drawing to a close. Attention is now turning to recovery, restoration and resetting health and care services. Simon Stevens and Amanda Pritchard’s letter to the NHS, issued on Wednesday 29th April, helpfully summarised the next steps for Phase Two, setting-out the current position and proposing new ways for the NHS to remodel health and care services in the coming days and weeks. The NHS remains in a Level 4 National Incident with all the altered operating disciplines that requires. There will be a gradual shift away from this in May as the Phase Two stabilisation period begins which will be in place until the end of June. During this stabilisation phase we will consider how best to restart urgent NHS services across SYB taking into account the needs of the population and the clinical priority of patients that need to be treated the soonest. Phase Three will be August to the end of March 2020. During this period we will conduct a comprehensive planning review and focus on building elective services and managing a potential further Covid-19 spike during the winter. Partners are already starting to take stock of the learning from the changes in ways of working since March as well as the experiences from patients, the workforce, SYB partners and the public. These findings will help to develop a framework to shape future working. Phase Four will be from April 2021 and will focus on recovering and developing the NHS towards the ‘new normal’. To support the early thinking on the SYB approach, a strategic workshop with Chief Executives, Accountable Officers, GPs, Primary Care Networks and the NHS England and Improvement Locality Director took place on 29th April. The basis of the discussions was to set out key principles for the reset process whilst working to ensure the prevention of System inequalities in any reconfiguration of services. It was a helpful exercise with insights and informative contributions from across sectors and the feedback is being used to work up the System response. Special thanks to Major Sam McEvoy, the SYB ICS Military Planner who formulated and facilitated the session. 2.2 Phase One reflections

As consideration turns to Phase Two and beyond, it is important to reflect on the enormous strides that have been made during Phase One. These have been in key areas such as workforce, critical care capacity, extensive partnership working and entering new terrain such as working side-by-side with the military. In SYB, a complex cross-regional development of a new Nightingale Hospital in Harrogate was co-

3

ordinated and the realignment of the FlyDSA Arena Sheffield as a local PPE storage facility was supported. In addition, new mobile testing sites in Barnsley, Sheffield and Doncaster opened, alongside the drive-through coronavirus testing facilities at Doncaster Sheffield Airport (DSA) for South Yorkshire and Bassetlaw key workers in health and care, including those employed in the independent sector, police, fire, local authorities and LRF partner organisations. NHS staff testing expanded with Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust and The Rotherham NHS Foundation Trust joining Sheffield Teaching Hospitals NHS Foundation Trust laboratory capacity to provide up to 2000 tests a day. Together with the key worker facility at DSA and mobile sites, the region is in a good position to maximise testing and allow staff currently unable to return to work because they or a member of their family or household have symptoms of coronavirus to know whether they do have the virus. The SYB System is also in a good position to widen community testing, especially to organisations that are fundamental to the local economy such as universities and colleges. More than 600 final-year nursing and allied health students from Sheffield Hallam University volunteered to join the NHS workforce and support the Covid-19 pandemic. This includes 376 nursing students who are joining NHS colleagues sooner than anticipated as part of the UK’s response to the virus. The healthcare students are in the final six months of their degrees and will be paid volunteers. In addition to work led by NHS England and supported by the ICS Procurement Hub to source PPE, the Mayor of the Sheffield City Region, Dan Jarvis, issued a call to South Yorkshire businesses to join the efforts to help make life-saving medical equipment. This initiative has seen around 50 businesses come forward, many of which are now supporting ongoing requirements for PPE for the region. 2.3 Supporting care homes In Phase Two the NHS will continue to partner with Local Authorities and Local Resilience Forums to provide mutual aid for care homes. In SYB this will build on work that has been taking place since the beginning of the outbreak. While the numbers of cases and deaths in hospitals are showing a downward trend, it is the opposite in care homes. NHS England is working with all regional providers including the North East and Yorkshire and the Humber Region to implement a new Enhanced Universal Support Offer to Care Homes. This is built around four key Principles: Leadership, Prevention, Additional Clinical Support and Workforce. The Enhanced Offer has been developed in conjunction across a number of key stakeholder groups; CCG Directors of Nursing, Directors of Adult Social Services in Local Authorities, Skills for Care, Primary Care, Public Health, Care Home Providers and others across the region. It provides a clear framework for support to care homes which will complement and, where appropriate, strengthen the support currently offered by these organisations. One of the first additional steps being taken, with regional senior nursing support, is for CCGs to quickly identify clinical leads to work alongside each care home. They will explore practical areas where additional support can be offered such as infection control, PPE training, staff not coming in to work if unwell, staff testing and pausing family visiting. 3. Finance update Based on draft year end results the System has exceeded its financial plan for the year. This has brought in £19m of cash support that would not otherwise have been available had the system not been in balance. This is a very creditable performance for the SYB System which has now exceeded its financial plan in each of the last three years.

4

4. Next steps An announcement is expected on Sunday 10th May from the Prime Minister on the Covid-19 lockdown exit strategy. We will use this to underpin our approach building on the transformation work seen in the last few months in SYB to reset the NHS over the coming year in four phases which are outlined above. Andrew Cash Chief Executive, South Yorkshire and Bassetlaw Integrated Care System Date 7 May 2020

Title Integrated Performance Report

Report to Trust Board Date 19 May 2020

Author Rebecca Joyce, Chief Operating Officer

Tim Noble, Medical Director

David Purdue, Director of Nursing, Midwifery and AHPs

Karen Barnard, Director of People and Organisational Development

Purpose Tick one as appropriate

Decision

Assurance x

Information

Executive summary containing key messages and issues

This report highlights the key performance and quality targets required by the Trust to maintain NHSI compliance. The report focuses on the main performance area for NHSi compliance for January 2020 including:

Cancer 62 day classic, measured on average quarterly performance

4hr Access, measured on average quarterly performance

18 weeks measured on monthly performance against active waiters, performance measured on the worst performing month in the quarter

Diagnostics performance against key tests

Infection control measures, C Diff and MRSA Bacteraemia The Quality report highlights the ongoing work with Care Groups and external partners to improve patient outcomes and a focus on mortality rates. The report contains a review of 7 day services against the National Standard.

D2

Key questions posed by the report

Key Questions for the Board are:

Is the Trust maintaining performance against agreed trajectories with our CCGs and in the context of national standards?

Is the Trust providing a quality service for the patients?

Are NEDs assured that the actions being undertaken to address underperformance and maintain current standards are robust and deliver the agreed improvements?

How this report contributes to the delivery of the strategic objectives

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

How this report impacts on current risks or highlights new risks

F&P6 Failure to achieve compliance with performance and delivery aspects of the Single Oversight Framework, CQC and other regulatory standards F&P15 Commissioner plans do not come to fruition and do not achieve the required levels of acute service reduction F&P5 Failing to address the effects of the agency cap

Recommendation(s) and next steps

The Board is asked to consider the report.

Local Target Actual Variance Local Target Actual Variance Target Actual Variance

A&E: Max wait four hours from arrival/admission/transfer/discharge Mar 20 95% 80.2% 81.7% 95.0% 88.0% -7.0% 92.0% 88.18% -3.8% 95.0% 88.2% -6.8%

Max time of 18 weeks from point of referral to treatment- incomplete pathway Mar-20 92% 74.2% 83.7% 92.00% 90.1% -1.9% 92.0% 90.1% -1.9%

Waiting list size (from 1/4/19) - 18 Weeks referral to treatment -Incomplete

PathwaysMar-20 .N/A .N/A .N/A 31,199 26,699 -4500 31,199 26,699 -4500

% waiting less than 6 weeks from referral for a diagnostics test Mar-20 99% 94.6% 95.8% 99.0% 89.9% -9.1% 99.0% 89.9% -9.1% 99.0% 89.9% -9.1%

31 day wait for diagnosis to first treatment- all cancers Jan-20 96.0% 96.4% 96.0% 96.0% 97.8% 1.8% 96.0% 99.7% 3.7% 96.0% 99.6% 3.6%

31 day wait for second or subsequent treatment: surgery Jan-20 94.0% 97.3% 91.6% 94.0% 100.0% 6.0% 94.0% 100.0% 6.0% 94.0% 100.0% 6.0%

31 day wait for second or subsequent treatment: anti cancer drug treatments Jan-20 98.0% 99.8% 99.3% 98.0% 100.0% 2.0% 98.0% 100.0% 2.0% 98.0% 100.0% 2.0%

62 day wait for first treatment from urgent GP referral to treatment Jan-20 85.0% 78.2% 78.0% 84.6% 82.5% -2.1% 85.0% 85.8% 0.8% 85.0% 86.1% 1.1%

62 day wait for first treatment from consultant screening service referral Jan-20 90.0% 85.0% 85.2% 90.0% 81.5% -8.5% 90.0% 86.5% -3.5% 90.0% 87.0% -3.0%

ED Attendances Feb-20 N/A N/A N/A 13442 154157

Daycase Activity - Discharges Feb-20 .N/A .N/A .N/A 4,092 4,126 34 45,571 44,828 (742)

Other Elective Activity - Discharges Feb-20 .N/A .N/A .N/A 782 696 (86) 7,620 8,031 412

Outpatient new activity (Contracted levels achieved) Feb-20 .N/A .N/A .N/A 11,158 11,237 79 126,646 126,969 324

Outpatient Follow Up activity (Contracted levels achieved) Feb-20 .N/A .N/A .N/A 22,557 23,298 741 255,988 260,861 4,873

Ambulance Handovers Breaches -Number waited <= 15 Minutes Mar-20 .N/A .N/A .N/A 78.4% 65.3% -13.1% 67.41%

Ambulance Handovers Breaches -Number waited >15 & <30 Minutes Mar-20 .N/A .N/A .N/A 21.6% 33.9% 12.3% 31.70%

Ambulance Handovers Breaches-Number waited >30 & < 60 Minutes Mar-20 .N/A .N/A .N/A 0.0% 0.7% 0.7% 0.73%

Ambulance Handovers Breaches -Number waited >60 Minutes Mar-20 .N/A .N/A .N/A 0.0% 0.1% 0.1% 0.16%

Proportion of patients scanned within 1 hour of clock start (Trust) Jan-20 48.0% .N/A .N/A 48.0% 52.6% 4.6% 48.0% 48.0% 0.0% 48.0% 47.8% -0.2%

Proportion directly admitted to a stroke unit within 4 hours of clock start Jan-20 75.0% .N/A .N/A 75.0% 59.6% -15.4% 75.0% 55.9% -19.1% 75.0% 55.4% -19.6%

CURRENT MONTH YEAR-TO-DATE YEAR END FORECAST

Activity

National

Target

National

Benchmarking

Peer

Benchmarking Category Indicator

Latest

Month

Reported

Cancer

NHSI Compliance

Framework

Stroke

Ambulance

Handover Times

NOTES 2Trend Graph (April 17 - stated month)

Percentage of eligible (according to RCP Guideline minimum threshold) given

Thrombolysis (Trust)Jan-20 90.0% N/A N/A 90.0% 100.0% 10.0% 90.0% 100.0% 10.0% 100.0% 100.0% 0.0%

Percentage treated by a stroke skilled Early Supported Discharge team Jan-20 40.0% .N/A .N/A 40.0% 84.1% 44.1% 24.0% 77.8% 53.8% 24.0% 77.6% 53.6%

Percentage discharged given a named person to contact after discharge Jan-20 95.0% .N/A .N/A 95.0% 95.5% 0.5% 80.0% 97.4% 17.4% 80.0% 97.5% 17.5%

Cancelled Operations (For non-medical reasons) Mar-20 N/A 1.1% 1.0% 1.6% 0.6% 0.8% 1.2% 0.4% 0.8% 1.2% 0.4%

Cancelled Operations-28 Day Standard Mar-20 .N/A .N/A 0 3 3 0 12 12

Out Patients: DNA Rate Mar-20 7.5% 6.79% .N/A 7.6% 11.6% 4.0% 7.6% 10.3% 2.7% 7.6% 10.3% 2.7%

Out Patients: Hospital Cancellation Rate Mar-20 .N/A .N/A 4.5% 21.7% 17.2% 4.5% 14.4% 9.9% 4.5% 16.8% 12.3%

Theatre Utilisation Mar-20 .N/A .N/A 87.0% 81.1% -5.9% 87.0% 83.8% -3.2% 87.0%

Clinic Utilisation Mar-20 .N/A .N/A 95.0% 81.6% -13.4% 95.0% 89.9% -5.1% 95.0%

Emergency Readmissions within 30 days (PbR Methodology) Mar-20 .N/A .N/A 5.7% 6.3%

Length of Stay (21 Days) - Number of Patients As at 30/01/2020 Mar-20 N/A N/A 71 53 -18 53

Length of Stay (21 Days) - Number of days As at 30/01/2020 Mar-20 N/A N/A 2597 2597

DTOC -Total Delays Feb-20 N/A N/A N/A 419

DTOC - Total Whole Bed Days Feb-20 N/A N/A N/A 20346

DTOC - % Feb-20 2.81% 4.08% 3.0% 2.06% -0.94%

Infection Control C.Diff Jan-20 .N/A .N/A 4 3 -1 37 40 3

Infection Control MRSA Jan-20 .N/A .N/A 0 0 0 0 1 1

HSMR (rolling 12 Months) Sep-19 100 100.0 83.6 -16.4 100.0 98.9 -1.1

HSMR : Non-Elective (rolling 12 Months) Sep-19 100 100.0 98.6 -1.4

HSMR : Elective (rolling 12 Months) Sep-19 100 100.0 112.4 12.4

Never Events Jan-20 0 0 0 0 3 3

Sis Jan-20 7 50

Safe

Effective

Stroke

Theatres &

Outpatients

N/A

2019-20 Pressure Ulcers Dec-19 56 13 71

2019-20 Pressure Ulcers

(Severe Harm SI)Dec-19 0 23


(Other)Dec-19 13 48

Falls that result in a serious Fracture Jan-20 0 3

SPECIFIC THEMES :

% of patients achieving Best Practice Tariff Criteria Feb-20 52.6% 50.0% 50.3%

36 hours to surgery Performance Feb-20 55.3% 54.0% 54.2%

72 hours to geriatrician assessment Performance Feb-20 94.7% 91.3% 91.5%

% of patients who underwent a falls assessment Feb-20 100.0% 96.8% 97.1%

% of patients receiving a bone protection medication assessment Feb-20 100.0% 97.2% 97.5%

% who underwent a pre-operative AMTS Assessment (Delirium Assessment) Feb-20 100.0% 96.6% 96.7%

Mortality-Deaths within 30 days of procedure Feb-20 5.3% 6.0% 5.7%

NHS England NHFD Benchmarking

95.70%

95.80%

97.20%

62.10%

Fractured Neck of

Femur

Safe

N/A

N/A

N/A

N/A

Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust PERFORMANCE EXCEPTION REPORT – March 2020

1

(A) 4hr Access Target

Trust

The 4 hour access target was not met in March 2020 with 87.97% achievement against a target of 95% ‐

in comparison to 93.08% in March 2019. The Trust managed 12396 ED attendances across sites and

streams during March 2020. This is 2655 less patients than in march 2019, a 17.7% decrease. 1491

patients were not treated within 4 hours – this is 449 more than in March 2019. Breach reasons are

outlined below with the main two categories remaining “Review by / to see A&E doctor”.

To support the Covid‐19 response, both Emergency Departments have been spilt into Yellow and blue areas, which has split both departments down the middle. These changes have taken a few weeks to fully embed and have delayed some pathways in the interim; however staff are now working fully with the new process. During March 2020 – particularly during the ‘lockdown period’ both Emergency Departments have seen a large reduction in patients attending with minor illness / injury – these figures would have previously increased our denominator improving performance. Number of patients attending the main Emergency Department and Resus areas have remained similar to that of previous months. Processes are being reviewed on a regular basis to ensure the newly introduced triaging criteria for Covid 19 remains effective. Following a temporary pause on recovery plans for 4 hour performance due to COVID, the teams are now developing a fresh approach to ensuring performance improves. Performance needs to improve and this should be possible with the reduced attendance, and now plans for COVID are in place.


2

Doncaster Royal Infirmary

The 4 hour access target was not met in March 2020 with 83.63% achievement against a target of 95% ‐

in comparison to 91.57% in March 2019. DRI managed 7183 ED attendances across streams, during

March 2020. This is 2069 less patients than in March 2019 seeing a decrease of 22.4%

In March 2020 14.78% of attendances were streamed from FDASS compared to 11.74% streamed in March 2019 Bassetlaw District General Hospital The 4 hour access target was not met in March 2020 with 90.86% achievement against a target of 95% ‐

in comparison to 93.86% in March 2019

BDGH managed 3347 ED attendances across streams during March 2020. This is 922 less patients than in

March 2019 seeing a decrease of 21.6%

In March 2020 8.04% of attendances were streamed from FDASS compared to 10.21% streamed in

March 2019.

Mexborough Urgent Treatment Centre

The 4 hours access target was met in March 2020 with 99.52% against a target of 95% in comparison to

100% in March 2019

MUTC managed 1866 attendances during March 2020. This is 336 more patients than in March 2019

seeing an increase of 18.1%

Ambulance Breaches

Month Hospital

Total

Arrivals by

Ambulance

Less Than

15 Minutes

(Includes

15:00:00)

% Less than

15 Minutes

Between

15 & 30

Minutes

% Between

15&30

Minutes

Total Waits 30‐60

Minutes 2019‐20

% Waits 30‐60

Minutes 2019‐20

Total Waits over 60

Minutes 2019‐20

% Waits over 60

Minutes 2019‐20

Longest Wait (Hours

and Minutes) 2019‐

20

Total % Over 30

including all them

over 60 2019‐20

Doncaster Royal

Infirmary 1968 1419 72.10% 540 27.44%6 0.30% 3 0.15% 02:12 0.46%

Bassetlaw Hospital 794 385 48.49% 396 49.87% 12 1.51% 1 0.13% 01:14 1.64%

Trust 2762 1804 65.31% 936 33.89% 18 0.65% 4 0.14% N/A 0.80%

Mar‐20

During March 2020, although there has been a decrease in ambulance arrivals in comparison to March 2019, the month was particularly challenging as the Trust was moving in to the COVID planning phase, and daily changes to guidance meant the processes related to hospital handover were being reviewed and changed on a daily basis. Moving in to April this process has become more robust with the collaboration between DBTH and YAS / EMAS.

All breaches over 30 minutes were investigated and escalated as appropriate.


3

(B) Referral to Treatment (RTT) The Trust achieved a month end position of 90.1% for March 2020. Taking a baseline position of 18th March 2020 (pre‐covid impact), the Trust achieved 91.7%. Due to the Trust’s response to Covid, from 18th March 2020 onwards routine operating and outpatient activity was significantly scaled down ‐ which meant the RTT position also started to fall. The Trust Information Department have modelled the final RTT position if Covid had not hit. The Trust would have achieved 92.7% without the impact of Covid, hitting the year‐end target and comfortably exceeding the 92 % standard. A more detailed breakdown of RTT performance is given in the Trust Wide Year End Plan – 18 weeks delivery paper.

The following table summarises the position by specialty compared to the national target of 92%

Speciality Under 18 Weeks 18 Weeks + Total Percentage

BREAST SURGERY 181 5 186 97.30%

CARDIOLOGY 1639 178 1817 90.20%

CLINICAL HAEMATOLOGY 104 2 106 98.10%

DERMATOLOGY 1234 51 1285 96.00%

DIABETIC MEDICINE 515 53 568 90.70%

ENT 2706 217 2923 92.60%

GENERAL MEDICINE 1754 77 1831 95.80%

GENERAL SURGERY 1786 213 1999 89.30%

GERIATRIC MEDICINE 141 11 152 92.80%

GYNAECOLOGY 1174 44 1218 96.40%

MEDICAL OPHTHALMOLOGY 271 15 286 94.80%

NEPHROLOGY 100 100 100.00%

OPHTHALMOLOGY 1889 183 2072 91.20%

ORAL SURGERY 1670 293 1963 85.10%

ORTHODONTICS 95 3 98 96.90%

PAEDIATRIC CARDIOLOGY 71 6 77 92.20%

PAEDIATRIC ENDOCRINOLOGY 46 5 51 90.20%

PAEDIATRIC EPILEPSY 30 30 100.00%

Incomplete Pathways March 2020 February 2020

Total (Trust) 26999 29360

% under 18 Weeks (Trust) 90.1% 90.4%

Total (Doncaster CCG) 15904 17716

% under 18 Weeks (Doncaster CCG) 90.7% 90.9%

Total (Bassetlaw CCG) 5266 5830

% under 18 Weeks (Bassetlaw CCG) 91.3% 91.1%


4

PAEDIATRICS 547 21 568 96.30%

PAIN MANAGEMENT 265 7 272 97.40%

PODIATRY 149 15 164 90.90%

RESPIRATORY MEDICINE 778 62 840 92.60%

RHEUMATOLOGY 577 112 689 83.70%

TRAUMA & ORTHOPAEDICS 4565 835 5400 84.50%

UPPER GI SURGERY 77 23 100 77.00%

UROLOGY 1246 181 1427 87.30%

VASCULAR SURGERY 400 27 427 93.70%

Grand Total 24054 2646 26700 90.10%

52 Week Breaches During March 2020, the Trust reported 1 x month end 52 week breach for:‐

Head & Neck (ENT & OMFS) – Derby & Derbyshire CCG Additionally two “in month“ breaches were reported:

One ophthalmology patient who was declared as a breach end of February and was subsequently treated in February

One diabetic patient whose diagnostic result was delayed due to COVID. The patient was treated before month end

A full breach report has been completed. The patient was not visible on the PTL due to an incorrect clock stop being recorded in the patient pathway. RTT training and improved administrative systems will mitigate against further similar breaches. It should be noted that with the cessation of routine elective work, there are likely to be 52 week breaches in April onwards until routine work resumes and the backlog is addressed. As part of its recovery plan and return to a new Business as Usual, following the initial COVID wave, the Trust now needs to move urgently to reinstate work to improve underpinning administrative and validation processes, building on progress made before COVID.

(C) Diagnostics The Diagnostic target was not met for March 2020 with 89.89% achievement against a target of 99%.

Exam Type <6W >=6W Total PerformanceLongest Breach (weeks)

MRI 1348 129 1477 91.27% 16

CT 1929 179 2108 91.51% 14

Non‐Obstetric Ultrasound 3806 549 4355 87.39% 18

Barium Enema 0 0 0 ‐

DEXA 178 5 183 97.27% 7 (x2)


5

Audiology 246 46 292 84.25% 11

Echo 101 0 101 100.00% ‐

Nerve Conduction 111 14 125 88.80% 8 (x5)

Sleep Study 27 0 27 100.00% ‐

Urodynamic 45 44 89 50.56% 28

Colonoscopy 234 0 234 100% ‐

Flexible Sigmoidoscopy 82 0 82 100% ‐

Cystoscopy 308 19 327 94.19% 12

Gastroscopy 346 0 346 100% ‐

Total 8761 999 9760 89.89% 28

Performance for the Trust, NHS Doncaster and NHS Bassetlaw is outlined below:

Waiters <6W

Waiters >=6W

Total Performance

Trust 8761 985 9746 89.89%

NHS Doncaster 5651 628 6279 90%

NHS Bassetlaw 2169 267 2436 89.04%

Missed Targets: Performance of the majority of diagnostic modalities has been severely impacted by Covid 19 as demonstrated in the table above. Due to the National & Local response to Covid 19, from 18th March 2020, the majority of the Trust’s routine activity ceased, thus limiting our ability to see patients already in the system, and those referred in within the 6 week timeframe. Services continue to see urgent & 2ww patients. It should be noted that with the cessation of routine elective work, performance against this standard will continue to be affected, but the Trust will closely track this to ensure as routine work returns, there is full understanding of what needs to be done to get waiting times back on track.

(D) Cancer Performance February 2020 All 31 day nationally reported measures were achieved in Cancer performance for February 2020. With the exception of 62 day screening, none of the 62 day nationally reported measures were achieved in Cancer performance for February 2020. Cancer Performance – February 2020

Standard Target Local Performance

31 Day Classic 96% 99.2%

31 Day Sub – Surgery 94% 100%

31 Day Sub – Drugs 98% 100%

62 Day – IPT Scenario Split 85% 72.7%

62 Day 50/50 Split 85% 75.5%


6

62 Day – Local Performance (local measure only) 84.7%

62 Day – Shared Performance only 50/50 Split (local measure only) 37%

62 Day Screening 90% 93.3%

62 Day Consultant Upgrades (local measure only) 85% (local) 84.2%

Cancer Performance by Specialty – February 2020

31 Day ‐ Classic

31Day Sub ‐ Surgery

31 Day Sub ‐ Drugs

31 Day Sub ‐ Palliative

62 Day – Classic 50/50 split

62 Day – Day 38 IPT split

62 Day Screening

62 Day Consultant Upgrades

Operational Standard

96% 94% 98% 94% 85%

85% 90%

85% (locally agreed target – no national standard)

Breast 100% 100% 100% 100% 90.9%

Gynaecology 100% 87.5% 75% 100%

Haematology 100% 100% 100% 100%

Head & Neck 100% 33.3% 28.6%

Lower GI 100% 50% 42.9% 100%

Lung 100% 90.9% 90.9% 70%

Skin 100% 96.6% 93.3%

Upper GI 100% 33.3% 28.6% 100%

Urological 97.3% 63.3% 63.3% 100%

Performance 99.2% 100% 100% 75.5% 72.7% 93.3% 84.2%

Cancer Performance Exceptions – February 2020

CWT Standard

Tumour Group

Performance against standard

High Level View

62 day

(using 6

scenario

data)

Gynaecology 75% 1 Patient – Shared care, pathway delays to investigations &patient choice

H&N 28.6% 4 Patients – All Shared care, all pathway delays to investigations

Lower GI 42.9% 4 Patients – 3 local pathways – 1 Complex diagnostic pathway , 2 clinical

decision altered treatment plan . 1 Shared Care pathway ‐ Complex

Diagnostic pathway Upper GI 28.6% 4 Patients – All Shared care – 1 diagnostic pathway delay, 1 adherence to

Clinical Trails, 2 Complex Diagnostic pathways . Urology 63.3% 11 Patients – 5 Shared Care – All delay to diagnostics. 6 Local Pathways ‐ 2

Complex Diagnostic pathway, 1 treatment delayed for medical reasons , 4

histology delays due to capacity 62 day consultant upgrade

Lung 70% 2 Patients – Both Shared Care ‐ 2 Complex Diagnostics Pathway, 1 pathway

delay around diagnostic results


7

62 Day Cancer Performance by CCG – February 2020

31 Day ‐ Classic

31Day Sub ‐ Surgery

31 Day Sub ‐ Drugs

62 Day – Classic 50/50 split

62 Day Screening

62 Day Consultant Upgrades

Operational Standard

96% 94% 98% 85% 90% 85% (locally agreed target – no national standard)

Doncaster CCG 100% 100% 100% 71.1% 100% 85.7%

Bassetlaw CCG 100% 100% 100% 80.5% 0% 66.7%

Key Issues

Delays in histology reporting

Complex Diagnostic Pathways

Medical Reason linked to Treatment planning delays

Patient Choice

Capacity issues at Tertiary Centre – Oncology OPD and Treatment

Capacity issues OPD at DBTH As part of COVID planning, the Trust has implemented a number of changes to ensure cancer patients are kept safe during this period. This includes protected operating for urgent cancer cases and other urgent electives, alongside protected inpatient and outpatient facilities at Parkhill. Vulnerable patient groups are also being protected and cohorted on the Chatsfield Suite. Additionally, a weekly Cancer Management Team meeting has been implemented with focused information reports to ensure both the solutions are working – and the impact on cancer pathways are closely monitored through the COVID period.

(E) Stroke Performance January 2020 The Direct Admission to Stroke Unit target was not met in January 2020 with 59.6% achievement against a target of 75%. The scan within 1 hour target was met in January with 52.6% against a target of 48%.

CCG

Direct Admission within 4 Hours Bassetlaw Doncaster Barnsley Rotherham Other Total

Yes 6 24 3 0 1 34

No 8 14 0 0 1 23

Grand Total 14 38 3 0 2 57

Performance 42.9% 63.2% 100.0% 0 50.0% 59.6%


8

Breach Breakdown

Category Sub Category Total

Organisational Stroke Unit Bed Availability 4

Pathway Delay in Transfer from ED 9

Delay ‐ transport BDGH to DRI 1

Clinical

Patient Presentation: secondary / late diagnosis of stroke. 6

Patient Needs 2

Exclude – Hospital Stroke 2

Further Investigation Required 1

Longest delay for direct admission: 2 days, 19 hours, 31 minutes – booked in to ED as UTI – re‐assessed days later and referred to stroke pathway. The direct admission into stroke whilst showed a slight improvement in October, then deteriorated during November‐January. The stroke unit has been extremely busy, as has both EDs at DRI and Bassetlaw. There were 4 hour breaches within EDs along with admitting capacity being stretched and additional beds being created on ward 17. The stroke Improvement Plan has now been agreed for 2020/21 and this is summarised below Issue Identified Improvement Planned Responsible Lead Timescale

Review clinic capacity in light of additional medical workforce now

in post and future development opportunity for SNP / ACP led clinicsPeter Anderton May‐20

Review clinic coding and clinic outcome documentation to ensure all

activity is recorded correctly.Julie Butler May‐20

Implementation of HASU / ASU pathway changesReview and update Operational Policy – include new patient

pathways, protocols and SOPsDinesh Chadha Dec‐20

Late diagnosis resulting in delays to stroke unit within 4 hours

to stroke unit

Development of Intra‐cranial haemorrhage pathway to improve early

stroke diagnosisAmhad Maatouk Jun‐20

Delay in 4 hour admission to stroke unitAdvanced Clinical Practitioner role introduced to increase specialist

outreach into ED for early identification of stroke patients.ACP team Oct‐19

Qii project to include all stakeholders:

ED

CT

Stroke team

Site management team

Use SSNAP data to focus on the key areas and draw up an action

plan, identifying quick wins and longer term objectives

Future development of post stroke spasticity managementDevelopment of Post Stroke Spasticity Management for the

prevention of contracture and deformity following stroke

Syed Zafar / Ahmad

Maatouk

2020/2021 ‐ specific

timescales to be agreed

following return to BAU.

System wide pathway review to improve overall performance

for inpatient admissions.

John Brinkley / Alice

Waweru / Julie

Butler

Delayed due to Covid‐19.

Timescales to be set in

line with return to BAU.

Failure to achieve TIA BPT

(F) Cancelled Operations The cancelled operations on the day (for non‐clinical reasons) target was not met in March 2020 with 1.55% achievement against a target of 1%. This equated to 66 operations being cancelled.

CCG Name Apr‐ 19

May‐19

Jun‐ 19

Jul‐ 19

Aug‐19

Sep‐19

Oct‐ 19

Nov‐19

Dec ‐ 19

Jan – 20

Feb – 20

Mar‐ 20

Year to Date

TRUST 0.83% 0.98% 0.91% 1.47% 0.91% 1.13% 1.63% 1.26% 1.41% 1.67% 1.17% 1.55% 1.24%

Of which Theatre Cancellations

0.39% 0.52% 0.59% 0.96% 0.66% 0.66% 0.51% 0.79% 0.93% 0.85% 0.57% 0.71% 0.67%

Of which Non‐Theatre Cancellations

0.43% 0.46% 0.32% 0.51% 0.25% 0.47% 1.13% 0.47% 0.49% 0.82% 0.59% 0.85% 0.57%

NHS DONCASTER CCG 0.77% 1.11% 1.05% 1.15% 0.92% 1.11% 1.58% 1.25% 1.42% 1.83% 1.14% 1.54% 1.24%

Of which Theatre 0.38% 0.56% 0.65% 0.93% 0.70% 0.68% 0.46% 0.82% 0.81% 1.01% 0.49% 0.73% 0.68%


9

Cancellations


0.38% 0.56% 0.40% 0.23% 0.22% 0.43% 1.12% 0.43% 0.61% 0.81% 0.65% 0.81% 0.55%

NHS BASSETLAW CCG 1.02% 0.79% 0.85% 2.53% 1.04% 1.15% 1.91% 0.97% 1.11% 1.57% 1.10% 0.95% 1.25%

Of which Theatre Cancellations

0.65% 0.44% 0.76% 0.94% 0.66% 0.53% 0.52% 0.62% 1.01% 0.44% 0.55% 0.53% 0.63%


0.37% 0.35% 0.09% 1.59% 0.38% 0.62% 1.39% 0.35% 0.10% 1.14% 0.55% 0.42% 0.62%

Category Sub Category Total

Non Clinical Cancellations on the Day

(Theatre & Non Theatre)

Staffing Issues 17

Insufficient Time 17

Other Urgent Cases 9

Equipment Issues 6

No Elective Bed 4

Other 13

28 Day Cancellations During March 2020, 21 cancelled operations were not re‐booked & undertaken within 28 days due to the cancellation of the majority of routine surgery due to Covid 19 from mid‐March 2020 onwards. Due to the number & nature of breaches, a full breakdown of each breach will not be given until routine surgery is reinstated. The Division has set up a theatre cancellation task & finish group to look at the main reasons for cancellations on the day. Action plans will be created for each of the main reasons & progress will be monitored through the T&F group with updates reported via the Accountability Framework. This was set up pre‐covid cancellations, but work will resume when business as usual recommences.

Length of Stay In response to the national guidance ‘COVID‐19 Hospital Discharge Service Requirements’ published in March 2020 – partners in Doncaster and Bassetlaw have worked together to

‐ ensure capacity in the system to manage discharges from hospital e.g. bed bases and access to packages of care

‐ develop a single point of access and ‐ enhance community services to further develop the discharge to assess model.

There are daily operational conference calls with partners to discuss pathways, specific patients and any pressures or obstacles to discharge. With the recent increasing incidence of Covid‐19 in care homes and bed bases, further guidance was issued advising swabbing of all patients due to be discharged to care homes. Over the last week, this has affected our ability to discharge permanent residents and new admissions to care homes. Partners continue to work together to identify solutions to manage these discharges and keep patients safe.


10

Following the publication of the Covid Workbook/report (submitted daily), the guidance identified that this replaced the weekly DPTL submission, so to date, there have been no further specific LOS reports completed. Average Length of Stay The following charts track average LOS for elective and non‐elective LOS over time. For future reports, this will be benchmarked against peer groups.

Super‐Stranded Patients


11

* The exclusions are as follows, based the data available on each snap shot date;

Any patient who was at Montagu Hospital

Any patient under the care of Rehabilitation

Any patient aged under the age of 18

Any patient on ward PARK, BARL, EPAU, ECL, ED WARD and DIS Delayed Transfers of Care (DTOC) DToCs are not being collected currently as we have KPIs against the new discharge guidance, 2hr turnaround which has not been met by any patient. This has been superseded by the necessity for swabbing all patients being discharged to Care Homes.

Quality & Patient Safety ‐ Executive Summary Board of Directors

March 2020

In July 2019, NHS improvement changed the definition of Patient safety to be about maximising the

things that go right and minimising the things that go wrong. It is integral to the NHS' definition of

quality in healthcare, alongside effectiveness and patient experience.

At DBTH, Patient Safety incidents are subject to initial scoping, investigation and conclusion,

therefore the data can sometimes change upon the conclusion of the investigation, once all facts

and outcomes are known. The information and data provided in the BIR are accurate at the month

end.

Patient Safety

Serious Incidents There were 22 Serious Incidents (SI) reported as Care Issues in 2019/20. This included four Never

Events. Two of these Serious Incidents were investigated by the Healthcare Safety Investigation

Branch (HSIB) as SI and a further two incidents investigated by HSIB that did not meet the threshold

for SI.

Two new Serious Incidents for care issues were reported in March 2020. One was a patient who died after contracting Clostridium difficile and the other one was delayed treatment for a patient with diagnoses if cancer. Both incidents are being investigated with patients and staff being supported through the process. Falls There have been a total of 47 falls with moderate or severe harm to patient’s this year. Four of these

incidents were escalated as a Serious Incident due to the significance of harm suffered by the patient

and the lapse in the care we provided. Two of these falls were on CDU at DRI, one on ward 16 and

one on S11.

27 of these patients suffered severe harm as a result of their fall. This includes 24 patients who

sustained a fractured neck of femur and three severe head injuries resulting in subdural haematoma.

20 of these patients suffered moderate harm as a result of their fall. All falls are investigated using

the Trust Multi‐disciplinary Inpatient Falls Investigation Tool (MiFIT).

Work continues with the new falls accreditation, which was introduced on 1 April this year. This

focuses on the proactive work the inpatient areas can do to reduce falls (audit, education and falls

link champions training). End of year accreditation will be shared at the celebration event which is to

be rescheduled.

Learning from falls was the focus in the March Sharing How We Care Newsletter. This will include all

the relevant points covered in the revised Royal College of Physicians National Audit of Inpatient

Falls (2019).

Hospital Acquired Pressure Ulcers There have been 94 Hospital Acquired Pressure Ulcers (HAPU), Category 2 and above this year to

date. Of these cases, 56 HAPU were Category 3 and 26 of these were escalated as a Serious Incident

due to the harm and lapse in the care we provided.

Following a Quality Improvement event on 29 January, the proposed changes to HAPU reporting

were approved by the Trust Clinical Governance Committee and local CCG. From April 2020, all

pressure ulcer reporting will be aligned to NHS improvement. HAPU 3 will be reported as a moderate

harm with local investigation and no escalation to Serious Incident.

Following a successful business case, static mattresses and chairs have now been replaced in the

Trust, with 150 additional dynamic mattresses now purchased.

The Trust previously had an internal dashboard system to report HAPU to the skin integrity team and

a large scale piece of work to integrate the dashboard into datix‐web completed mid‐December,

with further modifications continuing to ensure consistency in reporting and avoid duplication for

clinical areas. This has resulted in a rise in incidents being reported, but is in line with the NHS

improvement recommendations around reporting of HAPU.

Work is continuing with the new skin integrity accreditation, which was introduced on 1 April 2020.

This focuses on the proactive work the inpatient areas can do to reduce HAPU (audit, education and

champions training). Additional dates have been provided to meet the demand for training.

Infection Prevention and Control

Clostridium difficile There have been 45 cases of Clostridium difficile with 32 cases hospital onset, hospital acquired

(HOHA) and 13 cases community onset, hospital acquired (COHA). There have been no lapses in care

identified from the patients. All antibiotic prescribing has been appropriate.

Learning is also included in the IPC memo sent to all Trust staff, which has highlighted that known

patients with CDiff are being tested when they do not have symptoms. A process has been agreed

that only registered nurses can agree to sample. The functionality of ICE is being reviewed to ensure

only appropriate samples are tested.

The deep clean annual plan has been agreed and the process to ensure beds are available for

cleaning to take place.

MRSA bacteraemia There were two cases of MRSA bacteraemia, one in October 2019 and the other at the end of March 2020, with no lapse in the care of the patient identified. MRSA Colonisation

There have been 12 cases of MRSA colonisation year to date.

Patient Experience

There have been 473 formal complaints, for the financial year 2019/20 (1st April 2019‐ 31st March

2020). 24 formal complaints were received in March which is the lowest reported figure of the year .

The top themes from the formal complaints were communication, treatment, attitude & behaviour

and Diagnosis which are monitored through the patient experience and engagement committee

(PEEC),although this is currently stood down and reported directly to QEC/CGC.

A COVID‐19 Dashboard has been set up and there has been 1 complaint related to discharge, 1 ACQ

related to delay in surgery and 3 concerns related to appointments to date.

There are 39/146 complaints that are overdue at the time of writing. In response to the overdue

complaints, the whole complaints process was mapped in November 2019. Further work to improve

the process has continued with a third date held in January 2020. The new process was to launched

in April 2020 but has been paused in relation to the COVID ‐19 pandemic. However a new stream‐

lined process has been implemented to review all Complaints and Concerns working with the

Complainant and Divisions to either respond or pause for 3 months in line with National Guidance.

The PALS team are trialling a new RAG (Red, Amber, Green) rating system which will be pivotal to

the new process.

There is no FFT data for March 2020‐as this has been paused in line with COVID‐19 National

Guidance. The Friends and Family Test (FFT), was due to relaunched nationally from 1st April 2020

but this has been deferred until September 2020. Work has continued on developing the new FFT

card to allow better feedback about care. PALS team will be collating FFT data once this resumes,

and will be focussing on both the quantitative and qualitative aspects of the data.

To proactively manage the changes to visiting and specifically visiting patients receiving end of life

care, new arrangements have quickly been put into place. This includes;

Virtual Visiting

Using 20 existing tablets, these have been enabled to be used in the ward areas. Families can call

their loved ones in hospital and facilitated by the ward team, have a video conversation. Further

tablets have been requested on the amazon wish list.

Comfort hearts

Following an appeal to members of the public, comfort hearts are being knitted, sewn or crocheted

in pairs to allow one to stay with the patient and one to stay with the family. There has been a huge

response from within the community to provide these hearts and the teams are ensuring everyone

who would like to take part has what is required.

Letters to Loved Ones

Families can email in a letter, which the end of life team are printing off and giving to the patient on

the same day. This is also providing some comfort to patients and families at a time where they can’t

be together.

Telephone support

The End of Life team are picking up referrals and working with ward areas to communicate bad news

to families of the patients. This eases the pressure for the wards and provides some consistency to

the family. Arrangements for comfort hearts and letters are continued after the patient has died if

the family wish and families can be signposted to additional bereavement support if required.

Butterfly remembrance

Families are asked if they would like the name of their loves one placed on a butterfly and placed in

the hospital chapels. This will be collected during the pandemic and displayed for anyone wanted to

pay their respects. A remembrance service is being planned to take place when normal services are

resumed in the hospital.

2016 2017 2018 2019

January 116.80 99.21 94.86 105.78

February 99.94 97.73 105.44 98.13

March 90.54 97.37 88.42 101.87

April 105.91 88.50 98.37 100.82

May 101.15 96.60 91.20 92.92

June 80.27 93.67 89.98 99.43

July 92.56 97.73 107.07 105.95

August 100.27 87.52 94.65 113.58

September 90.26 95.34 90.09 84.14

October 90.29 88.66 96.74 101.90

November 88.98 82.30 99.04 89.00

December 82.30 93.52 80.45 102.95

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Trust 1.62% 1.36% 1.20% 1.28% 1.49% 1.12% 1.49% 1.26% 1.91% 1.93% 1.44% 1.69%

DRI 1.62% 1.36% 1.14% 1.30% 1.60% 1.15% 1.32% 1.22% 2.04% 1.89% 1.26% 1.76%

BDGH 1.91% 1.65% 1.61% 1.43% 1.36% 1.20% 2.36% 1.64% 1.71% 2.42% 1.57% 1.75%

HSMR Trend (monthly) Crude Mortality (monthly) - Mar 2020 (Month 12)(number of deaths/number of patient discharged)

Hospital Standardised Mortality Ratio (HSMR) - December 2019 (Month 9)

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

99.86

90

92

94

96

98

100

Feb

18

- J

an 1

9

Mar

18

- F

eb 1

9

Ap

r 1

8 -

Mar

19

May

18

- A

pr

19

Jun

18

- M

ay 1

9

July

18

- J

un

19

Au

g 1

8 -

Ju

l 19

Sep

t 1

8 -

Au

g 1

9

Oct

18

- S

ep 1

9

No

v 1

8 -

Oct

19

Dec

18

- N

ov

19

Jan

19

- D

ec 1

9

99.92

90

92

94

96

98

100

Feb

18

- J

an 1

9

Mar

18

- F

eb 1

9

Ap

r 1

8 -

Mar

19

May

18

- A

pr

19

Jun

18

- M

ay 1

9

July

18

- J

un

19

Au

g 1

8 -

Ju

l 19

Sep

t 1

8 -

Au

g 1

9

Oct

18

- S

ep 1

9

No

v 1

8 -

Oct

19

Dec

18

- N

ov

19

Jan

19

- D

ec 1

9

94.27

40

50

60

70

80

90

100

110

120

Feb

18

- J

an 1

9

Mar

18

- F

eb 1

9

Ap

r 1

8 -

Mar

19

May

18

- A

pr

19

Jun

18

- M

ay 1

9

July

18

- J

un

19

Au

g 1

8 -

Ju

l 19

Sep

t 1

8 -

Au

g 1

9

Oct

18

- S

ep 1

9

No

v 1

8 -

Oct

19

Dec

18

- N

ov

19

Jan

19

- D

ec 1

9

1.0%

1.2%

1.4%

1.6%

1.8%

2.0%

Mar

/19

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Crude Mortality(Trust)

0.5%

2.5%

4.5%

Mar

/19

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Crude Mortality(BDGH)

1.0%

1.5%

2.0%

2.5%

Mar

/19

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Crude Mortality(DRI)

Current YTD reported SI's (April-Mar 20) 57 56

Current YTD delogged SI's (April-Mar 20) 5 6

Serious Incidents - Mar 2020 (Month 12)(Data accurate as at 07/04/2020)

Overall Serious Incidents

Themes

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

Number reported SI's (Apr-Mar 19)

Number delogged SI's (Apr-Mar 19)

0.00

0.05

0.10

0.15

0.20

0.25

0.30

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Mar

/20

Pressure Ulcers - Cat 3 & 4 (HAPU) per 1000 occupied bed days

0.000.020.04

0.06

0.080.100.12

0.140.16

0.180.20

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Mar

/20

Care Issues per 1000 occupied bed days

0.00

0.02

0.04

0.06

0.08

0.10

0.12

0.14

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/19

Dec

/19

Jan

/20

Feb

/20

Mar

/20

Serious Falls per 1000 occupied bed days

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

0.40

0.45

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Mar

/20

Serious Incidents per 1000 occupied bed days

Reported Si's per 1000 occupied bed days

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

0123456789

10

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Mar

/20

Number Serious Incidents Reported(Trust & Divisions)

Clinical Speciality Services Medicine

Surgery & Cancer Children & Families

Number Reported SI's Number Reported SI's - Previous years performance

Standard Qtr 1 Qtr 2 Qtr 3 Jan Feb Mar Qtr 4 YTD Qtr 1 Qtr 2 Qtr 3 Jan Feb Mar Qtr 4 YTD

2019-20 Infection Control - C-diff 44 Full Year 9 11 17 3 2 3 8 45 HOHA 7 7 12 1 2 2 5 31

2018-19 Infection Control - C-diff 39 Full Year 6 2 7 5 0 0 5 20 COHA 2 4 5 2 0 1 3 14

2019-20 Trust Attributable 12 0 0 0 0 1 0 1 1

2018-19 Trust Attributable 12 0 0 1 0 0 0 0 1

Standard Qtr 1 Qtr 2 Qtr 3 Jan Feb Mar Qtr 4 YTD

2019-20 Serious Falls 6 Full Year 3 0 0 0 1 0 1 4

2018-19 Serious Falls 10 Full Year 1 1 3 1 0 1 2 7

Standard Qtr 1 Qtr 2 Qtr 3 Jan Feb Mar Qtr 4 YTD

2019-20 Pressure Ulcers 56 Full Year 18 20 34 6 12 4 22 94


(Severe Harm SI)9 6 12 4 7 1 12 39


(Other)9 14 22 2 5 3 10 55

Infection Control C.Diff - Mar 2020 (Month 12)

(Data accurate as at 07/04/2020)

Pressure Ulcers & Falls that result in a serious fracture - Mar 2020 (Month 12)

(Data accurate as at 07/04/2020)

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

process being completed.

Please note: At the time of producing this report there were 5 PU's

awaiting RCA

0

10

20

30

40

50

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Jan

Feb

Mar

C-diff

2019-20 C-diff Cumulative total 2019-20 CoHa Cumulative Total 2019-20 HoHa Cumulative Total

2018-19 C-diff Cumulative total Standard

0

2

4

6

8

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

Falls that result in a serious fracture

2019-20 Falls Cumulative Total 2018-19 Falls Cumulative Total

Standard

0

5

10

15

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Jan

Feb

Mar

Trust Attributable C-diff

2019-20 Trust Attributable Cumulative Total

2018-19 Trust Attributable Cumulative Total

Month

`

3

1

0

0

3

0

4

3

0

0

0

2

1

2

1

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

2019/20 4 4 11 7 8 9 4 4 5 5 4 5 70

2018/19 10 7 9 6 7 13 11 4 10 6 4 3 90

2019/20 5 4 1 4 0 2 5 3 1 1 4 0 30

2018/19 2 6 1 1 7 1 2 0 2 3 9 2 36

2019/20

7

Number Currently Outstanding

3

9

Parliamentary Health Service Ombusdman (PHSO)

Not Upheld

Case Withdrawn

Mar-20

Fully / Partially Upheld

Not Investigated

Number of cases referred

for investigation

Complaints & Claims - Mar 2020 (Month 12)Data accurate as at 07/04/2020

Complaints

Not Upheld

Outcomes

YTD

Complaints - Resolution Perfomance (% achieved resolution within timescales)

Complaints Closed - Outcome

2017/18

Number referred for

investigation

YTD

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

No further Investigation

Claims


Case Withdrawn

Outstanding

Clinical Negligence Scheme for Trusts (CNST) Not including

Disclosures

Not Investigated

2018/19

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

deadlines are excluded data.

Liabilities to Third Parties Scheme (LTPS)

0

Outstanding

No further Investigation

Not Upheld


Outstanding

4

March 2020Complaints Received

Risk Breakdown

20 Working Days

40 Working Days

90 Working Days

Year to DateComplaints Received

Risk Breakdown

0

10

20

30

40

50

60

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Mar

/20

Complaints Received

Complaints Mean UCL LCL

0

10

20

30

40

50

60

70

80

90

100

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Mar

/20

Concerns Received

Concerns Mean UCL LCL

30%40%50%60%70%80%90%

100%

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Mar

/20

Complaints Resolution Performance

0.00

0.20

0.40

0.60

Ap

r/1

9

May

/19

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Mar

/20

Number of CNST Claims per 1000 Occupied bed days

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

0

5

10

15

20

25

30

35


Act

ual

Nu

mb

er


Complaints Upheld 7 4 8 6 8 4 4 8 3 5 7 3

Complaints Partially upheld 21 31 23 14 24 14 24 14 13 13 16 17

Complaints not upheld 4 5 19 2 12 10 9 7 4 12 8 9

Outcome not reported 14 6 0 0 0 0 0 0 5 5 11 13

Closed Complaints - Outcomes


Number of complaints received - 2019/20 6 1 1 0 1 2 1 1 0 4 1 3 21

Number of complaints received - 2018/19 5 3 3 2 3 1 3 1 0 0 1 2 24

Diagnosis 10Communication 7

Staff attitude & behaviour 6

Competence 4Treatment 4Nursing - ADL 3Diagnostic Tests 3

Admissions/transfers/discharge procedure/sleeper out 3

Medication 2

Hospital Environment 2Other 1Patient equality, diversity and safety 1Nutrition & Hydration 1Medical records 1Complaint Handling 1Nursing - Continence 1Pain Management 1


Number of Datix Incidents Reported - 2019/20 33 29 35 33 29 33 36 38 28 26 37 26 383

Number of Datix Incidents Reported - 2018/19 25 31 42 34 27 27 25 52 34 26 32 34 389


Number of Serious Incidents Reported - 2019/20(including de-logged)

0 0 0 0 0 0 0 0 0 0 0 0 0

Number of Serious Incidents Reported - 2018/19(including de-logged)

0 0 0 0 0 0 0 0 0 0 0 0 0

Childrens & Young People - Quality Metrics

Mar 2020 (Month 12)(Data accurate as at 7/4/2020)

The main complaint theme is “Diagnosis” (19.61%), which breaks down to:

• Missed diagnosis (5)

• Time taken to make a diagnosis (3)

• Alleged wrong diagnosis (1)

• Disagreement between professions/organisations (1)

The second main complaint theme is around “Communication” (13.73 %)

• Breaching confidentiality (1)

• Inconsistent information between staff (1)

• Lack of information to other health professionals (1)

• Lack of information to relatives / NOK (4).

The second main complaint theme is around “Staff Attitude and Behaviour” (11.76 %)

• Abruptness/rudeness (1)

• Staff conduct / disposition (1)

• Inappropriate comments/staff calling patient by an inappropriate name (1)

• Insensitive to patient needs (2)

• Allegation of rough handling of patient (1).

Duty Of Candour (Doc)

Please note: An incident which has caused moderate, severe or patient death requires DoC to be completed

Thematic breakdown (Apr 19 - Mar 2020)

Please note that a direct correlation between the number of complaints received and the subjects within thematic breakdown can not been made as most of the complaints have more

than one subject noted.

Datix Incidents & Serious Incidents

Complaints

There have been 4 incidents within Children and Young Persons which have triggered Duty of

Candour to be completed. This was reported and the Verbal discussion completed in 75% of

cases (3/4), and Letter 1 in 50% of the records (2 out of 4). Letter 2 has been completed on

both of the closed records (100%).

0

5

10

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Jan

Feb

Mar

Workforce report – March 2020

1

Covid 19 Update

Across the People & OD directorate there has been a range of pieces of work underway as detailed above.

Recruitment Update Bringing Back Staff Scheme (BBS)

This is a national scheme co‐ordinating the return of registered (formerly registered) staff back to the NHS,

including doctors, nurses and AHPs. To date we have had the following returners offered to us and

accepted. In addition we have passed 6 nurses and midwives through to NHS Professionals:

No. Transferred for Employment No. Employed by Trust/Org

Nurses

10 2

Midwives

4 0

Doctors

3 1

Allied Health Professionals

10 1

GRAND TOTAL

27 4


2

Staff Testing – Current position DBTH took the decision to commence staff swabbing earlier than neighbouring Trusts to ensure safe staffing

levels to maintain service for the population of Doncaster and Bassetlaw. Drive‐Through Swabbing Teams

were set up at both DRI and BDGH for DBTH staff but also providing support to partner organisations

(RDASH, Doncaster CCG, Bassetlaw CCG and Primary Care) to enable swabbing of key staff.

Between 23 March and the 16 April 2020 there were a total number of 1833 DBTH staff members referred

through to the booking team. Of the 1833 staff members, 922 staff were reported as self isolating and

absent from work suffering from symptoms of Covid‐19 and providing they met the clinical criteria for

swabbing and there was sufficient capacity were tested. A further 543 members of staff were also self‐

isolating due to a member of their household being symptomatic resulting in them not being able to attend

work. For business critical members of staff, as determined by members of the Silver Command Team, a

very small number of staff family members have been tested to facilitate an early return to work. Managers

have been requested to submit information on a daily basis regarding staff unable to attend work due to

self‐isolation. 648 staff were swabbed with 130 being positive in that period. A verbal update will be

provided to the meeting.

Absence data COVID Related Absence and Return to Work Figures

Absence Reason Total Absences

Have not Returned Have Returned % returned

Carers COVID 67 26 41 61%

COVID‐19 Confirmed 36 15 21 58%

COVID‐19 Symptoms 404 55 349 86%

Medical exclusion with Covid 19 confirmed 38 11 27 71%

Medical exclusion with Covid 19 symptoms 210 40 170 81% Medical exclusion without Covid 19 symptoms

403 156 247 61%

Total COVID Related Absence 1158 303 855 74%

Absence percentages ‐ March

Absence

Occurrences

Days Lost % Rate Absence

Occurrences

Days Lost % Rate Absence

Occurrences

Days

Lost

% Rate

Doncaster & Bassetlaw Teaching Hospitals NHS FT 845.00 4883.83 2.81% 1017.00 8130.69 4.68% 1,862.00 13,014.52 7.49%

272 Chief Executive Directorate 0.00 0.00 0.00% 1.00 3.00 0.49% 1.00 3.00 0.49%

272 Children & Families Division 104.00 564.23 3.03% 127.00 1288.96 6.92% 231.00 1,853.19 9.94%

272 Clinical Specialties Division 202.00 1175.09 2.60% 270.00 2002.97 4.44% 472.00 3,178.06 7.04%

272 Directorate Of Strategy & Improvement 0.00 0.00 0.00% 1.00 2.00 0.86% 1.00 2.00 0.86%

272 Doncaster & Bassetlaw HC Services Ltd 0.00 0.00 0.00% 1.00 19.08 8.02% 1.00 19.08 8.02%

272 Education and Research Directorate 28.00 174.79 8.05% 8.00 79.00 3.64% 36.00 253.79 11.69%

272 Estates & Facilities 85.00 420.43 2.99% 98.00 708.80 5.04% 183.00 1,129.23 8.03%

272 Executive Team Board 0.00 0.00 0.00% 6.00 98.60 2.88% 6.00 98.60 2.88%

272 Finance & Healthcare Contracting Directorate 0.00 0.00 0.00% 2.00 55.80 1.35% 2.00 55.80 1.35%

272 IT Information & Telecoms Directorate 13.00 100.68 4.56% 12.00 37.14 1.68% 25.00 137.82 6.24%

272 Medical Director Directorate 0.00 0.00 0.00% 0.00 0.00 0.00% 0.00 0.00 0.00%

272 Medicine Division 244.00 1454.64 3.21% 277.00 2223.72 4.91% 521.00 3,678.36 8.12%

272 Nursing Services Directorate 8.00 55.20 2.66% 7.00 98.80 4.76% 15.00 154.00 7.41%

272 People & Organisational Directorate 9.00 68.05 3.65% 5.00 28.00 1.50% 14.00 96.05 5.16%

272 Performance Directorate 25.00 129.09 2.27% 30.00 193.29 3.40% 55.00 322.38 5.66%

272 Surgery and Cancer Division 135.00 741.63 2.65% 175.00 1291.54 4.62% 310.00 2,033.16 7.28%

Mar-20 CumulativeMar-20

COVID-19 Non- COVID-19 All Absence


3

ESR PIE Charts

eRoster daily absence ‐ April

Data from the electronic roster system is available in real time but up until recently only transferred into

ESR once a month for payment purposes. This system is used for approximately 70% of the workforce

(nursing, AHPs, estates and ancillary) so is a reasonable proxy for the whole Trust. However since 4 May

2020 we are piloting an absence hot line run by the People & OD team whereby all staff ring the line to

report their absence (as well as their manager for arranging cover) and this data is then fed into a database

which transfers to ESR and E roster several times a day. The pilot will be reviewed after 6 weeks to determine

if this approach delivers a return on investment.

0

100

200

300

400

500

600

700

800

Sickness & COVID Related Absence ‐ April 2020

Total Sickness & COVID Related Absence Medical Exclusion ‐ COVID Related Sickness (Non‐COVID) Sickness ‐ COVID Related Carers ‐ COVID Related

Title 18 weeks recovery plan


Author Claire Jenkinson, DCOO

Rebecca Joyce, COO


Decision

Assurance X

Information


This short briefing paper gives an update of the 18 week Referral to Treatment (RTT) performance at the end of March 2020. This briefing includes:

The impact of Covid 19 and a trajectory of the RTT outcome had routine activity not been

affected by COVID.

A review of performance against recovery plan trajectory and lessons learned

An update on Improving Administrative Processes and 52 week Breach Patients

Conclusions and implications of COVID for elective activity

In summary before the impact of Covid the Trust achieved a position of 91.7% on 18 March. From 18 March onwards routine operating and outpatient activity was significantly scaled down due to Covid. This meant the RTT position also started to fall. The Trust Information Department have modelled the final RTT position if Covid had not hit. The Trust would have achieved 92.7% without the impact of Covid, hitting the year‐end target and comfortably exceeding the 92 % standard. Due to the impact of Covid, the position fell to 90.1% by the end of March and significant work is now being invested into planning elective recovery.


The Board is asked to note the final position, delivery through 19/20 and the lessons learned moving into 2020/21.


D3

The delivery of strong performance is a key strategic theme for the organisation and contributes to the delivery of safe, outstanding care in line with our vision. We also need to be assured this plan supports the delivery of financial sustainability and our control total, alongside the RTT performance standard.


This report outlines the work taking place to mitigate risks on the Trust risk register related to the delivery of performance standards and specifically 18 weeks and supporting elective processes.


The Trust Board is asked to note the report.

Trust Wide Year End Plan – 18 weeks delivery

Trust Board Committee 19 May 2020

1. Introduction

This short briefing paper gives an update of the 18 week Referral to Treatment (RTT) performance at the end of March

2020. This briefing includes:

The impact of Covid 19 and a trajectory of the RTT outcome had routine activity not been affected by COVID.

A review of performance against recovery plan trajectory and lessons learned

An update on Improving Administrative Processes and 52 week Breach Patients

Conclusions and implications of COVID for elective activity

In summary before the impact of Covid the Trust achieved a position of 91.7% on 18 March. From 18 March onwards

routine operating and outpatient activity was significantly scaled down due to Covid. This meant the RTT position also

started to fall. The Trust Information Department have modelled the final RTT position if Covid had not hit. The Trust

would have achieved 92.7% without the impact of Covid, hitting the year‐end target and comfortably exceeding the

92 % standard.

Due to the impact of Covid, the position fell to 90.1% by the end of March.

2. Diagnosis of March Performance

The March 2020 position, for the benefit of this update, is reported in two elements a) the RTT position on 18 March

ie the date just prior to elective activity began to be affected with both patient and hospital cancellations and b) the

reported end of March 2020 position. In summary:

The 18 March position, once validated, stood at 91.7% after usual validation.

The end of March position, once validated and taking into account the cessation of most routine services, was

reported as 90.1%, this is a deterioration against the February position of 90.4%.

The performance trajectory for March 2020 was 92%, the reported position is clearly behind plan. However, based on

the position on 18 March 2020, the Information Department have been able to calculate that the end of March 2020

position would have been 92.7% had the delivery plans not been affected by the global pandemic.

The table below indicates the 18 March position, and where specialties delivered against the 92% standard.

Specialities which under achieved against 92% target Specialities which achieved the 92% target

General Surgery Upper GI Urology Trauma & Orthopaedics Oral Surgery Diabetes Geriatric Medicine Rheumatology

Breast Cardiology ENT Ophthalmology General Medicine Haematology Nephrology (achieved 100% on 18 March) Paediatric Cardiology (small service) Podiatry Paediatrics Medical Ophthalmology Gynaecology

N.B:

‐ It should be noted that with the exception of Geriatric Medicine, all specialties which did not achieve 92%

were making month on month improvements between January and March. Geriatric Medicine performance

delivered 91.4% on 18 March, lower than January, but as a relatively small specialty, small numbers of patients

over 18 weeks can make a big difference to % achievement.

‐ The projected March end position by specialty (see appendix 1) indicates that none of those NOT achieving

on 18 March would have achieved by the end of March, albeit some of the specialties would have been very

close.

This chart indicates which specialties need further support and focus to achieve the standard in the future, post COVID.

The detailed appendix (Appendix 1) outlines specialty level position against waiting list size (PTL) and % performance.

Appendix 2 provides further breakdown of the March 18 position specifically to show how the standard would have

been delivered.

3. Performance Against Overall Recovery Plan and Lessons Learned

The following table compares monthly delivery from August 2019 (when the recovery plan commenced) to March to

March End 2020 with performance compared to recovery plan trajectory. For March 2020, it includes the 18 March

position, along with the NO COVID projected March end performance and the March End Actual (COVID impacted):

The key themes from this table are:

From September onwards the Trust consistently over performed against the target for total waiting list size.

The initial recovery plan against % performance was not robust in November and December, with in particular,

the impact of the festive season not sufficiently taken into account for the December plan.

The revised recovery plan for % performance from Jan – March was much more robust, with significant

additional leadership action, and this was delivering largely in accordance with plan.

Key lessons learned from the reality of running the recovery plan were:

a. From January to March 2020 there was significant, widespread engagement from almost all specialties in

delivering the RTT standard and this broadly achieved results. There was also excellent team work across the

Trust including the OP Booking, Information, Performance, Finance, the Operational Divisions and Central

Operations.

b. Those specialties that achieved 92% or better had both good clinical leadership and good managerial

leadership, working effectively in partnership.

c. Some specialties had very challenging contexts and made significant improvement, albeit not reaching the

92% standard. Again, good clinical and managerial leadership working in partnership was the common feature.

On the contrary, there remain some specialties where skills, planning and confidence in delivery were assessed

not where they needed to be and this was reflected in performance which was below what the specialty should

have achieved.

d. There remain some specialties which need further support and focus to achieve the standard.

e. Along with the revised submission of specialty level activity plans to deliver required trajectory, the overall

Trust recovery plan comprised the following Trust wide themes:

Aug‐19

Sep‐19

Oct‐19

Nov‐19

Dec‐19

Jan‐19

Feb‐19

March 18th 2019

March End 2020

projected

NO COVID

impact)

March End ACTU

AL

(COVID im

pacted)

Original recovery plan trajectory 86.10% 86.20% 87.10% 88.10% 89.10% 90% 91% N/A 92% 92.00%

Revised recovery plan (Jan ‐ March) N/A N/A N/A N/A N/A 88.40% 90.60% N/A 92% 92.00%

Actual RTT Performance 85.70% 86.40% 87.10% 87.20% 86.80% 88.80% 90.40% 91.70% 92.70% 90.10%

Predicted Waiting List Size (PTL) 32609 32407 32205 32003 31801 31599 31397 31199 31199 31199

Actual Waiting List Size (PTL) 32811 32362 32277 31296 30093 29935 29362 28210 27319 26700

N.B

From Jan ‐ March Performance RAG rated against revised recovery plan

Refreshed leadership and greater leadership time at all levels

Refreshed governance: weekly COO led “Cabinet” meeting, weekly refreshed performance meeting

and weekly data report recording performance against plan

Refreshed information reports – provided detailed information to specialties on where to focus

COO led escalation meetings for high risk specialties

This approach enabled specialties to really get under the skin of their issues and make improvements,

with higher levels of accountability and focus.

f. The recovery plan’s strategy relied on the over performance of some specialties to deliver the standard.

Specialties were grouped into a number of categories:

100% Challenge Specialties – encouraging high performing specialties to go even further.

Faster, Further Specialties – specialties which could do better than their original recovery trajectory

Recovery Specialties – specialties which were unlikely to meet their original recovery trajectories, but

were expected to make consistent improvements towards those targets

Significant risks – where there was a lack of confidence in specialties delivering consistent and

sufficient upwards improvement

g. Whilst this strategy was effective in improving the Trust level performance and would have delivered 92.7%

at year‐end (without COVID), it does not represent a sustainable delivery strategy for the future. All specialties

need to work to achieve the 92% standard, so that the Trust has a more sustainable way of delivering 92%.

This aim was encapsulated in the pre‐COVID submitted annual plan which demonstrated how some specialties

would continue improvement and reach 92% in Q1 or Q2 of 20/21.

h. Administrative and clinical validation played a significant role in “cleaning up” the PTL and reducing the total

number and the importance of this in helping achieve the standard is important to note.

i. The validation model implemented Jan to March with data quality colleagues working out in the divisions

made a significant difference and is informing the revised validation model under discussion.

j. In some specialties significant work was needed to ensure patients were booked in order, and this improved

significantly in Q4 (most notably in Trauma and Orthopaedics). With this change, the planned delivery plan

then started to deliver in line with expectation.

k. There is still work to do to ensure all specialties deliver their core activity plan although understanding of

activity against contractual plans and RTT plans improved through this period of focus, supported through a

weekly dashboard developed by the information team.

It should be noted this paper does not include a costed assessment of the delivery of the activity plan, including the

additional income for private work and validation supported received from NHS England and this should be completed

as a final step in pulling together lessons learned.

4. Improving Administrative Processes and 52 week Breach Patients

Alongside the action plan to achieve the 92% standard and the total waiting list size standard, there was a clear

commitment to improving underlying administrative processes. This followed a high number of 52 week breaches

through 2018/19 and into 2019/20, which related to historic clock stop errors.

In terms of 52 week breaches, the following table summarises the picture from 18/19 and into 19/20. Whilst this shows

an improving trend, there remain too many 52 week breaches reported in 20/21.

To improve this, an action plan was pulled together. The table below gives a high level summary of the themes of the

plan and the progress made.

Theme of Plan Progress

Internal validation Validation proposal developed for Divisional focus and actions required to support this.

NECs validation Main NECS validation project complete. 2nd and 3rd line validation within Divisions still outstanding in some areas due to a) capacity b) skill in making system changes – majority of pathways have been reviewed by clinical teams.

Governance Governance model agreed

Performance Assurance Framework developed to monitor and give oversight of Patient Treatment Lists and validation of these lists.

Accountability meetings to oversee and challenge performance against KPIs

Missing Outcomes currently at lowest level

Procurement PIN notice currently live for patient pathway software to support staff in managing patient pathways more effectively and aiding validation.

Training Interim RTT trainer undertaken Programme of training over 5 months

Programme to continue with the commencement of the substantive appointment in May 2020

Appointment of a substantive RTT Trainer (start date 11 May 2020)

PPW (PAS) training has not been completed, due to the limited Training resource and inability of Divisions to release staff‐would propose ePPW to be rolled out

Communications Strategy has been communicated to Exec Team, GMs and Senior Leaders

Data Quality Group introduced throughout NECs project

Introduction of a Patient Administration Group to commence May 2020

Process SOPs within Central Outpatients have been developed

Ongoing improvement and refinement of processes with take place at the Patient Administration Group

E‐reconciliation has been rolled out within Medical Ophthalmology, however, roll out plan interrupted by Covid 19

Strategy “Outstanding Administration Strategy and Programme”.

Strategy Agreed

Action plan developed which focusses on o Training o Structure o Process

o People

Whilst, progress has been made in these areas, there is further work required and this needs to pick up following the

COVID crisis to progress the improvement of underlying administrative booking and RTT processes to ensure our

management of elective pathways are as effective as possible. An early priority will be agreeing and implementing the

new model of validation, to ensure a locally owned model of validation by divisions, whilst maintaining appropriate

data quality spot audits to ensure we have the right DQ oversight and governance.

5. Conclusions

The Recovery Plans which were developed and focused on following January demonstrate the Trust was well on track

on 18 March to deliver the 92% standard as a Trust, and indeed the modelled March end position (without the impact

of Covid) shows the Trust would have met its planned recovery. The overall position would have been delivered as a

number of specialties achieved higher trajectories to offset underperformance against the standard elsewhere.

There are lessons to be learned from the overall recovery plan which commenced in August, and areas of planning

which could have been improved. However, delivering 91.7% on 18 March demonstrates the Trust was on course to

deliver 92.7% at the end of March, had COVID not happened. This represents a significant achievement.

The exercise has demonstrated to the Trust and its partners, that achieving RTT and the systems and processes to

deliver this are understood and that the skills and belief are now in place to continue on this journey, once elective

services begin to return to some degree of normality. Crucial to this will be – as set out in the annual plan pre‐COVID

‐ both ensuring that all specialties reach the standard (rather than relying on over performance by some) and resuming

the work to improve administrative processes.

The RTT performance will continue to reduce due to COVID. At the end of March, the actual position was 90.1%. The

Trust is beginning to embark on new plans to be developed in readiness for the reintroduction of routine elective

workload. These plans will need to consider:

The speed on reintroducing routine elective surgery

The delivery of outpatient services via different media (telephone, video and face to face)

Potential surge in GP referrals

The impact of significantly reduced referrals during March/April, approximately 60% reduction

Likely challenging winter months, due to normal winter pressures combined with the likely pressure of Covid.

6

TFC

Specialty RTT (16

Aug 19 )RTT

Aug 19

Wg List

Aug 19

RTT

Sept 19

Wg List

Sept 19

RTT

Oct 19

Wg List

Oct 19

RTT

Nov 19

Wg List

Nov 19

RTT

Dec 19

Wg List

Dec 19

RTT

Jan 20

Wg List

Jan 20

RTT

Feb 20

Wg List

Feb 20

RTT

Mar 20

(month

end actual)

Wg List

Mar 20

RTT 18.3.2020

actual

RTT

Information

Projection /

forecast

Trajectory 100GENERAL SURGERY 84.8% 82.0% 2776 82.0% 2776 82.0% 2776 84.3% 2776 86.6% 2776 88.9% 2776 91.2% 2776 93.7% 2776 93.7%

Actual 84.8% 2808 85.6% 2741 88.1% 2780 88.2% 2537 88.7% 2399 90.0% 2391 90.5% 2292 89.3% 1999 91.30% 91.8%

Trajectory 106UPPER GI SURGERY 69.5% 69.5% 130 69.5% 130 73.3% 130 77.0% 130 82.0% 130 87.0% 130 90.0% 130 93.4% 130 93.4%

Actual 69.5% 82 72.8% 81 78.3% 75 75.5% 102 79.6% 103 74.5% 102 73.7% 95 77.0% 100 80.70% 85.7%

Trajectory 101UROLOGY 82.9% 79.5% 1638 82.9% 1630 84.4% 1622 85.9% 1614 87.4% 1606 88.9% 1598 90.4% 1595 92.4% 1592 92.4%

Actual 82.9% 1646 83.7% 1688 83.9% 1757 86.4% 1777 87.1% 1759 87.8% 1725 88.6% 1602 87.3% 1427 89.50% 90.1%

Trajectory 103BREAST SURGERY 97.3% 97.3% 481 97.3% 481 97.3% 481 97.3% 481 97.3% 481 97.3% 481 97.3% 481 98.0% 481 98.0%

Actual 97.3% 255 97.3% 260 99.4% 324 100.0% 343 100.0% 261 99.3% 294 100.0% 294 97.3% 186 99.30% 99.3%

Trajectory 107VASCULAR SURGERY 90.4% 89.0% 618 89.2% 593 90.1% 568 91.1% 543 92.0% 518 93.0% 493 94.0% 468 95.9% 448 95.9%

Actual 90.4% 643 93.1% 591 93.0% 564 92.5% 562 91.9% 517 94.2% 497 94.3% 511 93.7% 427 94.90% 95.3%

Trajectory 110

TRAUMA &

ORTHOPAEDICS83.1% 84.3% 6549 84.5% 6452 84.6% 6355 86.2% 6258 87.8% 6161 89.3% 6064 90.9% 5967 92.6% 5868 92.6%

Actual 83.1% 6646 84.1% 6440 84.3% 6308 84.2% 6158 82.8% 6027 84.1% 6077 85.5% 5955 84.5% 5400 87.70% 89.3%

Trajectory 320CARDIOLOGY 85.2% 88.5% 2123 88.5% 2102 88.5% 2081 89.5% 2060 90.5% 2039 91.0% 2018 91.5% 1997 92.0% 1977 92.00%

Actual 85.2% 2144 87.3% 2058 87.6% 2099 87.8% 2027 87.6% 1941 88.5% 1892 89.8% 1985 90.2% 1817 92% 93.6%

Trajectory 120ENT 82.1% 81.2% 3164 80.9% 3164 81.1% 3164 81.3% 3164 81.4% 3164 81.6% 3164 81.8% 3164 82.1% 3164 82.1%

Actual 82.1% 3147 82.7% 3117 83.9% 3128 83.5% 2980 84.0% 2969 88.2% 2853 91.4% 2952 92.6% 2923 93.30% 94.7%

Trajectory 130OPHTHALMOLOGY 85.7% 84.5% 3084 85.0% 3035 85.5% 2986 86.0% 2937 87.0% 2888 88.0% 2839 89.0% 2790 90.5% 2742 90.5%

Actual 85.7% 3133 84.7% 3022 85.8% 3112 85.2% 2685 84.9% 2629 86.9% 2355 90.0% 2110 91.2% 2072 92.20% 93.7%

Trajectory 140 ORAL SURGERY 89.4% 90.4% 1911 89.8% 1911 90.3% 1911 90.9% 1911 91.4% 1911 91.9% 1911 95.5% 1911 93.4% 1911 93.4%

Actual 89.4% 1559 89.2% 1714 90.5% 1725 88.3% 1935 85.1% 1927 85.2% 1941 86.8% 1924 85.1% 1963 88% 88.9%

Trajectory 143ORTHODONTICS 91.0% 90.0% 110 91.0% 105 92.0% 100 93.0% 95 94.0% 90 95.5% 85 97.0% 80 98.9% 78 98.9%

Actual 91.0% 100 91.1% 101 92.5% 70 92.2% 64 93.2% 88 97.1% 105 96.9% 96 96.9% 98 97.90% 98.6%

RTT & Waiting List Trajectories ‐ 2019/20 with Monthly Actual Performance Comparison

Appendix 1: Specialty Level Performance Against Plan

7

Trajectory 191

PAIN

MANAGEMENT 97.4% 95.8% 404 96.0% 404 96.2% 404 96.4% 404 96.6% 404 96.8% 404 97.5% 404 98.7% 404 98.7%

Actual 97.4% 305 95.4% 324 96.1% 294 96.3% 296 96.7% 304 95.7% 322 95.0% 278 97.4% 272 97.10% 98.6%

Trajectory 300GENERAL MEDICINE 78.8% 78.8% 2223 78.8% 2191 81.1% 2159 83.4% 2127 85.7% 2095 88.0% 2063 90.3% 2031 92.7% 2000 92.70%

Actual 78.8% 2255 79.0% 2144 79.0% 2189 83.1% 2083 86.0% 1950 91.8% 1932 94.5% 2067 95.8% 1831 94.40% 94.4%

Trajectory 303

CLINICAL

HAEMATOLOGY98.5% 95.2% 215 95.6% 210 96.0% 205 96.4% 200 96.8% 195 97.2% 190 97.6% 185 98.5% 182 98.5%

Actual 98.5% 194 98.8% 160 96.6% 183 98.1% 162 96.5% 141 97.3% 147 100.0% 136 98.1% 106 99.30% 100.0%

Trajectory 307DIABETIC MEDICINE 82.4% 84.4% 700 84.5% 690 84.6% 680 86.8% 670 89.0% 660 91.2% 650 93.4% 645 96.3% 640 96.3%

Actual 82.4% 670 85.7% 684 87.8% 730 86.1% 682 84.8% 683 87.7% 697 89.3% 654 90.7% 568 90.80% 91.8%

Trajectory 330DERMATOLOGY 93.5% 93.5% 1954 93.9% 1935 94.2% 1916 94.6% 1897 94.9% 1878 95.3% 1859 95.6% 1840 96.3% 1825 96.3%

Actual 93.5% 1973 93.3% 1913 93.3% 2439 93.0% 2051 92.3% 1607 95.8% 1815 96.9% 1652 96.0% 1285 96.40% 96.4%

Trajectory 340

RESPIRATORY

MEDICINE 87.5% 88.4% 1043 87.5% 1015 88.5% 987 89.5% 959 90.5% 931 91.5% 903 92.5% 875 94.0% 854 94.0%

Actual 87.5% 1071 89.9% 997 89.6% 983 89.1% 973 89.0% 970 90.4% 998 92.9% 1012 92.6% 840 93.50% 93.9%

Trajectory 361NEPHROLOGY 98.1% 92.4% 153 92.4% 149 93.3% 145 94.3% 141 95.2% 137 96.1% 133 97.0% 129 98.1% 126 98.1%

Actual 98.1% 157 96.7% 153 95.5% 136 96.9% 127 97.7% 128 93.8% 129 99.2% 123 100.0% 100 100% 100%

Trajectory 410RHEUMATOLOGY 78.9% 78.4% 982 78.4% 969 78.5% 956 78.6% 943 78.7% 930 78.8% 917 78.9% 904 79.5% 888 79.5%

Actual 78.9% 995 79.9% 969 81.2% 964 79.2% 924 78.8% 888 80.1% 826 81.4% 823 83.7% 689 86.40% 90.0%

Trajectory 420PAEDIATRICS 92.9% 93.3% 717 94.0% 717 94.5% 717 95.0% 717 95.5% 717 95.6% 717 95.7% 717 96.0% 717 96.0%

Actual 92.9% 566 95.5% 558 97.1% 522 95.7% 533 96.3% 520 97.60% 534 98.4% 572 96.3% 568 97% 97%

Trajectory 321

PAEDIATRIC

CARDIOLOGY 89.0% 89.0% 152 89.0% 152 90.0% 152 91.0% 152 92.0% 152 93.5% 152 95.0% 152 96.6% 152 96.6%

Actual 89.0% 127 92.2% 141 89.6% 119 93.9% 115 95.9% 121 92.7% 109 95.0% 99 92.2% 77 95.40% 95.7%

Trajectory 653PODIATRY 91.3% 91.3% 228 91.3% 227 91.8% 226 92.2% 225 92.7% 224 93.1% 223 93.6% 221 96.3% 220 96.3%

Actual 91.3% 229 92.0% 201 93.3% 212 92.2% 192 92.8% 209 92.4% 198 96.2% 208 90.9% 164 94% 94.0%

Trajectory 430

GERIATRIC

MEDICINE89.5% 88.1% 235 89.5% 234 89.9% 233 90.3% 232 92.8% 231 94.2% 230 96.6% 227 98.1% 225 98.1%

Actual 89.5% 237 91.7% 229 89.4% 241 86.3% 227 87.4% 231 93.7% 223 91.9% 184 92.8% 152 91.40% 91.4%

Trajectory 460

MEDICAL

OPHTHALMOLOGY90.6% 85.0% 321 85.0% 321 87.0% 321 90.0% 321 92.0% 321 92.5% 321 93.5% 321 94.3% 321 94.3%

Actual 90.6% 235 84.5% 193 90.1% 230 94.9% 257 93.7% 284 94.1% 341 94.6% 332 94.8% 286 96.30% 97.6%

Trajectory 502GYNAECOLOGY 95.8% 96.1% 1568 96.2% 1543 96.3% 1518 96.4% 1493 96.5% 1468 96.6% 1443 96.7% 1418 97.3% 1394 97.3%

Actual 95.8% 1593 96.5% 1592 95.5% 1655 95.8% 1385 95.8% 1328 97.4% 1288 97.3% 1272 96.4% 1218 97.80% 98.2%

Trajectory TRUST TOTAL 85.7% 86.1% 32609 86.2% 32407 87.1% 32205 88.1% 32003 89.1% 31801 90.0% 31599 91.0% 31397 92.0% 31199 92.00%

Actual 85.7% 32811 86.4% 32362 87.10% 32277 87.20% 31296 86.80% 30093 88.80% 29935 90.40% 29362 90.10% 26700 91.70% 92.7%

8

Appendix 2: Table outlining Information Department Project for end March 2020 based on performance at 18 March 2020

1

Title Financial Performance – Month 1 April 2020


Author Alex Crickmar – Deputy Director of Finance

Jon Sargeant - Director of Finance


Decision

Assurance

Information X


The Trust’s deficit for month 1 (April 2020) was £445k before the retrospective top up. However, in line with

national guidance the Trust has accrued a central retrospective top up payment of £445k in order to report a

break even financial position at Month 1.


N/A


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

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

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

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

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

F&P – 14 - Reduction in hospital activity and subsequent income due to increase in community provision

F&P 16 - Uncertainty over ICS financial regime including single financial control total


Update on risk relating to delivery of 2020/21 financial position.

F1

2


The Board is asked to note:

The Trust’s deficit for month 1 (April 2020) was £445k before the retrospective top up. However, in line

with national guidance the Trust has accrued a central retrospective top up payment of £445k in order

to report a break even financial position at Month 1.

3

FINANCIAL PERFORMANCE

Month 1- April 2020

4

Summary Income and Expenditure Position – Month 1

Month 1 £000

Income 34,889

Pay Substantive Pay -21,456 Bank -709 Agency -682

Total pay -22,847

Non-Pay Drugs -602 Non-PbR Drugs -1,343 Clinical Supplies & Services -2,050 Other Costs -5,369

Total Non-pay -9,365

Recharges and Reserves -1,949

EBITDA 729

Financing costs -1,174

Deficit Position as at month 1 before retrospective top up -445

Retrospective top up 445

Reported Position at month 1 0

The Trust’s deficit for month 1 (April 2020) was £445k before any retrospective top up. However, in line with

national guidance the Trust has accrued a central retrospective top up payment of £445k in order to report a break

even financial position at Month 1. Please note that the national guidance from NHS E/I sets out that the

retrospective top up is subject to a national assurance process and requires central sign off before it is confirmed

and paid.

The Trust’s month 1 financial position also includes revenue costs of c. £1.3m relating to COVID, of which c. £0.6m

relates to pay costs and £0.7m to non-pay costs. The financial governance arrangements regarding COVID

expenditure are in place and operated throughout April, with 38 orders approved by Gold Command in April.

The clinical income position reported at Month 1 is aligned to the national block arrangements currently in place as

previously set out to the Board. Activity levels across most points of delivery (POD) have reduced significantly. This is

shown in the table below which set out the percentage movement in activity for April 2020 compared to the

monthly average for 2019/20.

Point of Delivery % movement

Daycase -84.05%

Elective -76.99%

Non-Elective -42.36%

OP First -81.43%

OP Follow Up -79.31%

OP Procedure -87.14%

1. Month 12 Financial Position Highlights

As a result of the significantly lower levels of activity, uncoded activity has significantly reduced and the current

position for month 1 has 15 spells that remain uncoded by the deadline date, this is against an average of 2,361 for

last year. Following the changes required to service delivery to effectively manage the COVID19 situation, reviews

are currently being undertaken to ensure all activity is captured accurately.

The expenditure position in month was driven by reductions in costs (both pay and non-pay) as a result of reductions

in planned and emergency activity as set out above, offset in part by increases in spend relating to COVID activity.

Capital expenditure spend in month 1 is £1.6m, including COVID-19 capital spend of £1m. Excluding COVID-19, the

main area of spend in month is on Estates schemes, including £0.4m of spend is in respect of the HSDU works.

The main areas of spend on COVID-19 capital in month are £0.2m on DCC equipment, £0.2m on medical gases works

and £0.2m on increasing the capacity within the DRI mortuary. The ICS capital allocations have only recently been

issued and therefore the capital budgets for 2020/21 are yet to be agreed. The Trust is working with the ICS on a

revised capital plan for submission at the end of May.

The cash balance at the end of April was £62.4m (March: £30.8m). The increase of cash in month is as a result of the

Trust receiving 2 months’ worth of the block income in April.

The Board is asked to note:

The Trust’s deficit for month 1 (April 2020) was £445k before the retrospective top up. However, in line with

national guidance the Trust has accrued a central retrospective top up payment of £445k in order to report a

break even financial position at Month 1.

2. Recommendations

Title Use of Trust Seal

Report to: Board of Directors Date: 19 May 2020

Author: Fiona Dunn – Acting Head of Corporate Assurance / Company Secretary

For: For approval

Purpose of Paper: Executive Summary containing key messages and issues

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

Seal No.

Description Signed Date of sealing

120 Community Health Partnership Ltd and DBTH, Under lease for part of Sandringham Road Health Centre

Richard Parker Chief Executive

23 March 2020

Jon Sargeant Director of Finance

121 Community Health Partnership Ltd and DBTH Agreement for Grant of ULPA, Part of Sandringham Health Centre.

Richard Parker Chief Executive

23 March 2020

Jon Sargeant Director of Finance

Recommendation

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

G1

BOARD OF DIRECTORS – 19 MAY 2020

CHAIR’S ASSURANCE REPORT

FINANCE AND PERFORMANCE COMMITTEE – 28 APRIL 2020

Overview:

The meeting, exceptionally, took place by teleconference owing to the Covid 19 critical incident being managed across the Trust. All normal attendees took

part and the first 30 minutes were dedicated to an update on the management of the current emergency situation. We continue to be impressed by the

quality of the planning, mobilisation of the response and the leadership being shown across the organisation, particularly at senior levels. We particularly

noted the pro-active decision to source and implement in-house testing for staff which is to be commended. We were also briefed on the fluctuating

position re availability of different elements of PPE and steps being taken to manage that.

We discussed performance thoroughly, looking in particular at the Emergency Department four-hour access data and sought to understand slow progress in

achieving 4 hour access totals despite the drop in attendees. We will continue to monitor this closely.

We noted really significant progress with RTT immediately, where the data showed we had achieved 91.7% on 18th March (prior to the scale down of

routine elective activity for the Covid 19 emergency), with high degrees of confidence of delivery by year end. Information had modelled a position of 92.7%

by year end (without the impact of COVID) reflecting comfortable delivery of the standard in line with recovery plan. Due to the impact of COVID the

position had fallen to 90.1%. We had an in-depth discussion about how the pace might be sustained during return to normality, in particular inthose areas

which were proving more resistant to change and improvement.

In terms of Finance we received a verbal overview of the impact of Covid related activities, with a prediction of continuing future spend. There has also

been an impact upon the planned capital spending. At the time of writing this is all a fast moving feast. F+P were briefed on the basis of the first four

months of the current year’s finance being allocated on a block basis. It now appears that this approach could continue for some time longer. This is of

some concern as the Director of Finance believes the allocation mechanism means that DBTH broadly receives around £2m per month less than it needs in

G2

this way. However, the situation is under review and representations are being made. Board will receive an update paper before the next F+P with a

situation report on these issues.

Importantly, we delivered our control total for the year – a massive achievement. CIPs delivered £11.2m in savings. The cash position continues to be

strong, with £31m held in Trust accounts. The meeting also received the draft accounts for the Trust, noting the timely preparation in difficult

circumstances.

The workforce report again included a comprehensive update from Karen Barnard as to activity to best profile staff skills and availability against need, and

how those staff were being supported, gaining real assurance as to the efforts being made in this area.

Vacancies are currently at 8% against a target of 5% but taking into account the use of temporary staff the net vacancy is 2.2%. Approximately 129 administrative staff, 383 nursing staff and 13 medical staff have been redeployed as a result of the needs of the service reacting to Covid. Following the use of in-house testing, 75% of staff who were self absenting were found to be fit to return to work.

F+P received a revised and updated risk register which was understandably principally Covid-19 focused. The relevant risks were considered actively with

each paper received at the meeting. Fiona Dunn’s work in pulling the document together with colleagues was acknowledged.

AGENDA ITEM / ISSUE

COMMITTEE UPDATE NEXT ACTION LEAD TIMESCALE

Minutes and Actions from previous meetings

The Committee approved the minutes from the previous meeting and noted progress on actions being assured that all were appropriately tracked

An amendment was made to Action FP19/12/F2 for Jon Sargeant to speak with KPMG colleagues, as the BAF forms part of the year-end statements, to ensure they are aware of the current situation in relation to the BAF development, ensuring that the Trust didn't run into difficulties with year-end for 2020/2021.

JS May 2020

Covid-19 Operational Brieing

The Committee was assured by the personal report of the CEO and COO in relation to the management of the current emergency within the Trust and briefed as to progress across the region.

Integrated performance report

The Committee was assured by the report

62-Day Cancer Pathway Challenges Becky Joyce would provide an exception report on the 62-day cancer pathway challenges, including the blockages within tertiary referrals, at the Finance and Performance Committee meeting in May 2020. Cancer Patient DNAs Becky Joyce would provide a reflective report on the increase in cancer patient DNA’s and their outcomes. Integrated Performance Report – 52-Week Breaches Becky Joyce would separate any 52-week breaches in the Integrated Performance Report, against whether they were due to postponed care because of the Covid-19 pandemic or whether they were a normal validation breach.

RJ RJ RJ

May 2020 May 2020 May 2020

RTT progress The Committee noted progress and was assured by the current position

None N/A N/A

Financial performance

The Committee was assured by the report. It also received and noted the annual accounts.

Covid-19 Finance Report Jon Sargeant to include a Covid-19 section in the monthly finance report to the Committee. Payment Times against the 7-Day Target Jon Sargeant to report payment times against the 7 day target in the monthly report.

JS JS

May 2020 May 2020

2020/21 budget setting and control total

The Committee received a verbal report giving assurance that owing to the Covid-19 emergency monies were likely to be distributed on a block basis for the foreseeable future.

None N/A N/A

Workforce Management

The Committee was assured by the report

None N/A N/A

Corporate Risk Register

The Committee noted significant progress with the preparation of an updated risk register..

None N/A N/A

Information Items

The meeting also received and noted the minutes of a number of sub-committees and approved the minutes of its last meeting.

None N/A N/A

No escalations were received by the Committee and there were no escalations to the Board

KEY

CLOSED

ASSURED

PARTIALLY ASSURED / SOME ACTION TO TAKE

NOT ASSURED / ACTION REQUIRED

Title Infection, Prevention and Control Assurance Framework

Report to Board of Directors Date 19.05.2020

Author David Purdue, Chief Operating Officer


Decision

Assurance x

Information


As our understanding of COVID‐19 has developed, PHE and related guidance on required infection prevention and control measures has been published, updated and refined to reflect the learning. This continuous process will ensure organisations can respond in an evidence‐based way to maintain the safety of patients, services users and staff. NHSE/I have developed a framework for Trusts to assess themselves against the guidance as a source of internal assurance that quality standards are being maintained. It also helps to identify any areas of risk and show the corrective actions taken in response.


Is the Trust Board assured of the IPC processes in place?


This Framework supports the strategic direction by identifying areas of good practice and actions undertaken to mitigate any gaps.


G3

F&P6 Failure to achieve compliance with performance and delivery aspects of the Single Oversight Framework, CQC and other regulatory standards Leading to (i) Negative patient and public reaction towards the Trust (ii) Impact on reputation


That the report be noted.

Publications approval reference: 001559

2 | IPC board assurance framework

Infection prevention and control board assurance framework

4 May 2020, Version 1

Completed by, David Purdue, Ken Agwuh, Miriam Boyak, Cindy Storer, Carol Scholey.

To support this assurance framework, all divisions have completed individual checklist documentation.


Infection Prevention and Control board assurance framework

1. Systems are in place to manage and monitor the prevention and control of infection. These systems use risk assessments and consider the susceptibility of service users and any risks posed by their environment and other service users

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions

Systems and processes are in place to ensure:

infection risk is assessed at the front door and this is documented in patient notes

On both sites (DRI and BDGH) there are both Yellow and Blue areas/routes. Yellow is designated for those patients who are suspected or confirmed as having COVID-19. The Blue areas are primarily for those patients who are not suspected of having COVID-19 symptoms. Patients who are suspected of having COVID-19 and fitting the case definition, where they are transported by ambulance are brought into ED via the Yellow Resuscitation room and are treated in the Yellow treatment area. Those who are not presenting with COVID-19 symptoms and are transported by ambulance are brought into ED via the Blue Resuscitation room entrance. Those who walk into the department are booked in and triaged by the navigation nurse and are directed to either the blue or yellow pathway. This happens at both Bassetlaw Hospital and Doncaster Royal Infirmary.

DBTHFT Flow chart (18).pdf

With changing guidelines from the Public Health England this has to be updated regularly by the DIPC.

Updated guidelines upload on the HIVE


patients with possible or confirmed COVID-19 are not moved unless this is essential to their care or reduces the risk of transmission

compliance with the national guidance around discharge or transfer of COVID-19 positive patients

Those patients who require admission to hospital are then transferred via the Yellow corridor to the Yellow part of the Acute Medical Unit (AMU) or the Assessment Treatment Centre (ATC). Patients who require admission but are not suspected of having COVID-19 are transferred via the Blue route both at DRI and BH. Yellow areas are differentiated from Blue areas by signage, floor and wall stickers. If a Patient is considered to be aerosol generating, (e.g. high flow oxygen, Non-invasive ventilation) they are transferred via the yellow route/lift. There is a standard operating procedure in place that stipulates the process for taking the lift out of operation immediately after the patient has been transferred. This allows for the settling of any viral particles for 20 minutes before allowing the designated cleaning team to respond by cleaning the lift and the corridor in order to reduce the risk of transmission of COVID-19. Those patients who have been treated for COVID-19 and who are medically fit for discharge are referred to the Integrated Discharge Team as it has been recognised that there is some anxiety in community settings (care homes) when receiving patients that are being discharged. The integrated discharge team are working collaboratively with Clinical Commissioning Groups, care homes and other agencies to support those areas to facilitate a timely discharge. If patient discharged to own home, advice regarding continued self-isolation is provided. Staff providing direct care within 2 metres of any patient are wearing gloves, apron, Fluid

none Those patients who have been confirmed as having COVID-19 are not always leaving the hospital in a timely manner due to community settings (care homes) refusal to accept patients back due to anxiety around the risk of transmission.

Integrated Discharge Teams working collaboratively with clinical commissioning groups and care homes to facilitate timely discharge. Director of Infection Prevention and Control has been working with the CCG and have drawn up a standard operating procedure for action to be taken by care homes once patients are discharged that minimize the risk of transmission.


patients and staff are

protected with PPE, as per

the PHE national guidance

national IPC guidance is regularly checked for updates and any changes are effectively communicated to staff in a timely way

changes to guidance are brought to the attention of

repellent surgical mask and eye protection (wear there is a risk of splash). Guidance requires that this level of PPE is used for those patients who are suspected or confirmed of having COVID-19. DBTH staff are wearing this level of PPE for all patients regardless of their COVID-19 status. Where the patient is having aerosol generating procedures, the level of PPE is stepped up to long sleeved gown, FFP3 Respirators, eye protection, gloves and disposable aprons between patients. This level of PPE is for sessional use and is disposed of after each session. Aerosol generating procedures have been identified in the guidance and have been applied in the DBTH with the addition of further procedures, e.g. nasoendoscopies and oropharynx examination, to minimize the risk of transmission of COVID-19 to staff undertaking those procedures. PPE is centrally held and distributed to clinical areas. Supplies are available at the point of use and are stored in clean, dry areas. The centralisation of PPE has been a successful approach to managing demand. PPE is provided by a variety of suppliers, IPC help to inspect the quality. Most PPE is provided by the Centre and to a specification agreed by NHSE/I. Wearing of PPE not supplied by the trust is not encouraged to ensure only quality PPE is worn. Donations are taken to Silver for IPC / Quality sign off with advice and guidance of the IPC lead nurse. Changes to guidance are continually reviewed and updated by subject matter advisors and Trust staff are updated via the HIVE, closed

Nationally and locally there have been challenges with supply elements of PPE.

This is reviewed and escalated through Bronze, Silver and to Gold command on a daily basis. Daily stock takes are being completed across the Trust to ensure control is kept of PPE supplies. PPE supplies are held centrally at Doncaster Royal Infirmary. PPE Safety Officer programme has been initiated across the trust. Staff have been trained in the appropriate PPE to wear in specific circumstances. PPE safety officers have been put in place in priority areas to support staff in the clinical areas with correct wearing of PPE. The Director of Infection Prevention and Control with the assistance of the IPC Pandemic matron and laboratory and estates and facilities colleagues have considered contingency planning for critical shortages of PPE. Testing of contamination levels of used gowns and options for decontamination/cleaning for reuse have been performed to provide assurance around safe working practices for contingency plans. Care home letter

DPH Letter to care homes on hospital dis


boards and any risks and mitigating actions are highlighted

risks are reflected in risk registers and the Board Assurance Framework where appropriate

robust IPC risk assessment processes and practices are in place for non COVID-19 infections and pathogens

Facebook/WhatsApp groups and through word of mouth by divisional leaders and the IPC team. Any changes in relevant guidance are discussed at Silver command and escalated as appropriate to Gold command. Risks are reflected in risk assessments and through discussion at Silver command and escalated to Gold Patients are risk assessed on admission regarding their condition and also existing alert, policies and practices are followed. This has not been compromised throughout the COVID 19 pandemic.

2. Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections


Systems and processes are in place

to ensure:

designated teams with appropriate training are assigned to care for and treat patients in COVID-19 isolation or cohort areas

designated cleaning teams

with appropriate training in

required techniques and use

Ward teams use the principles of cohorting as per outbreak management, dedicated teams to care for group of patients to minimise the risk of cross contamination. For example Respiratory ward donning and doffing areas and additional training on PPE and PPE support officers. Trained hotel Service staff are assigned to COVID-19 areas. They are instructed in what PPE to wear and how to wear it. PHE donning and doffing of PPE videos are available for all

None


of PPE, are assigned to

COVID-19 isolation or cohort

areas.

decontamination and terminal decontamination of isolation rooms or cohort areas is carried out in line with PHE and other national guidance

increased frequency of

cleaning in areas that have

higher environmental

contamination rates as set out

in the PHE and other national

guidance

staff to access. Project Echo IPC training sessions have been accessed by service department. PPE training sessions have been facilitated for any staff to attend either by booking a place but also by just dropping in. All opportunity to train any numbers of staff in the appropriate use of PPE. ‘Clinical Management Pathway for Suspected/Confirmed COVID-19 Patient’ has been developed and is on the Hive. Frequent cleaning regimes have been put in place in ward areas and also in non-ward/department areas for frequent touch services. This is done by service assistants but also but nursing staff. Terminal cleaning is undertaken in accordance with guidance on decontamination of the environment and Trust policy. Environments have been reviewed and clutter removed to enable enhanced cleaning to take place in those areas that have COVID-19 positive patients. Environments have also been reviewed by estates staff for modification to areas to reduce the risk of transmission of COVID-19 and other pathogens. The opportunity has been taken to start the Deep Clean programme to reduce environmental contamination of COVID-19 but also other pathogens. Formal Walk rounds are conducted Monday, Wednesday and Friday at Doncaster Royal Infirmary and on Tuesday and Thursday at Bassetlaw hospital. Staff involved in this includes Consultant Microbiologist, IPC pandemic matron/IPC Lead nurse, Associate Directors of nursing for the divisions. Environmental reviews are conducted on the walk-round.


linen from possible and confirmed COVID-19 patients is managed in line with PHE and other national guidance and the appropriate precautions are taken

single use items are used

where possible and according

to Single Use Policy

reusable equipment is appropriately decontaminated in line with local and PHE and other national policy

All linen is treated in accordance with national guidance. Any linen used in areas where there are COVID-19 positive patients is treated as infectious. Disposable gloves and apron are worn when handling infectious linen. This is completed in the cohort areas or single room and taken to the ward disposal room for collection. Linen skips are taken to the bedside when required and are put away when not being used.

Single use items are used wherever possible.

Peracide is used at DRI and MMH or Difficile S is used at Bassetlaw (which is in the process of changing over to peracide) to decontaminate the environment and reusable equipment between patients.

3. Ensure appropriate antimicrobial use to optimise patient outcomes and to reduce the risk of adverse events and antimicrobial resistance

Key lines of enquiry Evidence

Gaps in Assurance Mitigating Actions

Systems and process are in place to ensure:

arrangements around antimicrobial stewardship are maintained

Antibiotic stewardship information is on the Hive. Antibiotic audits are conducted by Consultant Microbiologists and antibiotic pharmacist on a regular basis.

None

Continue to practice


mandatory reporting

requirements are adhered to

and boards continue to

maintain oversight

Medicines management and antibiotic usage is provided to divisions and disseminated through governance processes. Microbiologist conduct a daily walk round on DCC/ITU to review all antimicrobials. Extended use of Procalcitonin (test carried out in the laboratory) for all confirmed COVID19 as a bio- marker for bacterial infections. There is also a clinical management pathway with incooperated antibiotic policy for COVID-19 patients.

Pathway for Clinical Management of Suspe

Mandatory reporting is always completed and the Director of Infection Prevention and Control completes a report for board on a monthly basis

4. Provide suitable accurate information on infections to service users, their visitors and any person concerned with providing further support or nursing/ medical care in a timely fashion



implementation of national guidance on visiting patients in a care setting

Visiting has been restricted in all areas since the onset of COVID-19 pandemic. This is to reduce the risk of transmission of COVID-19 and to ensure that social distancing can be adhered to wherever possible. Recognising the impact that restrictions in visiting has on patients and staff, particularly at the end of a patients life, the Trust has been responsive in providing video calling via iPADS, facilitating letters to loved ones and initiating knitted hearts, one to stay with the person at the end of their life and one to stay with the


areas in which suspected or confirmed COVID-19 patients are where possible being treated in areas clearly marked with appropriate signage and have restricted access

information and guidance on

COVID-19 is available on all

Trust websites with easy read

versions

infection status is communicated to the receiving organisation or department when a possible or confirmed COVID-19 patient needs to be moved

relative of the patient. This has been facilitated by the End of Life Team. Areas treating COVID-19 patients are clearly signed. Pull up banners have been purchased and are being used. Clear signage is in place to indicate blue and yellow areas, for example AMU (blue) and CT (yellow). COVID-19 information is on the HIVE with links to relevant guidance. Infectious status of the patient is communicated via handover to any receiving destination. COVID-19 status is also flagged on the Nerve centre and CAMIS. A protocol has been developed for appropriate screening and safe movement of patients who are or have been COVID-19 positive to ensure that patients who have been in yellow areas are moved to blue areas. This means that the patient is not kept in a yellow area for any longer than they have to be, thus reducing the risk of transmission of infection. COVID-19 status is available on electronic systems for receiving departments to see. This is also communicated on ICE when requesting tests. Staff in departments is obtaining COVID-19 status before sending for the patient, e.g. imaging department.


5. Ensure prompt identification of people who have or are at risk of developing an infection so that they receive timely and appropriate treatment to reduce the risk of transmitting infection to other people



front door areas have appropriate triaging arrangements in place to cohort patients with possible or confirmed COVID-19 symptoms to minimise the risk of cross-infection

On both sites (DRI and BDGH) there are both Yellow and Blue areas/routes. Yellow is designated for those patients who are suspected or confirmed as having COVID-19. The Blue areas are primarily for those patients who are not suspected of having COVID-19 symptoms. Patients who are suspected of having COVID-19 and fitting the case definition, where they are transported by ambulance are brought into ED via the Yellow Resuscitation room and are treated in the Yellow treatment area. Those who are not presenting with COVID-19 symptoms and are transported by ambulance are brought into ED via the Blue Resuscitation room entrance. Those who walk into the department are booked in and triaged by the navigation nurse and are directed to either the blue or yellow pathway. This happens at both Bassetlaw Hospital and Doncaster Royal Infirmary.


patients with suspected COVID-19 are tested promptly

patients that test negative but display or go on to develop symptoms of COVID-19 are segregated and promptly re-tested

patients that attend for routine appointments who display symptoms of COVID-19 are managed appropriately

All patients who are admitted are now screened for COVID-19. In house PCR testing systems are in place in the laboratory to ensure efficiency in processing COVID-19 tests. Agreement is also in place for Sheffield Teaching Hospitals NHS FT to receive and test swabs if required. Those patients who are inpatients are swabbed if they develop symptoms to ensure that COVID-19 status is established at the earliest opportunity. Those patients who are suspected of having COVID-19 symptoms are either accommodated in a single room or are cohorted together. IPC have oversight of all positive patients and where they are accommodated. The level of PPE appropriate for the level of risk is worn in all departments. For those patients who are demonstrating symptoms of COVID-19, masks are advised for the patients. Decontamination of the environment and frequent touch surfaces are performed using the appropriate agent in accordance with Trust policy and guidance e.g. Peracide or difficile S.

6. Systems to ensure that all care workers (including contractors and volunteers) are aware of and discharge their responsibilities in the process of preventing and controlling infection



all staff (clinical and non-

clinical) have appropriate

training, in line with latest

The IPC team have facilitated PPE training for staff from all departments. PPE Safety Officer role has been developed to support appropriate use of PPE in clinical areas. Ad hoc training, advice and reassurance for staff is done daily


PHE and other guidance, to

ensure their personal safety

and working environment is

safe

all staff providing patient care are trained in the selection and use of PPE appropriate for the clinical situation and on how to safely don and doffit

a record of staff training is maintained

appropriate arrangements arein place that any reuse of PPE in line with the CAS alertis properly monitored and managed

any incidents relating to the re-use of PPE are monitored and appropriate action taken

by the IPC team on walk arounds and visiting the clinical areas. IPC team have facilitated training via Project Echo (virtual platform) for all staff. This is ongoing and responsive to what the departments and the organization need. PPE training sessions have been facilitated by the IPC team which includes safe donning and doffing. PHE training materials and videos are put on the HIVE for all staff to access. Ad hoc training on donning and doffing and the appropriate use of PPE is given on an ad hoc basis also. All staff training is recorded on OLM, paper copy is also kept. Contingency plans have been explored to address potential shortages of PPE. This includes processes to be used as a last resort and is in accordance with PHE and Infection Prevention Society guidance. In house testing has been completed to ascertain levels of contamination and ways of decontaminating gowns.

Recorded on Datix and discussed at silver and risk assessed for safety.

The IPC team conduct audits on the use of PPE and IPC practices.


adherence to PHE national

guidance on the use of PPE

is regularly audited

staff regularly undertake hand hygiene and observe standard infection control precautions

staff understand the requirements for uniform laundering where this is not provided for on site

all staff understand the

symptoms of COVID-19 and

take appropriate action in line

with PHE and other national

guidance if they or a member

of their household display any

of the symptoms.

Staff undertake hand hygiene using the WHO 5 Moments concept, using either alcohol hand rub and/or soap and water. Alcohol hand rub is available at the point of care. 52 sinks had been requested to put in place at exits and entrances across three sites (33 at DRI, 14 at BH and 5 at MMH). Hand hygiene pull up banners have been put in place to encourage hand hygiene. Hand hygiene audits are conducted by the IPC teams, and by ward teams. Hand hygiene audits are included in the IPC accreditation and as part of the quality dashboard and Hard Truths data. Scrubs provided in some locations. Staff encouraged to change at work, not to travel in uniform and to launder uniform on its own as per uniform policy. Staff swabbing hub is in place. Drive through swabbing is facilitated in the old ambulance station. A staff sickness absence telephone regarding self- isolation and instruction for when staff can return to work. IPC admin team has been increased in number using redeployed staff as part of the COVID-19 response. Telephone advice is given regarding the process for staff swabbing by the IPC admin team. Rainbow rooms have been established to provide a place for staff to leave the clinical areas and take some time out when dealing with difficult situations during the pandemic.

7. Provide or secure adequate isolation facilities




patients with suspected or confirmed COVID-19 are isolated in appropriate facilities or designated areas where appropriate

areas used to cohort patients with suspected or confirmed COVID-19 are compliant with the environmental requirements set out in the current PHE national guidance

patients with resistant/alert organisms are managed according to local IPC guidance, including ensuring appropriate patient placement

Patients who have suspected or confirmed COVID-19 are isolated in single rooms with ensuite facilities where possible. If single room availability is limited, then priority is given to those COVID-19 patients who have respiratory symptoms and/or are having aerosol generating procedure. A protocol has been developed to guide clinical staff in the appropriate placement of patients. Where patients are cohorted, doors have been put on bays by estates and facilities staff to minimize the risk of infection. Walls have been put up to facilitate segregation of patients with and without COVID-19 to reduce the risk of transmission. Guidance on placement and IPC practices are given by the IPC team and senior divisional leaders. Those patients who do not have COVID-19 but have other conditions that require isolation, are isolated in accordance with Trust policy and in collaboration with the IPC team.

8. Secure adequate access to laboratory support as appropriate


There are systems and processes in

place to ensure:


testing is undertaken by competent and trained individuals

patient and staff COVID-19 testing is undertaken promptlyand in line with PHE and othernational guidance

screening for other potential infections takes place

Swabbing of patients and staff is done by competent and trained staff. Information on how to perform the swab and complete the associated request form and PHE E28 form is available on the hive. Testing is completed in the Trust laboratory by biomedical scientists, over seen by Consultant Microbiologists. The Consultant Microbiology team feedback the results if positive patients to provide clinical advice and guidance on management. This service is provided from 09:00 until 22:00 hours seven days a week. Central guidance on absence if displaying symptoms or isolating was issued (https://extranet.dbth.nhs.uk/safety-quality/infection-prevention-and-control-ipc/coronavirus-covid-19/qa/qa-work/) and the purpose was to protect other staff and patients by reducing nosocomial transmission. Once notification has been received that a member of staff has symptoms, they are booked in by HR to an appointment slot either on the same day or the next day. The team of staff swabbing are accommodated in the old ambulance station. MRSA screening is completed on admission in accordance with national guidance and local policy.

9. Have and adhere to policies designed for the individual’s care and provider organisations that will help to prevent and control infections


Systems and processes are in place to ensure that:


staff are supported in adhering to all IPC policies, including those for other alert organisms

any changes to the PHE national guidance on PPE are quickly identified and effectively communicated to staff

all clinical waste related to

confirmed or suspected

COVID-19 cases is handled,

stored and managed in

accordance with current

national guidance

PPE stock is appropriately stored and accessible to staff who require it

IPC team has been strengthened with the addition of an IPC Pandemic matron and six administration members of staff to ensure that calls and questions are answered promptly and consistently. Records of calls have been recorded. All IPC guidance is put on the HIVE and is accessed via Trust policy. IPC nurses have been out and visible in the clinical areas supporting staff with IPC policies and practices, providing a seven day service. Risk assessments are made where patients may have alert organisms and side rooms may be limited. Cohort nursing an option at these times. PHE guidance is reviewed daily by members of the IPC team and the Director of Infection Prevention and control and discussed at Silver cell and disseminated via the Hive and through face to face contact between members of the IPC team and staff in the clinical areas. Waste from COVID-19 positive patients is treated as infectious clinical waste in accordance with current national guidance. Handled as category B waste. PPE stock is centrally stored and sent out to wards and departments based on the level of PPE that is required in the clinical areas. Daily stock takes are completed to ensure that wards/departments have the necessary stock of PPE and the point of use. As an ICS we are working together to order PPE to ensure good stock levels are in place


for future months. The ICS also work together on the supply of PPE with ICS wide stock takes and help each other with mutual aid.

10. Have a system in place to manage the occupational health needs and obligations of staff in relation to infection


Appropriate systems and processesare in place to ensure:

staff in ‘at-risk’ groups are identified and managed appropriately including ensuring their physical and psychological wellbeing is supported

staff required to wear FFP reusable respirators undergo training that is compliant with PHE national guidance and a

Department/ward managers complete a risk assessment for individuals to ascertain the level of risk associated with their position in the organization. This is overseen by divisional leaders. Staff who are at higher risk have been redeployed during the COVID-19 pandemic to minimize risk of infection to those members of staff. Individuals have met (virtually) to discuss the risks associated with BAME group of staff and a way forward. Risk assessments are completed for all members of staff who may be at increased risk of transmission of infection. Rainbow rooms are currently available for staff to take ‘timeout’ during their shift. 4022 members of staff have been Mask fit tested and appropriate respirators have been supplied to clinical areas and to individuals in some case. The Trust was assisted in mask fit testing by South Yorkshire fire and Rescue and Altrad/York Linings company. Records of


record of this training is maintained

staff absence and well-being are monitored and staff who are self-isolating are supported and able to access testing

staff that test positive have

adequate information and

support to aid their recovery

and return to work.

training have been kept and certificates/passports have been supplied to staff so that they are clear on which type of respirator they have been Fit tested for. Mask fit testing has been undertaken by members of the training and education team and led by the QI Trust Lead. The training was registered on OLM.

There are systems in place to monitor staff sickness. Those members of staff who are self-isolating within the Hospital accommodation and have difficulties getting provisions have been supplied with cooked meals by the Trust. Staff swabbing process is in place and visible on the Hive for staff to access. All positive results for Healthcare workers and their families are phoned directly by the microbiologist consultants or the SAS Ophthalmology doctors assisting with this COVID related duties. Standard advices based on PHE guidelines are given to HCWs and when they can return back to work and on isolation precautions for their entire household. They are also requested to ensure their line mangers aware of the results, while pointing them also the staff towards health and wellbeing if needed.

3 SOP for phoning with results V5.docx

FINANCE AND PERFORMANCE COMMITTEE

Minutes of the meeting of the Finance and Performance Committee

Held on Tuesday 31 March 2020 via StarLeaf Videoconferencing

Present:

Neil Rhodes, Non-Executive Director (Chair) Karen Barnard, Director of People & Organisational Development Pat Drake, Non-Executive Director Rebecca Joyce, Chief Operating Officer Jon Sargeant, Director of Finance Kath Smart, Non-Executive Director

In attendance: Fiona Dunn, Company Secretary Bev Marshall, Governor Richard Parker, Chief Executive (Part FP20/03/B1) Katie Shepherd, Corporate Governance Officer (Minutes) (KAS)

To Observe:

Apologies: None

ACTION

FP20/03/A1

Welcome and Apologies for Absence (Verbal)

Neil Rhodes welcomed the Members and attendees. No apologies for absence were noted.

FP20/03/A2 Conflict of Interest

No conflicts of interest were declared.

FP20/03/A3 Action Notes from Previous Meeting (Enclosure A3) The following updates were provided; Action 2 – On the basis that the number of Stroke measures had been reduced to four, and a discussion would be taken with the CCG to approve the reporting of these measures, the action would be closed; Action 3 – On the basis that Rebecca Joyce provided an update at the last meeting, that incremental changes would be made to the Integrated Performance Report, this action would be closed; Action 5, 6, 7 and 8 – This action would be deferred until July 2020; Action 9, 10, 12, and 17 – On this basis that these items were added to the Committee Work Plan, these actions would be closed;

FINAL FP20/03/A1– FP20/03/G6ii

H1

Action 11 – On the basis that Jon Sargeant had completed this, this action would be closed; Action 14 and 16 would be deferred until April 2020; Action 15 – This action was added to the work plan, however the date would be changed to July 2020; Action 19 – This item was on the agenda, this action would be closed.

The Committee:

- Noted the updates and agreed, as above, which actions would be closed.

Action: Katie Shepherd would update the Action Log.

KAS

FP20/03/A4 Request for Any Other Business (Verbal) There were no request for other business.

FP20/03/B1 Operational Briefing – Covid-19 (Enclosure B1) Richard Parker provided the Committee with an Operational Update on Covid-19 which included:

- DBTH had approximately 180 empty beds at DRI, and approximately 70 empty beds at Bassetlaw which had allowed for the implementation of the operational plans to deal with Covid-19;

- Yellow and blue zones had been introduced (yellow were for suspected and positive Covid-19 patients and blue zones were for patients that were not suspected as having Covid-19);

- Attendance at ED had reduced and continued to stay low, since the Government communications had increased;

- Significant ward and department changes/moves had taken place to create the right flow for patient and staff protection, and the additional beds were in place in line with the clinical model and management of PPE;

- A decision had been taken to cancel all annual leave for eight-weeks from 6 April 2020. This was to maintain the number of staff on site at what could be the peak of Covid-19 activity;

- A regional plan would take place to create a Nightingale Hospital at Harrogate. This would consist of 571 beds in total to service South Yorkshire, Bassetlaw and West Yorkshire;

- It was confirmed that a further three patients had passed away, one of which had been positive Covid-19 at the time of death, and the remaining two, suspected Covid-19 at the time of death;

- Respiratory and AMU at DRI were under significant pressure, however ITU had four empty beds;

- The process of swabbing staff that were self-isolating was introduced three-weeks ago, to get them back to work quicker if the result was negative, however this had presented its challenges;

- Testing would start on site within the next week, which would allow for 24-hour testing of staff, with results available within 24-hours;

- Jon Sargeant had set up a process for managing and authorising the finances

for Covid-19 and would report the financial impact to F&P;

- The consolidation of the two Maternity Services went live on 30 March 2020, with the move of Bassetlaw Maternity Services to DRI;

- Considerations had been taken of those vulnerable outpatients that still required treatment. It had been agreed that these patients would be seen within Park Hill facilities at DRI. Mexborough would be kept a Covid-19 free site;

- Leadership arrangements had been strengthened, and a silver tactical cell had been set up in the Incident Control Room at Doncaster between the hours of 08:00 and 20:00 which consists of one medical staff, one nursing staff and one manager;

- The antibody tests that had been discussed in the media, were not ready for use yet as they were currently being tested;

The Committee commended and thanked the Executive Team and colleagues on their leadership through this period, and noted that the communications had been outstanding with getting the key messages out and responding to questions asked on Facebook. A discussion took place regarding the article published the HSJ which highlighted that non-clinical NHS workers should stay at home if they were not key workers. Richard Parker advised that this article highlighted some of the staffing challenges that were being faced. Kath Smart highlighted that the article did not mention the redeployment of staff, which the Trust was engaging with to ensure that there was cover in areas that required it. A discussion took place regarding staff working from home. Richard Parker advised that back office staff would be required to provide assistance on wards to release Medical and Nursing staff from undertaking administrative tasks, and therefore if all non-clinical staff work from home, this would not be helpful to the organisation. Pat Drake noted that staff welfare was important including the support they require in terms of taking rests and breaks. Karen Barnard advised that an action plan was being developed which would include access to various wellbeing apps along with psychological support – this would include what was needed both during the pandemic and then in the recovery phase.

Guidance was being created for managers in relation to annual leave and what would be considered exceptional circumstances. A meal would be provided to all staff on site during their working day so that they don’t have the worry of trying to get food outside of work to bring whilst at work. Richard Parker left the conference call. Becky Joyce would circulate to the Committee the Covid-19 work streams and Objectives.

Action: Becky Joyce would circulate Committee the Covid-19 work streams and Objectives.

RJ

The Committee:

- Noted the Operational Briefing on Covid-19.

FP20/03/B2 Integrated Performance Report – February 2020 (Enclosure B2) Rebecca Joyce provided the highlights of the report including: 4 Hour Access

- The Trust delivered 85.43% against a national target of 95%, which continued

to be a challenge;

- Three main areas had been identified to improve 4-hour access which included

team working and leadership, variation in productivity of medical staff and the

culture amongst medical staff, and the capacity and flow;

- The plan to implement a short-stay pathway into ED had been postponed as

CDU was of use during the Covid-19 period.

RTT - The trust delivered 90.4% against the 92% trajectory during February 2020;

Significant improvements had been seen in a number of areas including Ophthalmology and Becky Joyce was confident that the Trust would have achieved the 92% trajectory by 31 March 2020 under normal circumstances, however the organisation faced the challenge now due to Covid-19. Becky Joyce highlighted that as of 19 March 2020 the RTT performance was provisionally stood at 91.84%. Diagnostics

- An achievement of 99.05% was reported against a target of 99% for February

2020 which presented an improvement from the January 2020 position.

Cancer - All 31-day nationally reported targets were achieved for January 2020, however

none of the 62-day nationally reported measure were achieved.

A discussion took place about how Covid-19 would affect performance targets. Becky Joyce advised that a notification had been received from the CCG which indicated that reporting should continue as normal, however it was noted that it should be made clear to the CCG that performance levels would be expected to drop over the coming months. Neil Rhodes noted that although not urgent at present, thought would need to be taken on returning to normal business and sustaining standards of performance. Becky Joyce advised that it would present an opportunity to refresh normal practice and whether practice that was changed during Covid-19 would be a permanent fixture. Kath Smart queried the capacity within Cancer Services due to the 62-day targets being missed in month. Becky Joyce advised that the Trust had a good Cancer Team, however a focus was required in Urology. It was noted that the Cancer Team would have less involvement in the Covid-19 response than other Teams, and therefore the expectations would be made clear to the team. Bev Marshall queried if the Trust had any issues with medical equipment or the supply of it. Becky Joyce advised that PPE had been a challenge at times however Procurement were working hard to ensure that there was a flow of supplies, and would be monitoring stock very closely. It was noted that there had been some changes to national guidance in relation to PPE, which the Trust had adapted to. Jon Sargeant added that there had been two issues surrounding PPE; the first had been the understanding of what PPE was required in what circumstances; and that it hadn’t been stock levels that had been an issue, but the delay in deliveries of the stock. Becky Joyce advised that she had received an email advising the weekly RTT return had been suspended.

Action: Becky Joyce would ensure that the CCG were aware that reported performance will reduce during the response period to Covid-19.

RJ

The Committee:

- Noted the Integrated Performance Report – February 2020.

FP20/03/B3 RTT Progress (Enclosure B3) This was discussed as part of Item B2 – Integrated Performance Report.

The Committee:

- Noted the RTT Progress.

FP20/03/C1 Financial Performance – February 2020 (Enclosure B1) Jon Sargeant provided an update on Month ten, including:

- The Trust’s deficit was £219k which was a favourable variance against a plan of £400k in month;

- The income position was £1,069k favourable to plan in month, with a £4,105k favourable YTD position;

- The cash balance was £27.1m;

- The capital budget was £7.3m behind budget YTD;

- The Trust was expecting to deliver its control total at year end, with the remaining risk being the impact of Covid-19;

- A block agreement had been reached with Doncaster CCG and Bassetlaw CCG;

- There would be Covid-19 related costs within 2019/20 financial year. Neil Rhodes noted that whilst the focus was on Covid-19, it was important that the efficiency improvements follow once normal business resumed. It was clarified that the capital expenditure wouldn’t create an issue as capital works had been deferred to 2020/21. It was noted that all Covid-19 related costs were being accounted for.

The Committee:

- Noted the Financial Performance Report for February 2020.

FP20/03/C2 2020/21 Budget Setting, Contracting, Control Total and Annual Plan (Verbal / Presentation) Jon Sargeant advised that he had submitted the plan as was discussed at the previous Board meeting. Guidance had been received that the first quarter of 2020/21 would be suspended and paid under a block contract, in which organisations will effectively be paid a lump sum by the CCG to ensure that there was cash flow. If spend exceeds this, funds would be topped up. It was highlighted that this scheme may be extended until the end of quarter 2, but it had been planned for the potential of three quarters. Neil Rhodes noted that the Trust had worked hard to get a grip on finance over the past several years, and therefore advised that the Trust must not lose focus on this throughout the Covid-19 period. Jon Sargeant advised that processes were in place to manage the ordering of petty items, and larger items. There would be an internal budget set each month, and each month would be run as normal to reconcile the months accounts. All financial concerns would be raised at the Executive Team meetings which were taking place daily. Kath Smart noted that it was important from a governance perspective to have budgets in place for Divisions and the Trust, even if they were impacted by the Covid-19 outbreak. Jon Sargeant noted that the support from the CCG’s had been good through the Covid-19 period.

Jon Sargeant advised that in relation to the recruitment on the service assistant roles, that these roles had never been up to budget before, and therefore if the roles were at capacity of budget, this would change our recurrent run rate.

The Committee:

- Noted the information in the 2020/21 Budget Setting, Contracting, Control Total and Annual Plan update.

FP20/03/C3 Going Concern (Enclosure C3) Jon Sargeant recommended the paper on Going Concern which included:

- The Trust should be considered a going concern for accounts preparation purposes;

- The Trust should prepare its annual accounts for the year 2019/20 and balance sheet as at 31 March 2020 on that basis;

- The annual report should clearly state this assessment whilst also outlining the

risks facing the Trust.

The Committee:

- Noted and approved the Going Concern paper.

FP20/03/D1 Workforce Report – February 2020 (Enclosure D1) Sickness Absence Karen Barnard highlighted that there were 929 members of staff self-isolating as of 30 March 2020. These staff would be offered testing on a priority basis with clinical staff being the highest priority. At the time of the meeting there were 27 positive members of staff, a number of which were medical staff. Sickness absence data would be run daily from the Roster system as this was updated by managers on a daily basis. There had been a challenge with some staff being in receipt of the 12-week shielding letter advising them to self-isolate for 12-weeks due to underlying health conditions. Some staff who were in receipt of this letter had returned to work and feel okay to work through this period. Some members of staff were experiencing childcare issues, such as their children going to different schools to normal, impacting the hours that some staff could work. Karen Barnard noted that the Trust was being flexible to ensure that staff continue to come to work. Recruitment It was noted that Recruitment would still continue. A generic advert had been out for people interested in volunteering for the service assistant and administrative roles where there were gaps. Recent recruitment had taken place for healthcare assistants and 71 were offered jobs. New healthcare assistants would usually undertake a Foundation of Care induction

programme. This was being managed by the Training and Education Department who were liaising with Doncaster College to get as many through the training as quick as possible. Letters had been sent to all that had retired within the last three years, as part of a national scheme to ask retired staff to return to practice during Covid-19. A central team would coordinate this and allocate nurses across the ICS region. The Trust was awaiting contact from HEE regarding final year nursing students. The approach would be that final year nursing students would be placed on the register and paid as a Band 4 Practitioner. The approach for Year-2 students would be to pay them at a Band 3 rate on an extended placement basis. Final year medical students would be brought in to work, however the allocation of where they would work had not yet been done. Any medical students that were on a career break or were on out-of-area placements, would be redeployed into roles. The Trust was awaiting on national documentation from HEE on what would be reasonable duties expected from trainees and consultants who would be redeployed into areas that were different to their speciality. It was advised that Kirsty Edmondson-Jones was in contact with Doncaster Council and local hotels to see if there were cleaning, portering or catering staff that wished to work at the hospital on an honorary contract with free childcare placement. The second round of international recruitment had been delayed. Ten of the first cohort recruitment had passed the OSCE’s, the others would remain on band 4 pay. The Occupational Health Team were busy with the swabbing of staff for Covid-19 which was being done via a booking process. Microbiology would contact positive patients, whereas The Occupational Health Team would contact negative Covid-19 staff to inform them. The People & Organisational Development Team were looking at how the organisation can promote mental wellbeing so that staff can maintain being fit and healthy through the Covid-19 period. A discussion took place about the redeployment of staff into other urgent roles. Karen Barnard advised that this would be managed by Tactical (Silver) Command to ensure that staff receive the support and correct training to carry out their redeployed roles. It was noted that NHSP and Holt were providing a weekly dashboard to monitor staffing levels of the bank and agency staff. Bev Marshall highlighted that he was very impressed with the professionalism of the wider team in dealing with Covid-19, and noted that it was fantastic that the Trust was undertaking the testing of staff that were self-isolating to get them back to work quicker if the result was negative.

The Committee:

- Noted the Workforce Report for February 2020.

FP20/03/F1 Escalation (Verbal) No issues were identified for escalation to/from:

- F1.1 F&P Sub-Committees; - F1.2 Board Sub-Committees; - F1.3 Board of Directors.

FP20/03/G1 Sub-Committee Meetings (Enclosure F1): The Committee noted the minutes of the:

- Capital Monitoring Group – 16 January 2020 - Efficiency and Effectiveness Committee – 3 February 2020 and 24 February 2020 - Workforce Education and Research Committee – 13 January 2020

FP20/03/G2 Minutes of the meeting held on 25 February 2020 (Enclosure G2)

The Committee:

- Noted and approved the minutes from the meeting held on 28 January 2020.

FP20/03/G3 Committee Work Plan (Enclosure G3)

The Committee:

- Noted the Committee Work Plan.

FP20/03/G4 Quality and Performance Report – Trolley Waits (included within Item B2 – Integrated Performance Report – February 2020)

The Committee:

- Noted the figures on Trolley Waits as outlined within the Quality and Performance Report.

FP20/03/G5 Quality and Performance Report – Weekend Discharges

The Committee:

- Noted the information within the Length of Stay Dashboard.

FP20/03/G6i Any Other Business (Verbal) Pat Drake advised the Committee that as some of the members of the Quality and Effectiveness Committee were clinical staff, the meeting taking place on 31 March 2020 had been stood down, however papers had been received and she would provide the Chair’s Report based on these papers. A discussion took place about whether the Finance and Performance Committee meeting should take place for May 2020. It was agreed that the meeting would take a lighter approach, with just the main papers on Performance, Finance and Workforce. The next meeting would take place via video conference.

FP20/03/G6ii

Date and time of next meeting (Verbal)

Date: Time: Venue:

Tuesday 21 April 2020 11:30 – 13:00 The Board Room, Doncaster Royal Infirmary/ Video-Conference

To.

Acute Trust Chief Executives,

Acute Trusts Medical Directors,

Yorkshire Team Clinical Leads for Organ Donation

Yorkshire Team Organ Donation Committee Chairs.

Lead Nurse Intensive Care Units

30th April 2020

Dear Colleagues,

We are writing on behalf of the Yorkshire Organ Donation Services Team to express our

thanks and to update you with deceased donation activity over the previous year, including the

current Covid-19 pandemic.

Yorkshire's eligible donor pool increased quite significantly in comparison to the previous year

- an increase of 93. We now have regular embedded SNOD presence in all of our regional

hospitals ensuring effective and accurate data collection. Referral rates have increased very

slightly for both donation after brainstem death (DBD) and donation after circulatory death

(DCD) in comparison to last year and remained high with a combined referral rate of 96.9%.

Our consent rates 2019-20 were: DBD 76% and DCD 61%.

We managed to achieve the same number of proceeding donors as the previous year (136)

but Yorkshire had 199 consents in 2019-20. We had foreseen that this would be our most

successful year to date but unfortunately, due to the COVID-19 pandemic, this affected our

potential donor pool in March. Our team and that of the Critical Care units within our region

have worked extremely hard as always, this year and the number of proceeding donors does

not reflect the number of consents achieved.

Despite the COVID-19 pandemic, referrals are still being made from our busy and

overstretched departments. Our units continue to support our programme and even though

referral rates have declined significantly from the start of the pandemic to present, our Critical

Care colleagues continue to refer, and we have still had consented and proceeding donors

during this time. From 23/03/20 to present we have had 10 families consent to organ donation.

We have experienced some difficult cases over the last few weeks which has taken the

tenacity and dedication of all involved to ensure the retrievals went ahead. A huge thank you

from all of us for everything you continue to do during this unprecedented time.

Following on from our previous correspondence about the redeployment of some members of

our team, we can now update that we have successfully redeployed some of the team back

into ICU’s across the region. We have some team members who were identified as vulnerable

and they have been trained and are assisting the National Bereavement Helpline where their

skills will be utilised to support grieving families and direct them to relevant bereavement

agencies. As you are aware, we retained some of our team to ensure we had enough staff to

continue to provide our service.

The retained team are in the process of being trained to assist the Blood Donation teams

within our region and they will undertake this work in between their on-call rota commitment’s.

Yorkshire, North West and Northern Regional

Administration Team

NHS Blood and Transplant

Bridle Path

Seacroft

Leeds

West Yorkshire

LS15 7TW

Tel: 0300 123 0912

Fax: 0113 820 0873

Email: [email protected]

www.nhsbt.nhs.uk

H2

http://www.nhsbt.nhs.uk/

The retained team will also be assisting with the Plasma Convalescence Programme recently

introduced by NHSBT to collect convalescent plasma from people who have recovered from

COVID-19 in the hope that, following clinical trials, this will benefit others who are diagnosed

in the future.

Solid organ donation and transplantation has continued despite pressures on both donor and

recipient critical care units and theatres with amazing results as shown by this news:

https://royalpapworth.nhs.uk/our-hospital/latest-news/Phill-Hardwell-army-heart-transplant

Completion of the Organ Donation (Deemed Consent) Act 2019 through UK Parliament

currently remains on target for 20th May 2020. It would be at risk of major delay due to post

Covid-19 and Brexit parliamentary business if postponed. However, NHS Blood and

Transplant and Department of Health and Social Care are mindful of pressure on NHS at this

time and that delivery of training and public awareness has not yet been completed due to the

Covid-19 pandemic.

Each Trust will receive a formal Trust activity report in due course as usual, but we wish again

to express our thanks and appreciation for your continued support for deceased organ

donation.

Please contact us, local Clinical Leads for Organ Donation or Specialist Nurses for Organ

Donation if you wish.

Yours Sincerely,

Dr Andrew Davidson, Dr Helen Buglass (Regional Clinical Leads for Organ Donation

Yorkshire)

Gordon Crowe (Regional Manager Yorkshire and North West Organ Donation Teams)

Sarah Whittingham, Clare Jones, Jenny Hughes (Team Managers - Yorkshire Organ Donation

Services Team)

https://royalpapworth.nhs.uk/our-hospital/latest-news/Phill-Hardwell-army-heart-transplant

DONCASTER AND BASSETLAW TEACHING HOSPITALS NHS FOUNDATION TRUST

AGENDA ITEM LEAD FREQUENCY NEXT DUE

19

-Ma

y-2

0

16

-Ju

n-2

0

21

-Ju

l-2

0

15

-Se

p-2

0

23

-Oc

t-2

0

17

-No

v-2

0

15

-De

c-2

0

Chair's Welcome and Apologies for Absence Suzy Brain England Each Meeting Next Meeting

Declaration of Interests Company Secretary Each Meeting Next Meeting

Conflict of Interests Register Company Secretary Annually Jun-20

Action Log - Update on Actions from Previous Meetings Company Secretary Each Meeting Next Meeting

Various - As Agreed by Chair Various Each Meeting Next Meeting

Executive Team Objectives - Setting Richard Parker Annually Jun-20

Executive Team Objectives - Quartely Updates Richard Parker Quarterly Consider Nxt Mtg Q1 / Q2

NHS Long Term Plan Richard Parker As Required Consider Nxt Mtg

CQC David Purdue As Required Consider Nxt Mtg

Budget Setting/Business Planning/Annual Plan Jon Sargeant/Marie Purdue Annually Jul-20

NHSI Plan Jon Sargeant/Marie Purdue Annually Consider Nxt Mtg

Committees in Common Company Secretary As Required Consider Nxt Mtg TOR

SY&B Pathology Programme Richard Parker As Required Consider Nxt Mtg

Quality and Performance Report Becky Joyce Each Meeting Next Meeting Mar Apr May Jul Aug Sept Oct

Report from Guardian for Safe Working Jayuant Dugar Quarterly Feb-21

Maternity CNST David Purdue (Lois Mellor) Annually Jul-20

The NHS Patient Strategy Sewa Singh (Cindy Storer) Annually Jul-20

Winter Plan Becky Joyce Annually Oct-20

Workforce and Recruitment Plan Karen Barnard Annually Jul-20

Thematic P&OD Report Karen Barnard Each Meeting Next Meeting

Workforce Race Equality Standards Karen Barnard Annually Jul-20

Workforce Disability Equality Standards Karen Barnard Annually Jul-20

ERIC Return Kirsty Edmondson-Jones Annually Jun-20

Staff Survey Results Karen Barnard Annually Feb/Mar-20

Staff Survey Action Plan Karen Barnard Annually Apr-20

Mixed Sex Accommodation Kirsty Edmondson-Jones Annually TBC

EU Exit Becky Joyce As Required Feb-20

Finance Report Jon Sargeant Each Meeting Next Meeting Apr May Jun Aug Sept Oct Nov

Control Total Jon Sargeant Annually Jan-21

Use of Trust Seal Richard Parker/Company Secretary As Required Consider Nxt Mtg

CCG Contracts Jon Sargeant Annually Private?

Reference Costs Jon Sargeant Annually Private?

Going Concern Jon Sargeant Annually Next Meeting

MEETING DATES

ANNUAL BOARD CYCLE OF BUSINESS

COMMITTEE BUSINESS

PUBLIC SESSION

STRATEGY

PRESENTATIONS

QUALITY PERFORMANCE AND SAFETY

FINANCE AND CONTRACT MATTERS

CAPACITY AND CAPABILITY

H3

NHS Providers Licence Self-Assessment / Certification Company Secretary Annually Jul-20

SO's SFIs, Standards of Business Conduct, Board Powers Jon Sargeant/Company Secretary Annually Jul-20

Board Assurance Framework Company Secretary Quarterly Jul-20

Corporate Risk Register Company Secretary Quarterly May-20

Chair's Assurance Log for Finance and Performance Cttee Neil Rhodes Each Meeting Next Meeting Apr May Jun Jul Sept Oct Nov

Chair's Assurance Log for Quality Effectiveness Cttee Pat Drake Bi-Monthly Next Meeting May Jul Sept Nov

Chair's Assurance Log for Audit and Risk Cttee Kath Smart Quarterly Next Meeting May Jul Nov

Chair's Assurance Log for Charitable Funds Cttee Sheena McDonnell Quarterly Next Meeting Jun Sept

Terms of Reference for Finance and Performance Cttee Neil Rhodes Annually Oct-20

Terms of Reference for Quality and Effectiveness Cttee Pat Drake Annually Oct-20

Terms of Reference for Audit and Risk Cttee Kath Smart Annually Oct-20

Terms of Reference for Charitable Funds Cttee Sheena McDonnell Annually Next Meeting

Board Effectivess Review Company Secretary Annually Jun-20

Annual Report of the Finance and Performance Cttee (inc Effectiveness Review) Neil Rhodes Annually May-20

Annual Report of the Quality Effectiveness Cttee (inc Effectiveness Review) Pat Drake Annually May-20

Annual Report of the Audit and Risk Cttee (inc Effectiveness Review) Kath Smart Annually May-20

Annual Report of the Chaitable Funds Cttee (inc Effectiveness Review) Sheena McDonnell Annually May-20

Board Cycle of Business (inc Meeting Dates) Company Secretary Each Meeting Next Meeting

Chair and NEDs' Report Angela O'Mara Each Meeting Next Meeting

Chief Executive's Report Company Secretary Each Meeting Next Meeting

Minutes of the Finance and Performance Committee Company Secretary Each Meeting Next Meeting Mar Apr May Jun, Jul Aug Sept Oct

Minutes of the Quality and Effectiveness Committee Company Secretary Bi-Monthly Next Meeting March May Nov

Minutes of the Audit and Risk Committee Company Secretary Quarterly Jul-20 Feb/March Jul

Minutes of the Charitable Funds Committee Company Secretary Quarterly Next Meeting Mar Jun Sept

Minutes of the Management Board Company Secretary Each Meeting Next Meeting Nov - Apr May June July Aug/Sept Oct Nov

Minutes of the Council of Governors Company Secretary Each Meeting Next Meeting Oct / Jan May July

ICS Update Richard Parker Each Meeting Next Meeting

Bassetlaw Integrated Care Partnership Bulletin Company Secretary As Required Consider Nxt Mtg Bulletin Bulletin Bulletin Bulletin Bulletin Bulletin Bulletin

Minutes of the Previous Meeting Company Secretary Each Meeting Next Meeting Apr May Jun July Sept Oct Nov

Any Other Business Suzy Brain England Each Meeting Next Meeting

Governor Questions Suzy Brain England Each Meeting Next Meeting

Date and Time of Next Meeting Company Secretary Each Meeting Next Meeting Jun July Sept Oct Nov Dec Jan

Withdrawal of Press and Public Suzy Brain England Each Meeting Next Meeting

Planned for Future Meeting(s)

Items Added to Individual Meetings as Required

OTHER ITEMS

Not Considered as Planned

GOVERNANCE AND RISK

Presented as Planned

ITEMS FOR INFORMATION

Public Council of Governors’ Meeting – 30 October 2019 Page 1 of 11

COUNCIL OF GOVERNORS

Minutes of the meeting of the Public Session of the Council of Governors Held on Wednesday 30 October 2019, at 5:45pm

in the Education Centre, Doncaster Royal Infirmary

Present: Chair Suzy Brain England OBE

Public Governors Peter Abell

Michael Addenbrooke Philip Beavers Hazel Brand Mark Iain Bright Kay Brown David Cuckson

Linda Espey David Goodhead Dave Harcombe Geoffrey Johnson Lynne Logan Steve Marsh

Beverley Marshall Susan McCreadie David Northwood Liz Staveley Churton Sheila Walsh Doug Wright

Staff Governors Karl Bower Duncan Carratt

Vivek Panikkar Lorraine Robinson

Mandy Tyrell

Partner Governors Robert Coleman Kathryn Dixon Antony Fitzgerald Griff Jones

Jackie Hammerton Ainsley MacDonnell Victoria McGregor Riley

Susan Shaw Rupert Suckling Clive Tattley

In attendance: Board Members Karen Barnard - Director of People and Organisational Development

Pat Drake – Non-Executive Director Becky Joyce – Chief Operating Officer Sheena McDonnell – Non Executive Director Sewa Singh - Medical Director Richard Parker OBE – Chief Executive David Purdue – Deputy Chief Executive Neil Rhodes – Non-Executive Director

Staff Ken Anderson – Head of Digital Transformation (for Simon Marsh) Kirsty Edmonds-Jones – Director of Estates and Facilities Fiona Dunn – Acting Deputy Director of Quality and Governance and Clinical Governance Lead for Clinical Specialties Division Jeannette Reay – Head of Corporate Assurance / Company Secretary (Minutes) Emma Shaheen – Head of Communications and Engagement Katie Shepherd – Corporate Governance Officer Rosalyn Wilson – Corporate Governance Officer

Other Andrew Goodhead – Chief Operating Officer, Healthwatch Doncaster

Apologies: Governor Apologies Ann-louise Bailey

Steven Wells

CP19/10/A1 – CP19/10/G

FINAL


Board Member Apologies

Kath Smart – Non-Executive Director

ACTION

CP19/10/A1


Suzy Brain England welcomed the Members and attendees to the meeting. The apologies for absence were noted.

CP19/10/A2 Declaration of Governors’ Interests (A2)

No changes to the declaration of Governors’ interests were noted. No conflicts of interest for the meeting were declared.

The Council:

- Noted and confirmed the Declaration of Governors’ Interests.

CP19/10/A3 Action Notes from Previous Meetings (Enclosure A3)

Action Points 1 to 4 – Governors noted that all actions had been completed and could be closed.

The Council:

- Noted the updates and agreed actions could be closed. A brief discussion took place on the Confidential session where the recommendations of the Appointments and Remuneration Committee had been presented to the Council of Governors for approval. The meeting in public was advised of the reappointments of Neil Rhodes as a Non-Executive Director and of Suzy Brain England as the Chair – each for a further term of three years.

CP19/10/B1 Healthwatch Doncaster and The Work That We Do (Presentation)

Andrew Goodall provided a presentation on the work of Healthwatch Doncaster. Governors noted that Healthwatch provided a strong independent voice for the people of Doncaster to improve the quality of local health and social care service and that, as an independent Community Interest Company, it had a role of engaging, informing and influencing. Andrew Goodall took the meeting through Healthwatch’s:

- Purpose;


- Vison; - Values; - Current plans; - Achievements.

The CCG had commissioned Healthwatch to coordinate Governing Body stories and Anthony Fitzgerald reported that this worked well. Members noted that a similar offer could be brought to DBTH. Healthwatch was commissioned in Local Authority Areas and worked together across boundaries – including South Yorkshire and Nottinghamshire. Andrew Goodall advised that he attended the Trust’s Patient Engagement Committee and that work was in train to shape current PLACE work. Victoria McGregor Riley was eager to have joint conversations with Healthwatch to work collaboratively and to share learning. Geoffrey Johnson referenced that Healthwatch was working on a Children’s/Young Person’s Charter – it was expected that this would include young carers.

The Council:

- Noted the presentation on Healthwatch; - Thanked Andrew Goodall for his clear and thorough presentation.

CP19/10/C1 Reports on Activity, Performance and Assurance (Presentation C1)

CP19/10/C1.1 Hazel Brand – Lead Governor Update (Presentation C1.1)

Hazel Brand provided an update on her recent activities as Lead Governor. She advised of:

- A second workshop for the Guiding coalition;

- Governor preparations for, and input to, the CQC’s Well-Red Review;

- The Non-Executive Director appointments process;

- The Annual Members’ Meeting;

- Training opportunities for governors, including:

World Patient Safety Day

CQC Briefing

Masterclass

Skills/education event (Bassetlaw).

Governors commented positively on the Trust’s Annual Members meeting, noting a few areas for further improvement in future years:

- Better signage on the Keepmoat site; - A request for shorter presentations;


- Longer for tables to discuss and formulate questions.

The Council:

- Noted the update from the Lead Governor.

CP19/10/C1.2

Neil Rhodes – Finance and Performance (Presentation 1.2) Neil Rhodes provided the finance and performance headlines as at the end of September 2019 and an update on the Trust’s catering contract with Sodexo. Finance Headlines The Trust was slightly ahead of plan in its finances at the end of month six and held a very strong cash position. Expenditure on capital was acceptable. Governors noted that the most likely projected outturn at the year-end was £6m below the control total. The recovery plan focused on the progression of cost improvement plans (CIPs) at £2.4m, winter pressures at £2.4m and a requirement for mature conversations with ICS colleagues on shared issues. Governors noted that elective income was off target but that focus was being placed on areas of underachievement and that reporting to the CCG was at speciality level. Richard Parker commented that the Trust’s individual finances were complex and that PLACE and ICS commitments required that partnership finances also be balanced. Further challenges came from contracting issues and a blended ED tariff. The Trust, and the system, could not rely on income to achieve balance. To address these issues the Trust was working on a waste/cost reduction programme and contracting negotiations had been started early. Finances were a priority for the Trust and continued to be a focus of reporting at the Trust’s Finance and Performance Committee and the Board of Directors. Performance Headlines

The Trust’s four hour ED position stood at 88.7% - which was below target but represented an improvement on the prior period, and was higher than the national average. Governors noted that the Board of Directors had agreed an investment plan (including extra staffing) at its September 2019 meeting and that this was being monitored closely. The 18 week referral to treatment (RTT) position stood at 86.2% - missing the national target (92%) but representing an improvement on the prior period and higher than the national average. A recovery plan was in place and this was being monitored closely by the Finance and Performance Committee and the board of Directors.


Four of the five stroke measures were on target but a presentation – provided to the Finance and Performance Committee – had identified improvement areas. Four of the five cancer targets had been hit. Cancer performance continued to be an improving position.

Neil Rhodes highlighted to Governors that local issues, including the current pension rules and high levels of sickness, were adversely impacting on the achievement of the Trust’s targets and the speed at which actions in the recovery plans were being achieved. Sodexho Contract The Trust’s Finance and Performance Committee had received a positive presentation on the current position of the Sodexo contract and, in recognition of Governor interest in catering matters, Neil Rhodes shared the headline information with the meeting. Governors were advised that approximately 75,000 meals were served on the Trust’s sites each month and that patient satisfaction surveys had reached 95% in December 2018, stabilising above the KPI for ten months. Although recent individual incidents had been widely reported as a cause for concern, the number of incidents on Datix was negligible. Governors noted that a new quality assurance process had been put in place in recent months and that this had led to improvements in service. Moving forwards attention would be given to the staff and retail offers provided by Sodexo – in particular the quality of offer at sites other than DRI. Karl Bower and Susan Shaw raised detailed queries on food provision and Kirsty Edmonson-Jones agreed to pick up their points following the meeting. In response to a Governor query, the meeting was advised that coloured trays were provided for patients with visual impairments across all three sites.

The Council:

- Noted the update from Neil Rhodes.

CP19/10/C1.3

Sheena McDonnell – Charitable Funds (Presentation C1.3) Sheena McDonnell reminded Governors that she had been a Trust Non-Executive Director for 15 months. With a regulatory background in Housing and, as a HR professional, Sheena highlighted a passion for leadership. She expressed that, as a non NHS professional, she was in a good position to ask lots of questions of the Executive Directors.


Governors noted that Sheena McDonnell was Chair of Trust’s Charitable Funds Committee and that she had recently taken on the Chairmanship of the Fred and Ann Green Advisory Group. The dual chairmanship enabled close working of the meetings and arrangements had been streamlined to bring decision making closer together. Sheena McDonnell highlighted that Charitable Funds were all about enhancing patient care ‘above and beyond’ the normal expectations of the NHS. Governors noted that the last meeting of the Charitable Funds Committee had agreed to focus on maternity fundraising and had signed off the Charitable Fund accounts - three months in advance of requirements. Sheena McDonnell had recently become the Non-Executive Director supporting Freedom to Speak Up which would see her working closely with the Trust’s new Freedom to Speak Up Guardian, Paula Hill. Governors noted that Sheena McDonnell was a member of both the Trust’s Quality Effectiveness Committee and Audit and Risk Committee and that she sat on the Ethics Committee. Her other regular commitments for the Trust were noted.

The Council:

- Noted the update from Sheena McDonnell.

CP19/10/C1.4

Pat Drake – Quality and Effectiveness (Presentation C1.4) Pat Drake provided the quality and effectiveness headlines as at the end of September 2019. Cdiff cases stood at 21 against an annual target of no more than 44. Reporting had changed from prior years with community associated infections now included in the Trust’s figures. No lapses in care had been identified. Pressure ulcers stood at 38 against an annual target of 58. A review of equipment was being undertaken to ensure that patients could access required items as required. Harms were below the national average with three serious falls in the year to date. Set training was currently at 86.74% against a target of 90% - expected to be achieved by the year-end - and appraisal results for the year were good at 84.99%. The Trust’s HSMR was at 97.5 against the expected range of 100. All cases were examined in real time and a coding audit was being undertaken to ensure that all patient admissions were categorised correctly (emergency/elective). The expectation was that the HSMR would fall in the next few periods.


A review of the Trust’s complaints processes had been undertaken with a view to improving response times and the quality of responses. The outcomes of the review were to be reported in detail to the Quality and Effectiveness Committee in December 2019. Information on the Accessible Information Standards (AIS) had been provided to the Quality and Effectiveness Committee meeting in October 2019. These standards had been in place since July 2017 and were mandatory for the NHS and Social Care providers. The Trust had pockets of good practice for supplying information but it was currently non-compliant with the standards as a whole, and an action plan was in place to redress this – including the creation of a policy to formalise the Trust’s approach. Governors noted that an appointment had been made to the Medical Examiner post, with a start date for the successful candidate of December 2019.

The Council:

- Noted the update from Pat Drake.

CP19/10/C1.5

Suzy Brain England, OBE (Presentation C1.5) Suzy Brain England provided an update on her work during the last month, highlighting a number of celebratory events. The Governors noted that Suzy had attended/participated in:

- World patient safety day and the launch of the Quality Accreditation Tool (dQAT);

- The Annual Members’ Meeting; - The CQC inspection process; - The launch of the refreshed Doncaster PLACE Plan; - Receipt of the NHS Long-Term Plan and the ICS’ response to the content; - The launch of the continuity of carer work by the Maternity team; - The induction of the Trust’s new Library Services Manager, Katherine

Frances; - National Allied Health Professionals day.

The Chair highlighted that staff responses to the CQC – during its inspection visits – had appeared to be more positive than in prior years, which was felt to be a reflection of the preparatory work that had taken place during the preceding months.

The Council:

- Noted the update from the Chair.

CP19/10/C1.6

Richard Parker, OBE (Presentation C1.6)


Due to time constraints Richard Parker did not present his slides in detail. The headings for the items were noted as:

- The CQC inspection had been completed in early October 2019; - E-Observations had been launched; - 400 colleagues had attended the Star awards; - 3000 staff had been provided with the flu jab; - The new corporate directorate ‘Education and Research’ had been

launched; - Doncaster and Bassetlaw Health Services pharmacy had been launched; - The Trust had received region-leading Cancer Patient Experience results,

a vast improvement over the previous year; - The Trust had been named amongst 78 others to receive a share of £200m

for cancer screening. Governors were interested to know whether the CQC had asked follow up questions after its inspections. The Trust’s preparations this year had been extremely robust and, although some follow up questions had been posed, there were not as many as in previous years. The introduction of E-Observations was particularly welcomed, with Governors noting the benefits of the technology for nursing staff. In response to a detailed query on which scanners may be funded at which sites, Governors noted that the Trust was awaiting final confirmation.

The Council:

- Noted the update from the Chief Executive.

CP19/10/C1.7 Governor Questions (Item C1.7)

Governor questions had been addressed throughout the presentation.

CP19/10/E1 Feedback from NHS Providers Governors’ Advisory Panel – GAC (Verbal)

Peter Abell provided an update on the Governor Advisory Committee (GAC) of NHS Providers that had taken place on 22 October 2019. A description of DBTH’s Annual Members meeting had been provided to the Committee and the format had been noted as good practice. Discussions at the Committee had highlighted that a further improvement to future Annual Members meetings could be the inclusion of presentations from Clinicians.

The Council:

- Noted the update from the GAC meeting in October 2019.


CP19/10/E2 Feedback from Governor Events (Verbal)

CP19/10/E2i PLACE Visit – Montagu Hospital Philip Beavers had been involved in the PLACE visit to Montagu Hospital in the previous week. He commented on a positive experience and that he had come away assured of processes on matters examined, including food inspection, with only minor issues for improvement noted (no safety issues).

CP19/10/E2ii Montagu Hospital Richard Parker advised that the Trust had applied for funding of £0.5m from the Cancer Alliance to support the implementation of a Rapid Diagnostics Centre at Mexborough. This was seen as a trial which the ICS may develop as strategy in future years. It was possible that the future of Montagu Hospital could be as a specialist cancer centre for the region.

CP19/10/F1 Minutes of the Previous Meeting (Enclosure F1)

Karl Bower had been incorrectly recorded under apologies but had been in attendance at the meeting.

The Council:

- Received and approved the minutes of the public meeting of the Council of Governors’ held on 25 July 2019, subject to the amendment above.

CP19/10/F2 Minutes of the Board of Directors (Enclosure F2)

The Council:

- Noted the link to the Board of Directors’ meetings held in September and October 2019.

No queries were raised on the content.

CP19/10/G1 Questions from Members of the Public (Verbal)

CP19/10/G1i Mr Sprakes Mr Sprakes queried whether a large salad was still available for patients as his

experience was that the size of the salad was now very small. Kirsty Edmondson-Jones agreed to respond outside of the meeting. Post Meeting Note: Kirsty Edmondson-Jones confirmed that patients were able to order a full size ham salad on a dinner plate.


Mr Sprakes also queried whether a hot breakfast option was available. Post Meeting Note: Kirsty Edmondson-Jones confirmed that DBTH’s offering was the same as Sheffield Teaching Hospitals – that only those with nutritional needs were provided with a cooked/hot breakfast.

CP19/10/G1ii Mr Webb Mr Webb queried the RTT position – noting its presence on the Board of Directors’ agendas. Richard Parker advised that the current year target of 92% presented a substantial challenge. The Trust had believed that RTT would be deliverable in Quarter three, but had been unable to implement a recovery programme due to the adverse impact of pension rules for senior staff – including Consultants who were less willing to work additional shifts. RTT was a significant issue across the ICS partners were also finding the targets a challenge. The recovery of RTT was a priority for the Trust – with a continued ambition to achieve the target by the year-end. RTT was a focus of reporting at the Trust’s Finance and Performance Committee and the Board of Directors. Mr Webb requested detail of the Trust’s HSMR position. Sewa Singh advised that HSMR had been recalibrated at National Level so the percentages appeared different from prior years. Sewa Singh considered that HSMR had now levelled out and he advised that a full report on this matter would be provided to the Board of Directors’ meeting in November 2019. The Trust continued to review all deaths and crude mortality ratio was currently at the lowest level that it had ever been.

CP19/10/H1 Annual Report and Accounts (Per Link)

The Council:

- Noted the link to the Annual Report and Accounts.

CP19/10/H2 Any Other Business (Verbal)

CP19/10/H2i Questions

In response to a query from Doug Wright, it was noted that public questions were scheduled at the end of council meetings as queries on the content of papers or matters discussed could well have been answered throughout the course of the meeting.


CP19/10/H2ii Sewa Singh Suzy Brain England advised that Sewa Singh would retire from the Trust on 31 March 2020. Sewa Singh had been employed as the Trust’s Medical Director for eight years, prior to which he had worked as a vascular surgeon. Whilst there would be future opportunities to recognise Sewa Singh in the future, the Council of Governors wished to formally record it thanks for his work with the Trust throughout his career.

CP19/10/H3 Items for Escalation to the Board of Directors (Verbal)

No items for escalation were noted.

CP19/10/H4 Date and time of next meeting (Verbal)

The Council:

- Noted the arrangements for the next meeting:

Date: Time: Venue:

Thursday 30 January 2020 5:30pm Education Centre, Bassetlaw Hospital

CP19/10/H5 Meeting Arrangements for 2020 (Enclosure H5)

The Council:

- Noted the arrangements for the 2020 Council meetings.

CP19/10/G Meeting Close

The meeting closed at 8:00pm.

Suzy Brain England Date: 30 January 2020

Chair of the Board

Public Council of Governors’ Meeting – 30 January 2020 Page 1 of 16

COUNCIL OF GOVERNORS

Minutes of the meeting of the Public Session of the Council of Governors Held on Wednesday 30 January 2020, at 17:30hrs

in the Education Centre, Doncaster Royal Infirmary

Present: Chair Suzy Brain England OBE

Public Governors Peter Abell

Michael Addenbrooke Hazel Brand Mark Iain Bright David Cuckson

Linda Espey David Goodhead Dave Harcombe Geoffrey Johnson Lynne Logan

Steve Marsh Susan McCreadie David Northwood Liz Staveley Churton Sheila Walsh

Staff Governors Karl Bower Kay Brown

Duncan Carratt

Vivek Panikkar

Partner Governors Robert Coleman Kathryn Dixon

Antony Fitzgerald Griff Jones

Victoria McGregor Riley Clive Tattley

In attendance: Board Members Karen Barnard - Director of People and Organisational Development

Pat Drake – Non-Executive Director Becky Joyce – Chief Operating Officer Sheena McDonnell – Non-Executive Director Richard Parker OBE – Chief Executive David Purdue – Deputy Chief Executive Jon Sargeant – Director of Finance Sewa Singh - Medical Director Kath Smart – Non-Executive Director

Staff Kirsty Edmondson-Jones – Director of Estates and Facilities Tim Noble – Medical Director Designate Jeannette Reay – Head of Corporate Assurance / Company Secretary (Minutes) Emma Shaheen – Head of Communications and Engagement Alasdair Strachan – Director of Education and Research Rosalyn Wilson – Corporate Governance Officer

Apologies: Governor Apologies Philip Beavers

Jackie Hammerton Ainsley MacDonnell Beverley Marshall

Lorraine Robinson Susan Shaw Rupert Suckling

Mandy Tyrell Steven Wells Doug Wright

Board Member Apologies

None

CP20/01/A1 – CP20/01/G

FINAL


ACTION

CP20/01/A1


Suzy Brain England welcomed the Members and attendees to the meeting. The apologies for absence were noted. Questions from Members of the Public At the Confidential meeting of the Council of Governors which had preceded this meeting, the Council had approved the inclusion of paragraphs on future Council of Governor meetings to be held in Public - to clarify the process for questions from members of the public to be asked. Jeannette Reay read out the agreed guidance for the benefit of the members of the public in attendance.

CP20/01/A2 Declaration of Governors’ Interests (A2)

No changes to the declaration of Governors’ interests were noted. No conflicts of interest for the meeting were declared.

The Council:

- Noted and confirmed the Declaration of Governors’ Interests.

CP20/01/A3 Action Notes from Previous Meetings (Verbal)

There were no outstanding action points from previous meetings. CP20/01/B1 Climate Change Emergency – DBTH Position (Presentation B1)

Kirsty Edmondson-Jones provided information on the Climate Change Emergency, and the Trust’s position. The Governors were advised of the requirements of the UK Climate Change Act (2008) which placed a duty on the UK to lower greenhouse gas emissions, and the National NHS carbon reduction targets. The NHS carbon footprint was measured by emissions associated with energy use, travel to and from site and goods and services purchased by the NHS, and it was proposed that the new NHS Standard Contract for 2020/21 include a requirement for providers to have a ‘Green Plan’ to outline the Trust’s actions in these areas. Any Green Plan would need approval by the Council of Governors. The Governors were advised of the Trust’s carbon reduction performance and recent initiatives which had led to the achievement of the energy target two years


early. A summary of future initiatives was provided but the limitations of progressing some - due to the age and state of the Trust’s main site - were noted. Referencing Doncaster Council’s declaration of a Climate Change Emergency, Hazel Brand advised that, whilst steps had been taken in Nottinghamshire to reduce emissions, Bassetlaw Council had not yet declared an emergency. David Cuckson highlighted some simple steps that could be taken by all staff, such as turning lights off when not in use. He suggested that signage to remind colleagues of such steps would help to show the Trust’s commitment. Kirsty Edmondson Jones agreed that some of the most productive steps came from behavioural changes and she advised that promotional would be undertaken in this respect. Peter Abell queried how renewable carbons and nuclear power fitted into the Trust’s plan. Governors noted that all options to enable a carbon neutral build at a new site for Doncaster Royal Infirmary would be considered.

The Council:

- Noted the presentation on Climate Change Emergency; - Thanked Kirsty Edmondson Jones for her clear and thorough

presentation.

CP20/01/B2 New Build (Presentation)

Kirsty Edmondson-Jones and Jon Sargeant presented the Trust’s progress, and future steps to be taken, towards a new Build for Doncaster. Governors accepted that, despite the Trust maximising usage, the current Doncaster Royal Infirmary site did not enable the best patient experience due to the age of buildings and layout. The design needed to be around pathways. There was growing national, and local, political support recognising the need for a new Hospital and the South Yorkshire and Bassetlaw ICS had the new build as its number one priority scheme going forward. The Government was looking at how new build schemes could be accelerated but Jon Sargeant cautioned that there were still a number of steps to be taken – the first of which was to secure ‘seed’ funding to progress an outline (initial) business case. The presentation concluded with ‘teaser’ slides depicting how a new Hospital might look. There was huge excitement in and around the Doncaster area about the project. Richard Parker highlighted the requirement to continue with the maintenance of the current site whilst the new plans were pursued – to ensure that it remained fit for purpose. Similarly the initiatives at all Trust sites, including the £20m upgrade of front door services at Bassetlaw Hospital, and improvement plans for Montagu, continued to be progressed.


In response to Governor questions, the following points were noted:

- Planning work would ensure affordability and compliance with current and future building regulations and would make use of the latest technology – including artificial intelligence;

- A green transport plan would be incorporated. This would look at how staff, patients and visitors could attend the site without increasing the carbon load, and would include the requirements for car parking;

- Options for unused land (for example land at Bassetlaw Hospital) would be considered in the Trust’s overall plans;

- All stakeholders – including Governors – would be consulted, and involved in the planning work as appropriate. The intention was to hold workshops on the site options and design, and a full public consultation programme would be invoked;

- Partners (including RDaSH) would be involved in the planning to maximise on system working and opportunities to improve pathways and integration in the interest of patients;

- The focus on design would be to a gold standard and would include initiatives which were proven to maximise patient experience and recovery - including sensory and relaxation areas and children’s play areas.

The Council:

- Noted the presentation on a new build for Doncaster; - Thanked Kirsty Edmondson-Jones and Jon Sargeant for their clear and

thorough presentation.

CP20/01/C1 Reports on Activity, Performance and Assurance (Presentation C1)

CP20/01/C1.1 Hazel Brand – Lead Governor Update (Presentation C1.1)

Hazel Brand provided an update on her recent activities as Lead Governor. She advised of: Recruitment of Non-Executive Director The appointment of Non-Executive Directors was one of the core responsibilities of Governors. The Council of Governors had used its Sub-Committee – the Nominations and Remuneration Committee - to lead the recent process. The Committee’s unanimous decision and recommendation, to appoint Mark Bailey for a three-year period, had received full Council approval at the confidential meeting of the Council of Governors which had preceded this meeting. Recruitment of a Medical Director A panel of eight Governors had been involved with the selection of a new Trust Medical Director, with the successful candidate identified as Dr Tim Noble.


‘Clear the Air’ Session An open session for Governors had been held on 7 January 2020. The issues raised were:

- Historical grievances – these were noted for closure and would inform future working;

- Training – topics to cover included wider induction, Council Committees (inc terms of reference and relationship to the full Council), statutory duties, holding Non-Executive Directors to account, representing constituent views, and Governor information needs. A survey would be undertaken of all Governors to confirm the areas for Governor training and development and it was likely that an external training provider (eg NHS Providers) may be used for some of the courses;

- Arrangements for Governor meetings – further input from Governors would be required to inform optimum arrangements for Governor Briefings, Forums and events (preferred days, times, location and duration).

Maternity Qi On 27 January 2020, an open session had been held to hear how Maternity services had embarked on a quality improvement drive following a disappointing 2018 CQC rating. Two Governors had attended the session. Sewa Singh had highlighted how the Qi drive had energised and empowered staff and how mothers had been directly involved in re-designing services. The work on antenatal services had been recognised at the Trust’s Stars awards and further initiatives would continue into 2020. Board Secretary Post Jeannette Reay’s secondment to the role of Board Secretary would end in May 2020. The substantive post was to be advertised nationally in the near future and Governors would be involved in the selection process. Governor Network NHS Providers, the membership organisation for Trusts, was exploring the possibility of facilitating a local Lead Governor network – possibly aligning in geography with that of the ICS. Hazel was to visit an East of England Lead Governor network in March 2020, to see how a regional group operated, and whether it would be of benefit in the Trust’s ICS patch. ICS - Governor Engagement The ICS was looking at ways to better involve Governors in its work. Suzy Brain England was an advocate of this and had met with the Communications Director of the ICS. It was likely that any involvement would start with a Governor survey to identify Governor knowledge of the ICS and skills that could support it in its work.


The Council:

- Noted the update from the Lead Governor.

CP20/01/C1.2 Pat Drake – Quality and Effectiveness (Presentation C1.2) Pat Drake provided the equality and effectiveness headlines as at the end of January 2020.

The latest Quality and Effectiveness Committee meetings had taken the opportunity to look at ‘hot topics’ for the Trust: Equality and Diversity The organisation was seeking to improve on equality and diversity and had a Quality and Diversity group to champion this. The group looked specifically at, and reported on, workforce disability standard metrics, the agenda pay gap, black history month, transgender awareness, and participation in Doncaster and Worksop Pride events. Governors were advised of the Trust’s involvement with the Rainbow pledge for inclusiveness, to which 2100 staff were already signed up. Forms and badges were available for Governors to join. E Observations and Digital transformation Since implementation at Bassetlaw Hospital, 69,000 observations had been undertaken on the E Obs app – equating to improved data and 144 hours saved in collection. Staff had welcomed the system which was nurse led and the patient safety benefits had been shared with the Quality and Effectiveness Committee. The E Obs system was to be rolled out at Montagu Hospital during February 2020, and at Doncaster Royal Infirmary in March 2020. Sepsis in Adults and Children An update on the management of Sepsis was received – with positive data noted. The increased use of digital records would further assist with reporting on Sepsis which was a national issue and was complex as many patients had comorbidities. Complaints and Patient Experience The December meeting of the Quality and Effectiveness Committee had received the plan to improve complaints management and reporting, and a detailed progress report would be provided to the Council of Governor’s at its meeting in April 2020. Mortality Rates A presentation on HSMR – to explain the complicated processes for calculation and presentation – had been welcomed by the Committee, which had noted the expectation that the numbers would reduce in the coming months.


In response to a query from David Northwood, Pat Drake advised that the Quality and Effectiveness Committee had been assured by the Trust’s approach – in particular the focus on elective mortality – with every case being examined in detail. Sewa Singh’s offer of a Governor workshop on the calculation and presentation of HSMR was not accepted – with Governors content that the Non-Executive Directors had been assured by the presentation at the Quality and Effectiveness Committee. Organ Donation Committee A meeting of the Organ Donation Committee had recently been held. One of the discussions had been around whether the Trust should have a memorial for the families of those who sadly lost their lives and whose organs were then donated, and David Purdue was to set up a task and finish group to look at this matter.

The Council:

- Noted the update from Pat Drake.

CP20/01/C1.3

Neil Rhodes – Finance and Performance (Presentation 1.3)

Neil Rhodes provided the finance and performance headlines as at the end of January 2019. He highlighted that a lot of assurance could be provided by how the Trust was perceived in terms of its leadership, budgeting and quality, noting that:

- The budget showed a strong cash position; - Scrutiny continued to ensure that the Trust held its position as the year-

end approached, in order to achieve its control total; - The position had moved from a potential deficit of £7.7m (reported to the

October 2019 Council of Governors’ meeting) to a gap of £2.3m. - The current state had been achieved through hard work, which would

continue - with a focus on cost improvement programmes (CIPs) and income - to the year-end, and into 2020/21;

- The link between RTT and income was noted. The Trust was working with the CCG to agree year-end settlement figure (contingent on achieving 92% RTT).

Neil also recognised the importance of strong delivery, noting that:

- The Trust had experienced increased numbers of patients into its Emergency Departments (6% at DRI and 12% at BH) which it was managing with the same staffing levels as previous years;


- The increased attendances had had an impact on the four hour access target which was below the National target (but remained above the National average, and in the top half of performing Hospitals);

- The 70% increase in patients (from the prior month) at Montagu Hospital could be attributed to its changed status from a Minor Injuries Unit to an Urgent Care Treatment Centre (which saw minor ailments as well as minor injuries);

- Focus continued on the improvement of the RTT position and an in depth examination by speciality was being progressed;

- The Finance and Performance Committee was to receive an update on key areas of Finance and Performance from the Divisional Director or Surgery and Cancer, at the February 2020 meeting.

Peter Abell highlighted the importance of RTT to patients - given its inclusion in the NHS Constitution - and that the Trust’s position on RTT was much lower than for that of the ICS (currently at 91%). In response to a query on partner concerns, Richard Parker acknowledged the Trust’s position in the collaboration which was striving to be a top performer for all targets. He advised that work continued with partners (whose performance had recently stated to deteriorate) and that the Trust continued to plan to achieve, and maintain, an improved position - based on a validation of waiting lists. Governors were concerned on issues relating to appointment letters, including multiple/duplicate issues and cancellations. The Trust’s implementation of Dr Doctor had aimed to improve this, but efforts were adversely affected in some areas due to staff vacancy rates. Richard Parker confirmed that focused efforts were being made in this area with weekly performance reports being provided on the backlog of letters starting to show improvements. Investment in a post to progress the administration improvement action plan would be made in the next 12 months.

The Council:

- Noted the update from Neil Rhodes.

Action: An update on the progress of the administration improvement action plan – including the position on appointment letters – would be included on the agenda for the Council of Governor’ meeting on 23 April 2020.

RJ


CP20/01/C1.4

Sheena McDonnell – Charitable Funds (Presentation C1.4)

Sheena McDonnell provided the charitable fund headlines as at the end of January 2019:

- A fundraising strategy on the birth appeal had commenced (target £100k);

- A local author had written a book ‘The Boy who Lost his Burp’ – following

his family’s positive experience of the Trust (all funds to Charitable funds);

- Improved controls had been implemented for Charitable fund accounts;

- The Charitable Funds Development Committee had considered smaller

items for colleague bids (many relating to health and wellbeing);

- The Fred and Ann Green was promoting bids for funding. Ideas were

welcomed, with exciting potential to support a Regional Diagnostic Centre

/ Cancer Treatment Centre at Montagu Hospital.

Sheena McDonnell also advised of her work to support a mayoral visit to Montagu

Hospital at Christmas time, attendance at the Trust’s Ethics Committee and her

involvement in the recruitment of the Non-Executive Director.

Mark Bright advised – in his capacity as a lay member on the Ethics Committee –

of recent matters considered: Issues around planned family access to the

mortuary, access to patient records and prisoner appointments.

The Council:

- Noted the update from Sheena McDonnell.

CP20/01/C1.5 Kath Smart – Audit and Risk (Presentation C1.5)

Kath Smart presented the audit and risk headlines as at the end of January 2020:

- The most recent Audit and Risk Committee meeting had taken place in November 2019, and the next meeting was to take place on 6 February 2020;

- The November 2019 Committee had received five internal audit reports; - Significant assurance had been provided on the final reports for CNST,

safeguarding and core financial controls; - Partial assurance had been provided on the final report on IT Contract

Management; - Early sight of the reporting stocktake audit (which was at draft report

stage) was provided to the Committee as that review had resulted in partial assurance with a number of recommendations included to improve processes;

- The processes for follow up of audit recommendations had improved in recent months, resulting in a low level of items which had passed original implementation dates;


- In depth reports were provided on Counter Fraud activity, Local Security Management, and Health, Safety and Fire;

- There was a need to improve the Corporate Risk Register and Board Assurance Framework reports – to include up to date controls and assurances.

Kath Smart also highlighted her work to support Mock CQC inspections and as the Non-Executive Director supporting Procurement. She had attended meetings relating to fire safety and the NHS Providers NED network. In response to a query on the Trust’s Counter Fraud Activity, Kath Smart confirmed that the Trust took a proactive report to prevention.

The Council:

- Noted the update from Kath Smart.

CP20/01/C1.6 Richard Parker – Chief Executive’s Report (Presentation C1.6) Richard Parker provided an update on recent Trust matters, including:

- The receipt of the draft CQC inspection report – for factual accuracy checking, prior to final report expected on 8 February 2020;

- The receipt of the draft staff survey results – showing significant improvements;

- A visit from the Prime Minister and Health and Social Care Minister for the Trust – which included an announcement of funding (now £20m) for improvements to the ‘front door’ at Bassetlaw Hospital;

- A second visit from Matt Hancock to discuss plans for a new Hospital in Doncaster;

- The recent and proposed changes to Montagu Hospital; - The Appointments of a Director of Education and Research, a joint Chief

Allied Health Professional (with RDaSH) and a Medical Director.

The Council:

- Noted the update from Richard Parker.

CP20/01/C1.7

Suzy Brain England, OBE (Presentation C1.7)

Suzy Brain England provided an update on her work during the last month, highlighting her representation of the Trust both internally and externally. Governors noted her attendance at / participation in:

- The launch of the refreshed Doncaster PLACE plan; - The Non-Executive Director appointment (approved at the meeting in

Private which had preceded this meeting);


- The Trust’s hosting of Boris Johnson and Matt Hancock – taking the opportunity to highlight the organisation’s achievements and challenges, and the need for an update of the Estate / New Build.

The Chair advised that invitations to visit the Trust had been extended to the NHS Provider’s new Chair – Sir Ron Kerr, and to Dan Jarvis – Mayor for the Sheffield City Region.

The Council:

- Noted the update from the Suzy Brain England.

CP20/01/C1.8 Governor Questions (Item C1.8)

Governor questions, relevant to presentation topics, had been addressed throughout the presentation. Some further matters were addressed: Coronavirus In response to a query on how the Trust would respond to Coronavirus, it was noted that efforts would be on containment until a vaccine was available. The Infection Control Team had assessed the Trust’s sites to look at the response that that Trust would take if it received a patient / patients with the virus. Whilst local response was being prepared it was noted that management of any outbreak would be managed at National level. Pianos Governors had previously been advised that the purchase of a piano for each Trust site would be funded by Sodexo. As an alternative the pianos had been paid for from Charitable Trust funds as there was evidence that music improved the patient experience. Since their siting (in the dining room at Doncaster Royal Infirmary and Bassetlaw Hospital, and in the waiting area at Montagu Hospital), the Trust had received both positive and some negative comments. This was a trial and the position would be monitored. A number of surgeons who had worked an intense night shift had been using the pianos as stress relief. A live outside broadcast with Radio Sheffield was being pursued. The Council:

- Noted the queries and comments from Governors and the responses

provided.

CP20/01/D1 Governor Approvals (Verbal)


Hazel Brand highlighted discussions at the December 2019 Governor Briefing Session, where a suggestion to use a Task and Finish Group to consider the current Code of Conduct for Governors had been made.

The Council:

- Approved the creation of a Task and Finish Group to consider the code of Conduct for Governors.

Action: Governors were to advise the Trust Board Office of interest in membership of the Task and Finish Group for the Governor Code of Conduct.

GOVS

Jeannette Reay advised that Doug Wright had expressed an interest in membership (via email).

CP20/01/E1 Feedback from NHS Providers Governors’ Advisory Panel – GAC (Verbal)

Suzy Brain England had attended the Governor Advisory meeting on the morning prior to the Council of Governors’ meeting. The topics covered – and for future possible consideration at DBTH - had included:

- Focus areas for the July 2020 meeting* – possibly IT/Digital, Mental Health, Overview of the state of the NHS;

- Sharing of local Governor experiences, including involvement with Non-Executive Director and Director appointments (as at DBTH);

- A suggestion raised on the detail of Director titles – replacing OF with FOR (ie Director OF P&OD would become Director FOR P&OD);

- A suggestion to increase Non-Executive and Governor engagement by placing Board of Director and Council of Governor meetings on the same day – with a shared lunch in between;

- Support for regional Governor networks (as referenced in the Lead Governor update at CP20/01/C1.1);

- The work of NHS Providers in raising the profile of Workforce, Capital and Finance/Funding changes;

- The success of Governwell Effectiveness Reviews – followed by training and development programmes (referenced as a possible start to informing Governor training needs at DBTH in the Lead Governor update at CP20/01/C1.1);

- Initiatives to showcase at the National Conference* (7 July 2020 in

London).

With respect to showcasing the Trust’s work, Peter Abell suggested that Governor involvement in the New Build (which should have progressed by July 2020) be considered.

The Council:

- Noted the update from the GAC meeting on 30 January 2020.


*Action: For the next meeting and National Conference on 7 July 2020, two

additional places for DBTH Governors were available (over and above those secured for Suzy Brain England and Peter Abell). Interested Governors were to advise Hazel Brand if they wished to attend.

GOVS

CP20/01/E2 Feedback from Governor Events (Verbal)

No updates were provided.

CP20/01/E3 Governor Portal (Verbal)

In response to Governor requests for guidance on the content and use of the Governor Portal, Ros Wilson advised that time to provide this would be built into the next Governor Briefing.

The Council:

- Noted the update on the Governor Portal.

CP20/01/E4 Car Parking (Verbal)

To assist colleagues in meeting the requirements of the new permit recognition scheme, Governors had been asked to confirm their car registration details to the Trust Board office. Ros Wilson confirmed that one permit would be provided, detailing more than one car registration where relevant, and that this could be laminated to transfer between vehicles. A query arose on the availability of a car parking attendant at the Racecourse Park and Ride site, and whether this post was written into the service contract with SABA. Kirsty Edmondson-Jones confirmed that there had been no change to the contract – including the provision of a parking attendant at the Racecourse site – but, she advised that one of the attendants had recently left (but had not been made redundant, as was queried) and that, as the individuals used the bus to make use of facilities at DRI, there may be occasions when the car park did not have a presence. Governors were also advised that the current contract included robust plans for security, over and above those of previous agreements – including attendants, CCTV, lighting and working with the Police.


The Council:

- Noted the update on car parking – both at the Hospital sites and at the Racecourse Park and Ride site.

Action: Kirsty Edmondson-Jones would investigate concerns that mobility bays were being incorrectly used, leading to limited spaces for those in need.

KEJ

CP20/01/F1 Minutes of the Previous Meeting – 30 October 2019 (Enclosure F1)

Kirsty Edmondson-Jones had been missed from the attendance list in error. A typographical error at G1 required correction to read: ‘Members of the public’.

The Council:

- Received and approved the minutes of the Council of Governors’ Meeting held in Public on 30 October 2019, subject to the amendments noted above.

CP20/01/F2 Minutes of the Annual Members Meeting held on 26 September 2019 (Verbal)

This item was deferred until the next meeting.

CP20/01/F3 Minutes of the Board of Directors (Enclosure F2)

The Council:

- Noted the link to the Board of Directors’ meetings held between September and December 2019.

No queries were raised on the content.

CP20/01/G1 Questions from Members of the Public (Verbal)

CP20/01/G1i Mr Sprakes

Mr Sprakes referenced the query he had raised at the previous meeting on the availability of a cooked breakfast. This matter had been investigated and it had been confirmed that the Trust’s offer was the same as that of Sheffield Teaching Hospitals. Mr Sprakes had been answered personally by letter and a post meeting note – providing the response - had been included in the draft minutes of the meeting held on 30 October 2019.

CP20/01/G1ii Mr Webb


Mr Webb thanked Richard Parker for the information he had provided in response to previous queries on RTT. In response to a query as to whether the Trust was aware of the number of patients who left the Trust’s waiting lists to have private work undertaken, the meeting noted that reasons for patients leaving lists were not recorded but that numbers transferring to an alternate provider were known. Richard Parker advised that, Consultant contracts included an obligation for colleagues to offer additional work to DBTH before any other provider. There were surgeons who undertook additional work and this information was recorded. Private work and contracts were currently being examined nationally.

Mr Webb raised a detailed query on behalf of a patient who experienced a fall six weeks’ previously, resulting in a fractured femur. David Purdue would liaise with Mr Webb outside of the meeting on this matter.

The Council:

- Noted the queries and comments from the members of the public and

the responses provided.

CP20/01/H1 Any Other Business (Verbal)

CP20/01/H1i Comment on Meeting

Suzy Brain England thanked all for their contributions to the meeting, highlighting an incredibly positive meeting which had reiterated to colleagues the strong current position of the Trust, and it’s exciting plans for the future. Colleagues were requested to share the positive messages widely.

The Council:

- Noted the closing remarks.

CP20/01/H2 Items for Escalation to the Board of Directors (Verbal)

No items for escalation were noted.


CP20/01/H3 Date and time of next meeting (Verbal)

The Council:

- Noted the arrangements for the next meeting:

Date: Time: Venue:

Thursday 23 April 2020 17:30hrs Education Centre, Bassetlaw Hospital

CP20/01/G Meeting Close

The meeting closed at 8:45pm.

Suzy Brain England Date: 13 May 2020

Chair of the Board

Management Board - 18 November 2019 Page 1 of 7

MANAGEMENT BOARD

Minutes of the meeting of the Management Board held in on Monday 18 November 2019 at 2.00pm in the Education Centre, Doncaster Royal Infirmary

Present:

Richard Parker, OBE – Chief Executive (Chair) Karen Barnard - Director of People and Organisational Development Eki Emovon - Divisional Director, Children and Families Becky Joyce Joyce – Chief Operating Officer Marie Purdue – Director of Strategy and Transformation David Purdue – Deputy CE and Director of Nursing and Allied Health Professionals Jon Sargeant – Director of Finance Nick Mallaband - Divisional Director, Medicine Antonia Durham ‐ Hall, Divisional Director ‐ Surgery & Cancer Jochen Seidel - Divisional Director, Clinical Specialities (JSe)

In attendance:

Lesley Hammond – Funeral Manager (Emergency) Dr Andrew Oates – General Medicine Clinical Director Dr Anurag Agrawal – Endoscopy and Gastro Clinical Director Mandy Espey – General Manager Surgery and Cancer Kirsty Clarke – Associate Director of Nursing Surgery and Cancer Mr Paul Haslam – Trauma and Orthopaedics Clinical Director Mr Olumuyiwa Olubowale – Cancer Lead for DBTH NHS FT Simon Brown – Associate Director of Nursing Clinical Specialities Dr Ken Agwuh – pathology Clinical Director Lauren Ackroyd – General Manager (O&G) Helen Burroughs – General Manager Tri Health & Paediatrics Andrea Bliss – Intrim Head of Nursing (C&F) Mrs Manju Singh – Obstetrics & Gynaecology Clinical Director Dr Anuja Natarajan – Acute Paediatrics Clinical Director Julie Butler – General Manager Medicine Dr Ian Stott – Speciality Medicine Clinical Director Mark Brookes – Associate Director of P&OD Anthony Jones – Deputy Director of P&OD Cindy Storer – Acting Deputy Director of Nursing Midwifery and AHPs Mr Willy Pillay Deputy Medical Director Workforce and Productivity Rosalyn Wilson – Corporate Governance Officer (Minutes)

Apologies: Jeannette Reay – Head of Corporate Assurance/Company Secretary

MB18/11/A – MB18/11/H FINAL


ACTION

MB18/11/A COMMITTEEE BUSINESS

MB18/11/1 Apologies (Verbal)

The Management Board:

- Noted the apologies for absence.

MB18/11/A Matters Arising (Enclosure A2) The Management Board:

- Noted the updates on actions from previous meetings.

MB18/11/B STRATEGY

MB18/11/B1 Financial Recovery (Enclosure B1)

Jon Sargeant advised the extended Management Board that at month 6 the Trust had reported a sizable negative variance to against the financial plan. Jon took Management Board through an interactive exercises to identify senior staffs understanding on the key challenges which had been reported in the proceeding months and the planned Financial Performance for 2019/20. The answers confirmed that the key points were not widely known, and as result unlikely to be owned and communicated across the organisation. Richard Parker advised of the Executive’s concern regarding the current financial position, and advised colleagues that the reason for holding the extended meeting was to ensure that the wider Management Board Team, the senior leadership team, is focused on the actions needed to ensure that the Trust meets its financial targets - and the consequences if it did not. Jon advised that a focus would take place on three key areas over the coming weeks/months:

1) Delivery of CIPs; 2) Immediate actions to control and challenge spend; 3) Short/Medium term actions.

Monthly meetings would take place with Divisions to monitor CIP’s, however fortnightly meetings would take place to address the delivery of CIP’s in areas that were under delivering.


Jon discussed the implementation of CCG commissioning rules for procedures of limited clinical value (part of CCG QIPP plans), which were non-chargeable if the Trust did not comply with referral agreements. The importance of ensuring that the referrals were in line with the CCG’s guidance for referral eligibility was emphasised - as there had recently been instances that would need to be referred back to GP surgeries. Jon went on to explain further what actions would take place in the short to medium term, including:

- The centralisation of some administrative services, to further control

spend and maximise opportunities for efficiency in the following

areas:

rota co-ordination;

medical staffing;

recruitment;

booking services;

typing;

- A review of business case delivery;

- Presentation/update to Executives on current job plans and the job

planning process going forward.

The Financial Recovery Plan would be presented to the Finance and Performance Committee meeting on 22 November 2019. No questions were raised on the content of the presentation but Dr Ken Agwuh commented on the achievement of the CQUIN targets, in particular the UTI’s. Colleagues were requested to ensure that documentation was accurate in relation to prescribing for UTI’s. Five Year Plan Jon highlighted that the Control Totals assigned to the organisation was unlikely to be achievable and that discussions were being held to achieve a realistic target. If the Trust did not deliver its control total it would lose its PSF/FRF - a sum of £4.6m.

Action: The Five Year Plan would be circulated once finalised.

JS


- Noted the update on the Financial Recovery Plan.

MB18/11/B2 Future Planning (Tabled) Becky Joyce went through her presentation and discussed the long term plan.


The detail of the timetable for completion of the work plan, including divisional contributions was discussed and it was noted that the draft CQC action plan would need to be worked into the planning. A 30 minute timeout session was held with attendees to look at the five key areas and discussions were held on what colleagues felt should be added. Each Executive Director worked with groups to get the key points: Research Education and Innovation – David Purdue Ambitions – University in Doncaster Portfolio work Main drive enhance academic research work Responsiveness of students Work in partnership Place plan Job planning Finance and Use of Resources – Jon Sargeant Better links GIRFT better Discussion around ambition Discussions around not delivery Quality of Care – Sewa Singh What is the definition of being the safest Trust in the UK Need to agree what is core business

- ED - Cancer – life threatening conditions - Everything else none core

People Plan – Karen Barnard Growing and transforming the workforce HE accept more specialist training required funding Ultra-Sonographer Engagement with younger people Progression for admin – Band 4+ Apprenticeships Operational Performance – Becky Joyce Sort out RTT and ED first Positive appendixes No feedback from plans

Annual Planning (Presentation tabled) Marie Purdue and Becky Joyce discussed the Trust strategic plan from 2018 which was being revised following the publication of the NHS long term (five year) plan.


Since August 2019 the Trust had been supporting the ICS with implementing its three stage plan.

- Delivery plan; - Strategic Planning Tool; - Strategic LTP collection template.

Richard Parker asked the senior staff to focus on the three stage plan over the next five months.


- Noted the updates on actions from previous meetings.

MB18/11/C DEEP DIVES

MB18/11/C1 SAS Doctor Charter (Enclosure C1) Mr Willy Pillay introduced Helen Sekyryskaya and gave a brief overview of the presentation. The Management Board discussed the SAS Charter and what was required from the Trust to ensure compliance. The Management Board noted that the Charter would support issues the Trust had with staffing and retention.

Action: The SAS Clinical coding for systems would be examined – to determine why it was working in some division but not all.

DP / RJ

MB18/11/D CORPORATE ISSUES

MB18/11/D1 Pension Update (Verbal)

Karen Barnard provided an update on the annual and lifetime NHS Pensions issues and the adverse impact that it had had on the Trust. Consultation with Beechcroft LLP had taken place to determine what options the Trust had to share with staff and Karen Barnard presented a Pensions policy on which she requested input from colleagues by 22 November 2019. Management Board agreed that the Trust would pay the majority of the employer pension contribution to staff who wanted to freeze their pension contributions. The payment would be c. 12%. Eligible for this would include being in the NHS Pension scheme for one month prior to an application. Richard Parker was clear that the Trust was unable to offer any pension advice and staff would be advised to obtain specialist financial advice from an accredited provider.



- Noted the verbal pensions updated and noted the above.

MB18/11/E DIVISIONAL ISSUES

MB18/11/E1 Escalation Process for Elective Long Waiters (Enclosure E1)

Becky Joyce gave an update on the new escalation process and Divisional actions. The paper was agreed by all Management Board attendees.


- Noted the Escalation Process for Elective Long Waiters update; - Supported the escalation process for Elective Long Waiters.

MB18/11/E3 Replacement Consultant Anaesthetist (Verbal)

Management Board agreed the request and the post will progress to the next vacancy control panel.


- Approved the vacancy.

MB18/11/F INFORMATION ITEMS

MB18/11/F Information Items to Note (Enclosures F1 – F4)


- Noted the items for information: Corporate Risk Register Children and Families Board Update – 4 October 2019 Minutes of the CIG Meeting – 2 September 2019 Urgent and Emergency Care Steering Group – October 2019

MB18/11/G Items to Approve

MB18/11/G1 Minutes (Enclosure H1)


- Approved the minutes of the previous meeting.


MB18/11/H Any Other Business (Verbal)

MB18/11/H1

Tier 2 Paediatric Surgery Hub Status Antonia Durham Hall highlighted a recent report that had been developed by the ICS as an update on Tier 2 Status. The Trusts position on appendectomy and torsion of testes was being considered. Antonia Durham Hall raised concerns about the information and undertook to look into the issues.

Action: Antonia Durham Hall would look at the plan and report back to the next meeting in December 2019.

RP / SS / ADH

MB18/11/H2 Items for escalation to the Board of Directors (Verbal)

There were no items for escalation.

MB18/11/H3 Items for escalation from Sub‐Committees (Verbal)


MB18/11/H4 Date and Time of Next Meeting (Verbal)


- Noted the date and time of the next meeting:

Monday 9 December 2019 14:00 The Board Room, Doncaster Royal Infirmary

MB18/11/H5

Close of meeting (Verbal)

The meeting closed at 17:25

Management Board – 20 January 2020 Page 1 of 4

MANAGEMENT BOARD

Minutes of the meeting of the Management Board held in on Monday 20 January 2020, 2.00pm in the Room 1 & 2, Education Centre, Doncaster Royal Infirmary

Present:

Richard Parker, OBE – Chief Executive (Chair) David Purdue – Deputy CE and Director of Nursing and Allied Health Professionals Eki Emovon - Divisional Director, Children and Families Rebecca Joyce – Chief Operating Officer Marie Purdue – Director of Strategy and Transformation David Purdue – Deputy CE and Director of Nursing and Allied Health Professionals Jon Sargeant – Director of Finance Nick Mallaband - Divisional Director, Medicine Antonia Durham ‐ Hall, Divisional Director ‐ Surgery & Cancer Jochen Seidel - Divisional Director, Clinical Specialities (JSe) Emma Shaheen – Head of Communication and Engagement Alasdair Strachan – Director of Education and Research Kirsty Edmondson Jones – Director of Estates and Facilities Ken Anderson – Acting Chief Information Officer

In attendance:

Rosalyn Wilson – Corporate Governance Officer (Minutes) Mr Willy Pillay – Deputy Medical Director Dr Robert Parker – (MB20/01/B1) Lois Mellor – Head of Midwifery (MB20/01/B1)

Apologies: Jeannette Reay – Head of Corporate Assurance/Company Secretary Sewa Singh – Medical Director Karen Barnard - Director of People and Organisational Development

MB20/01/A

14:00 until 17:00 Annual Planning Session A1 to A7. Richard confirmed that General Managers, Clinical Directors and Associate Directors of Nursing to discuss Annual planning had been invited to this interactive session to support the further development of the divisional draft annual plans. One of the key areas of feedback at the start of the annual planning process was that you colleagues wanted to develop better joined up plans between divisions. This session will support facilitated workshops to move forward. Draft notes were taken from each Division on flipchart to support the development sessions.

ACTION



MB20/01/B COMMITTEEE BUSINESS Commenced 17:00

MB20/01/B1 Apologies (Verbal)



MB20/01/B2 Matters Arising (Enclosure B2) Action 1 – Karen Barnard not at the meeting, to bring an update to February’s meeting. Action 2 – Antonia Durham Hall to pick this up with Trauma & Orthopaedics and Gynaecology. Action 3 - No update available to come back to February’s meeting. Action 4 – Becky Joyce to look into what the Trust currently has and what is required. The Management Board:

- Noted the updates on actions from previous meetings and agreed, as above, which actions would be closed.

MB20/01/C DIVISIONAL ISSUES

MB20/01/C1 LMS/Continuity of Carer (Enclosure C1) Dr Robert Parker and Lois Mellor gave a presentation to Management Board around Continuity of Carer and the LMS requirements for local Maternity Services. This is a NHSE transformation project and DBTH are within the South Yorkshire and Bassetlaw Local Maternity Systems and this mirrors the ICS. Discussions took place on the issues likely to impact on providing continuity

of carer; vacancies, the impact of the blended tariff within maternity

services based on the data now within CCG’s, the target of 51%. Sewa Singh

asked Divisional Management to drive this project.

Lois Mellor advised management Board that Robert Parkers role within the Trust is about to end and the deadline for a further fellow has passed. Richard Parker asked that information on what is required to Alasdair Strachan asap.

All


- Noted the Maternity Transformation update.


MB20/01/C2 Additional Sessions Mr Pillay discussed the paper in relation to standardising arrangements across the Trust for additional sessions and noted that the ICS are asking Trusts to sign up to at an ICS level to standardised payments. HRDs are leading this work across the ICS and Karen Barnard is the DBTH lead. Nick Mallaband expressed concerns around the agency cap and where the medical staff will work. Jochen Seidel discussed the pension tax that is causing many problems within the Trust and Nationally Jochen suggested that additional work for time back instead of being paid this may need to be considered. As Karen Barnard was not in attendance it was agreed to discuss the issues outside of Management Board and update the next meeting


- Noted the Additional Sessions paper. - To take back to ET for discussion.

WP/ KB

MB20/01/C3 Diabetes and Endocrinology Consultant Recruitment (Enclosure C3) Request to approve Job Description and Person Specification to allow the post to go out to advert.


Approved the Job Description and Person Specification. Action: RW to inform Bridget Harrison and Medical HR

RW

MB20/01/D INFORMATION ITEMS

MB20/01/D1&D2

Information Items to Note (Enclosures D1 – D2)


- Noted the items for information:

Elective Care Steering group – NO PAPERS SENT

CIG Minutes 25 November 2019


MB20/01/E Items to Approve

MB20/01/E1 Minutes (Enclosure E1)


- Approved the minutes of the previous meeting 18 November 2019.

MB20/01/F Any Other Business (Verbal)

MB20/01/F1 Items for escalation to the Board of Directors (Verbal)


MB20/01/F2 Items for escalation from Sub‐Committees (Verbal)


MB20/01/G1 Date and Time of Next Meeting (Verbal)



Monday 10 February The Board Room, Doncaster Royal Infirmary

MB20/01/H



Management Board – 10 February 2020 Page 1 of 4

MANAGEMENT BOARD

Minutes of the meeting of the Management Board held in on

Monday 10 February 2020, 2.00pm in the Board Room Doncaster Royal Infirmary

Present:

David Purdue – Deputy CE and D of N&AHP (Chair) Rebecca Joyce – Chief Operating Officer Marie Purdue – Director of Strategy and Transformation Nick Mallaband - Divisional Director, Medicine Antonia Durham ‐ Hall, Divisional Director ‐ Surgery & Cancer Jochen Seidel - Divisional Director, Clinical Specialities (JSe) Emma Shaheen – Head of Communication and Engagement Alasdair Strachan – Director of Education and Research Kirsty Edmondson Jones – Director of Estates and Facilities Ken Anderson – Acting Chief Information Officer Jeannette Reay – Head of Corporate Assurance and Company Secretary

In attendance: Alex Crickmar – Deputy Director of Finance Anthony Jones – Deputy Director of People and Organisational Development Jayne Collingwood – Head of People and Organisational Development Lauren Ackroyd – General Manager (O&G) Rosalyn Wilson – Corporate Governance Officer (Minutes)

Apologies: Richard Parker, OBE – Chief Executive (Chair) Karen Barnard - Director of People and Organisational Development Eki Emovon - Divisional Director, Children and Families Jon Sargeant – Director of Finance

MB10/02/A

14:00 until 17:00 Annual Planning Session A1 to A5. David Purdue confirmed that General Managers and Associate Directors of Nursing to discuss Annual planning had been invited to this interactive session to support the further development of the divisional draft annual plans. One of the key areas of feedback at the start of the annual planning process was that colleagues wanted to develop better joined up plans between divisions. This session will support facilitated workshops to move forward. Draft notes were taken from each Division on flipchart to support the development sessions.

ACTION

MB10/02/B COMMITTEEE BUSINESS Commenced 16:15

MB10/02/B1 Apologies (Verbal)





MB10/02/B2 Matters Arising (Enclosure B2) Action 1 – David Purdue to speak to Sheffield Teaching Hospital and Sewa Singh for an update and update at March’s meeting. Action 2 – Antonia Durham Hall to pick this up with Dr Khai Shahdan. Action 3 – Agreed to be closed due to ongoing with in ED and with CCG Partners. Action 4 – Ongoing work, guidance has been produced and will go to July’s LMC and then back to Management Board. The Management Board:

- Noted the updates on actions from previous meetings and agreed, as above, which actions would be closed.

MB10/02/B3 Corporate Risk Register Jeannette Reay gave an update on the Corporate Risk Register, One risk has been escalated via Datix in January 2020 which Management Board is asked to consider. Risk number 2426 should be added to the Corporate Risk Register, a business case will go to CIG on Wed 12 February 2020 for funds. The director of Finance has approved the business case in principle. Management Board agreed to add to the Corporate Risk Register following a discussion with Ken Anderson to gain an understanding on the business case and what is required. Nick Mallaband as about adding Nights at Bassetlaw, Tier 4 level cover in ED high risk, scored at 20. Paper has been sent to Becky Joyce for consideration. Agency spend has reduced in Doncaster. Sewa Singh advised Management Board that all Clinical Risks should go to Clinical Governance for discussion prior to Management Board. Action: To go onto Clinical Governance Agenda, email to Karen Humphries. The Management Board: Noted the updates relating to the Corporate Risk Register.

RW

MB10/02/C DIVISIONAL ISSUES

MB10/02/C1 EAU in Emergency Department (Enclosure C1) There was a discussion between the Divisional Directors around the issues around seeing patients on ESAC, Antonia Durham Hall asked that this is discussed at Divisional Clinical Governance Committees including the Trust Clinical Governance Committee.


Antonia Durham Hall advised that this is down to manpower but also requires a multi-disciplinary approach to improve the patient’s journey and flow. The re-design of CDU is the ultimate outcome in the future.


- Noted the paper on EAU in Emergency Department.

MB10/02/C2 Escalation Risk Relates to Orthopaedic Theatre Environment (Verbal) David Purdue discussed the risk with the current Orthopaedic Theatre environment, this follows on from a QI project that was conducted with staff. The outcomes of the QI project were discussed, and the move of theatre 3&4 With Park Hill. It was agreed that this needed to be a more thought out process and the option to be brought back to a future meeting for discussion and approval. Management Board to agree the changes. Action: Jochen Seidel to bring the options appraisal back to Management Board in March. There have been a number of risks raised within the theatre area with fire doors being blocked and equipment blocking fire exits. All Immediate risk has been mitigated.

JSei


- Noted the update on the Orthopaedic Theatre Environment.

MB10/02/D INFORMATION ITEMS

MB10/02/D1,D2 & D3

Information Items to Note (Enclosures D1, D2 & D3)



Elective Care Steering group – January 2020

CIG Minutes January’s meeting cancelled

Board Assurance Framework

MB10/02/E Items to Approve

MB10/02/E1 Minutes of the Meeting 20 January 2020 (Enclosure E1)


- Approved the minutes of the previous meeting 20 January 2020.

MB10/02/F Any Other Business (Verbal)


Terms of Reference to be recirculating by David Purdue Action: Buddies – who are the buddies in divisions how to use critical friend. Agenda item for next month. Formal process for escalating of cost was discussed and will be reviewed outside of this meeting.

RW

MB10/02/F1 Items for escalation to the Board of Directors (Verbal)


MB10/02/F2 Items for escalation from Sub‐Committees (Verbal)


MB10/02/G1 Date and Time of Next Meeting (Verbal)



Monday 9 March 2020 The Board Room, Doncaster Royal Infirmary

MB10/02/H



Management Board – 9 March 2020 Page 1 of 6

MANAGEMENT BOARD

Minutes of the meeting of the Management Board held in on

Monday 9 March 2020, 2.00pm in the Board Room Doncaster Royal Infirmary

Present:

Richard Parker, OBE – Chief Executive (Chair) David Purdue – Deputy CE and D of N&AHP Rebecca Joyce – Chief Operating Officer Nick Mallaband - Divisional Director, Medicine Jochen Seidel - Divisional Director, Clinical Specialities (JSe) Alasdair Strachan – Director of Education and Research Eki Emovon – Divisional Director Ken Anderson – Acting Chief Information Officer Sewa Singh – Medical Director Dr Tim Noble – Medical Director Karen Barnard – Director People, Organisational Development

In attendance: Laura Fawcett – General Manager Medicine Howard Timms – Deputy Director of Estates and Facilities

Adam Tingle - Senior Communications and Engagement Manager Rosalyn Wilson – Corporate Governance Officer (Minutes)

Apologies: Jon Sargeant – Director of Finance Antonia Durham ‐ Hall, Divisional Director ‐ Surgery & Cancer Jeannette Reay – Head of Corporate Assurance and Company Secretary Kirsty Edmondson Jones - Director of Estates and Facilities Ken Anderson – Acting Chief Information Officer Emma Shaheen – Head of Communication and Engagement Marie Purdue – Director of Strategy and Transformation

MB09/03/A1

Apologies for absence

ACTION

MB09/03/A2 Matters Arising / Action Log Action 1 – Update from Jochen, Action 2 – Closed Action 3 – Closed Action 5 – Was removed from agenda to be rolled over to Management Board in April 2020. Management Board Noted the updates on actions from previous meetings and agreed, as above, which actions would be closed.

MB09/03/A – MB09/03/I FINAL


MB09/03/B1 Working with Prisons (Enclosure B1)

Fiona Littlewood Senior Programme Manager discussed the work that has been carried out with the 4 Prisons within Doncaster. This work has been commissioned by NHS England. Positive work has been done within the MSK team with the Virtual Fracture Clinic. The work within the Prison environment highlighted a need to review the Tissue Viability services and was noted that there was very limited resources available. There has now been a business case submitted to NHS England to look at what services need to be made available within the South Yorkshire Prison Cluster. Certain elements of the Pre Op Assessments process are now being carried out within the Prison Healthcare setting by Care UK. Fiona Littlewood has a number of work streams to look at which include

- Work with South Yorkshire and Nottinghamshire Police Forces to look at illegal activity whilst attending A&E

- Continual work with SABA relating to escorted A&E attendances - Pathway review with FCMS for out of hours GP work and attendances - Video link Consultations - Work with HMPPS (her Majesty’s Prison and Probation Service) for the use

of Healthcare Technology within the Prison setting. HMP Doncaster now has a better lives service set up for every Friday where a number of tertiary services within Doncaster attend to offer support and information to Prisoners prior to release and DBTH support this. Richard Parker asked Fiona what questions you have for Clinical Colleagues. Fiona Littlewood asked for the Medical and Clinical colleagues to support the work on developing e-clinics, work on Outpatients appointment and what can be looked at electronically. Also would Telehealth be an option. Alasdair Strachan suggested that a training needs analysis is carried out with Care UK staff and support them to achieve this with a view to reduce hospital attendances. Tim Noble asked for a focus on referrals to the Trust and analysis carried out on if they are appropriate also Trauma and Orthopaedic referrals to ensure the correct team are reviewing the patients and if there is a need for clinics to be moved on site. Other specialities to be reviewed are MSK, ENT, Respiratory and Diabetes. The work that Fiona Littlewood has done with the South Yorkshire Prisons has been nationally recognised and Management Board Congratulated Fiona on this. The Management Board: Noted the updated on the work done with South Yorkshire Prisons.


MB09/03/C1 Coronavirus (Verbal) 14:30 – Senior Managers Arrived. Richard Parker noted that this information with the planning data was particularly sensitive and not to be discussed outside of this meeting. Becky Joyce presented to Management Board on Coronavirus the current strategy that was released by the Government and what the Trust plans are to support the National Strategy. It is to be noted that this is a level 4 incident with 4 stages to the national strategy. Contain Delay Research Mitigate Becky Joyce requested colleagues to review the Flu Pandemic policy which would be the policy framework for managing COVID-19 Becky Joyce outlined the series of National requirements that we need to respond to in terms of our management approval. Becky also discussed the reasonable worst case scenario and reasonable best case scenario figures provided by Public Health. Becky Joyce discussed the impact for Doncaster and Bassetlaw population based on the data provided by Rupert Suckling at Public Health Doncaster. Questions Q) Is there a re-infection rate? A) The evidence is currently mixed on whether there is a risk of reinfection. Nick Mallaband – Patients are given biologics and chemo, which means they are immune compromised and will be more vulnerable to infection. It may be possible to delay without harm and this may need to be considered, further national guidance would be awaited. Richard Parker requested that team review the outpatient and inpatients list to start planning what could be delayed. He also indicated the importance of a robust workforce plan. Other points raise:

Simon Stevens – Point of Care testing under development Student Nurses 3rd year students and 5th Year Medical Students to be

potentially brought in

There will be a national instruction on elective care Training requirements to be identified for all divisions and departments Additional FIT kit may need to be ordered for Training

Masks & supplies for training need to be considered

Ken Agwuh discussed the current position within Doncaster and Bassetlaw Ken has checked the National guidance on this.


2 Positive cases so far. (but neither Doncaster residents) Richard Somerset advised that FFP3 is very low on stock. Alasdair Strachen advised that the Education team are involved in Swabbing on site, staff will be trained in FIT testing. FIT testing takes around 15 minutes and there are only 4 pieces of Kit. Richard Parker discussed how do we support staff in this including training on appropriate PPE, Catering and Parking. Staff side need to be engaged. It was agreed there should be a dedicated team for dealing with COVID-19. It was also agreed:

- To step down non-essential meetings

The Management Board: Noted the updated on Coronavirus and plans to be in place

MB09/03/C2 Corporate Risk Register There is no update on the corporate risk register since the last update to Board in February 2020. David Purdue gave an update to Management Board regarding the new format of the Corporate Risk Register and Board Assurance Framework that will be rolled out across the Trust in the coming Months. Due to the delay on the progress of the current format of the BAF and the Corporate Risk Register this will no longer be presented to the committees in this current format. The Management Board: Noted the updates relating to the Corporate Risk Register.

MB09/03/C3 RTT – Referral to Treatment (Enclosure C3) Becky Joyce congratulated the teams on the provisional February month end position of 90.0%. Work to finalise the position will be complete this week.

MB09/03/D1 Orthopaedic Theatre Environment - Options Appraisal (Removed from Agenda) Action: To be added to next month’s Agenda.

RW


- Noted that this paper would be presented in April 2020.


MB09/03/D2 Divisional Buddies and Critical Friend (Verbal) David Purdue updated Management Board and advised members that the Terms of Reference (TORs) have been sent for comment to Divisional Directors, looking at how buddied and critical friend. David Purdue asked Management Board how steering group meetings feed into Management Board. The Terms of Reference will outline this and David Purdue will arrange a meeting with the 4 Divisional Directors.


- Noted the update Divisional Buddies and Critical Friend.

MB09/03/D1,D2 & D3

Information Items to Note (Enclosures E2 &E3)



Elective Care Steering group – No papers to note

CIG Minutes 19 December 2019 – Work on the Woman’s Hospital is due to

start on Wednesday 11 March. There had been talks to re-open 10 beds at

Mexborough. Discussions with SYB and possible more theatre over in

Mexborough will be had.

Children and Families Board

6 December 2019 - Noted

3 January 2020 - Noted

Urgent & Emergency Care Steering – No papers

MB09/03/F1

Minutes of the Meeting 10 February 2020 (Enclosure F1)


- Approved the minutes of the previous meeting.

MB09/03/F2 Replacement of Consultant Obstetrician and Gynecologist vacancies x2

1 retirement post straight forward replacement provides cost benefit. 1 straight forward (Mr Beckett) Both replacement posts, benefit of productivity and cost savings. The Management Board:

- Approved the two vacancies for one Consultant Obstetrician and one Gynecologist.


MB09/03/F3 Paediatrics Consultants - Recruitment to posts x3

Helen Burroughs presented the three vacancies. One vacancy is a straight forward replacement post, this was approved. Two vacancies become vacant over time, the pressure for the Trust Neonatal rota to enable the Trust to rotate a Consultant of the week will require 16 consultants to implement the rota. Cost for the two Consultants have been reviewed and the budget setting is wrong for Paediatrics in the 20/21 Financial Year and requires Finance to sign off. Finance were not present at Today’s meeting to discuss so it was agreed that the two vacancies would need to go to CIG. Action: Helen Burroughs to take the vacancies to CIG for approval. The Management Board:

- Approved one vacancy for recruitment. The other two vacancies to go through CIG first and then can be approved.

HB

MB09/03/G1 Any Other Business (Verbal)

Outcome of NHS budget for 4 new Hospitals will be reviewed and published on Wednesday 11 March 2020. If DBTH is approved the Executive Team will look at developing a programme board for the new build Hospital.

MB09/03/G2 Items for escalation to the Board of Directors (Verbal)


MB09/03/G3 Items for escalation from Sub‐Committees (Verbal)


MB09/03/H1 Date and Time of Next Meeting (Verbal)



Monday 20 April 2020 Room 2, Education Centre, Doncaster Royal Infirmary

MB09/03/I



Board of Directors – Public Meeting – 21 April 2020 Page 1 of 13

BOARD OF DIRECTORS – PUBLIC MEETING

Minutes of the meeting of the Trust’s Board of Directors held in Public on Tuesday 21 April 2020 at 11:30 in the Board Room, Doncaster Royal Infirmary via StarLeaf Video

Conferencing

Present:

Suzy Brain England OBE - Chair of the Board (In the Chair) Mark Bailey – Non-Executive Director Karen Barnard - Director of People and Organisational Development Pat Drake - Non-Executive Director Rebecca Joyce – Chief Operating Officer Sheena McDonnell – Non-Executive Director Richard Parker OBE – Chief Executive David Purdue – Deputy CE and Director of Nursing and Allied Clinical Health Professionals Neil Rhodes – Non-Executive Director and Deputy Chair Jon Sargeant – Director of Finance Kath Smart – Non-Executive Director Tim Noble - Medical Director

In attendance: Fiona Dunn – Acting Deputy Director Quality & Governance/Company Secretary Marie Purdue – Director of Strategy and Transformation Katie Shepherd – Corporate Governance Officer (Minutes)

Public in attendance:

None

Apologies: Emma Shaheen – Head of Communications and Engagement

ACTION

P20/04/A1 Apologies for absence (Verbal)

The apologies for absence were noted. Suzy Brain England welcomed those in attendance via StarLeaf videoconferencing. Hazel Brand, Lead Governor was welcomed on behalf of the members of the public and the Council of Governors, and confirmed she would share the best of the meeting with the Governors following the meeting. Suzy Brain England highlighted what a magnificent job Team DBTH was doing in response to Covid-19, and thanked them for everything they have done to get us as well prepared as possible during the pandemic. The Board of Directors paused to remember Kevin Smith, a Plaster Technician, who worked at DBTH for almost 40 years, whose passing was marked by staff with applause the previous week, a memorial book was available for signature to pass onto Kevin’s family. The Board’s thoughts were with Kevin’s wife and family, and wished to extend a thank you

P20/04/A2 – P20/04/J FINAL

I1


for the lifetime devotion that Kevin contributed to Doncaster and Bassetlaw Teaching Hospitals. Richard Parker informed the Board that there was a medical Consultant member of staff that was critically ill on ITU, and a further two inpatient members of staff being treated for Covid-19, and therefore sent their best wishes to those individuals.

Action: A message of thanks to all employees would be shared with Emma Shaheen and circulated as part of the daily communications.

ES

P20/04/A2 Declaration of Interests (Verbal)

No declarations of interest were declared.

The Board:

- Noted the Declaration of Interests pursuant to Section 30 of the Standing Orders.

P20/04/A3 Actions from Previous Meetings (Enclosure A3)

The following updates were provided: Action 1 - This item was not due until July 2020, however it was noted that progress had been made on this action due to many meetings taking place virtually throughout the Covid-19 period, and therefore Richard Parker was hopeful that the Trust would be in a better position to improve the Trust’s system for streaming and conference calling between the three sites; Action 2 – This item was note due until July 2020; Action 3 – This item was not due until July 2020; Action 4 – On the basis that this item was added to the Quality and Effectiveness Committee Work Plan, this item would be closed; Action 5 – This item was not due until July 2020; Action 6 - On the basis that a clear message had been added to the Trust website highlighting that meetings would take place virtually, this item would be closed.

The Board:

- Noted the updates and agreed which actions would be closed.

P20/04/C1 ICS Update (Enclosure C1)

The Board noted the performance report from the ICS, and talked through the key information: PPE

- Nationally, regionally and locally, challenges had been presented with PPE, however advised there was a national system in place for delivery of PPE on a ‘just


in time’ basis, which had proven relatively successful to date. The Trust had experienced some pressure points however, work was being undertaken across the ICS region to ensure that a mutual aid process was in place for when Trusts were experiencing shortages of PPE;

- It was anticipated that as the number of Covid-19 positive patient’s fall, the challenges with PPE would drop, however anticipate that these challenges may increase during the winter period;

- Discussions and testing of the repurposing of gowns had taken place, however this had not yet been implemented. A similar process would take place with fit masks.

Kath Smart noted that there had been positive feedback from staff on social media, however asked if there had been any other feedback from staff relating to PPE. Richard Parker advised that the feedback had been relatively positive to date. Communications had been circulated to staff to encourage maintaining gowns for a full shift, however feedback had not yet been received on this recent communication and was therefore expected that afternoon. Mark Bailey asked for a view on the position if the Trust was not in receipt of PPE delivery at this time. It was advised that it would depend on the particular item as PPE consisted of a range of five items. The most critical point had been for the general use surgical masks the previous day, which were not used directly with Covid-19 positive patients, and were only for use when moving patients through the corridors. As a Trust we were using approximately 4,000 per day, which was larger in comparison to other larger Trusts. PPE champions had been introduced which was a key role implemented into patient areas to ensure that PPE was being used appropriately and to highlight where training was required if it wasn’t being used correctly. Sheena McDonnell noted the difficult situation the Trust was in and to be mindful to engage staff in the solution to some of the issues presented so they feel safe when on duty. Richard Parker advised considerations have been made when resolving issues relating to PPE and used the example that any changes to guidance had been implemented midweek when there were more senior staff on duty to assist with dissipating staff anxieties and training. A discussion took place about medium and long-term plans and creating a new-normal. The challenges that would present during these timeframes would be as lockdown was lifted and the winter period, and how expectations for PPE would change through this time. Richard Parker advised that a resilient and robust plan would be produced to manage this effectively. This would include a local industry approach to PPE to ensure there was a productive infrastructure in place to deal with PPE demand in the future. It was staff engagement was important. Karen Barnard highlighted that engagement with the Unions was key to responding to any issues, and good engagement had been kept with the Staff Side Chair who had an understanding of what the Trust was doing to provide support to employee wellbeing. Key Worker Testing

- The Doncaster Sheffield Airport had been approved as a drive-through mass testing centre for key workers including healthcare, public service and social care staff. When the outbreak started there was limited capacity for testing which


included supply chain issues. The Trust now had its own testing platform which can cater for 100 tests per day for on-site staff. The Doncaster Sheffield Airport testing facility caters for 1,800 tests per day which would increase to 2,800 per day the following week;

- The Doncaster Sheffield Airport mass testing centre would be a drive-through only and therefore presented its challenges for those that do not drive;

- Antibody testing was not proving reliable at present and therefore was not in use;

Neil Rhodes asked for clarification for an understanding of the concept of testing, and referenced Germany as an example of good practice. Richard Parker advised that Germany was a country that produces one of the test kits and therefore had significantly bigger capacity to start testing earlier in a seek an destroy approach that would test those presenting with symptoms and anyone they had been in contact with. This was the initial approach in the UK however, there wasn’t enough laboratory capacity initially to undertake this approach, and when the laboratory capacity had been increased to deal with it, the country was in a position of lockdown. The process of testing for staff that were self-isolating was outlined by Karen Barnard. A daily return was submitted by managers to People and Organisational Development and the Swab and Book Team. This team then contact the staff member to check symptoms, and when they became symptomatic. Staff are then expected to attend the testing station at Doncaster or Bassetlaw for testing. Any patients that are confirmed positive for Covid-19 are contacted by Microbiology directly, and any members of staff that are negative are contacted via telephone by the People and Organisational Development team, with the aim to get them back to work. There was a similar approach for those that are self-isolating due to a household member being symptomatic. This was a drive-through process and therefore presents the issue of staff that are unable to drive, therefore a number of options were being reviewed to allow testing for these individuals in an alternative way. It was noted that Suzy Brain England would continue to update the Non-Executive Directors of any updates via email following her telephone meeting that she had with Richard Parker.

The Board:

- Noted the update from the ICS.

P20/04/D1 COVID-19 Update (Verbal)

Rebecca Joyce advised that a Command and Control Structure was fully implemented and all senior managers that are on the on-call rotas have received major incident training on the refreshed policy presented and also specifically in the management of Covid-19. The number of deaths at Doncaster and Bassetlaw Teaching Hospitals had risen to 55 up to and including 19 April 2020. The organisation was behind the projected figures received for Infections, hospitalisations, critical care beds and projected deaths. A plan had been published by NHS Providers which seems consistent with the plan in place at the Trust. It was noted that the organisation had undertaken many years’ worth of transformation in two-to-three weeks and the whole team have worked extremely hard to get the plans into place effectively. Suzy Brain England noted the transformational


progress and highlighted that it was important to keep the best of the changes that have been implemented. At the last Board of Directors meeting it was noted that there were 900 staff self-isolating. This had reduced to 300 staff per-day on average which includes staff and/or household members are symptomatic. Covid-19 related Sickness absence for March 2020 was reported at 2.5%. The first two weeks of April 2020 were higher however this had since reduced. In total there have been 1,800 staff self-isolate, 648 of which have been swabbed. 130 of those had tested positive for Covid-19. Marie Purdue and Jon Sergeant’s teams have been tasked with the planning process which would include lessons learned, capturing innovation, capturing risk and benefits and establishing which changes would be a benefit in the future. There would be triggers throughout the recovery phase when reviewing the impact of service changes. This would be a structured approach to capture the lessons learned. Mark Bailey highlighted an interest in the behavioural change throughout Covid-19, as staff had adapted to change and innovation in a short space of time. Although this was not a priority at present, it would be helpful to include this in the review process. It was agreed that patient feedback should be included as part of the review process and what their expectations are in the future. Marie Purdue assured the Board that this would be part of the review process using Qi methodology. The draft management plan had been to Management Board earlier that week and would be shared with senior management later that week. Richard Parker advised that many service changes were for the specific purpose of managing Covid-19, and these changes would form part of the review of ensuring that service delivery was in the patient’s best interest, however the delivery of some services were contractual and therefore would return to normal practice after the management of Covid-19 had reduced. Mark Bailey noted that the expectations of society would change due to the pandemic and all of the scenario planning in the past may no longer be relevant. It was confirmed that strategic planning would take a focus on what the new normal would be. Neil Rhodes noted it would be encouraging to see the lessons learned whilst heading towards a new normal. Rebecca Joyce advised that the Royal College of Surgeons had produced some guidance on the priority of elective surgery for use during the phased return to normal. Guidance had also been received on pre-admissions and pre-operative screening. A discussion took place about the public anxiety of catching Covid-19 was stopping potentially ill patient from coming to hospital for treatment for fear of catching the virus. The Communications and Engagement Team was working with local media to promote that the hospital was open for business and if members of the public require emergency treatment, to come to hospital as normal. It was advised that practical work was underway with Divisions to formulate a plan to scale elective activity up, however staffing issues would need to be accounted for in these plans.


The Board:

- Noted the update on Covid-19.

P20/04/D2 Operational Update (Enclosure D2)

Rebecca Joyce provided an operational update, including:

- The trust delivered 90.4% against the 92% trajectory during February 2020 and were on track pre COVID to deliver the 92% standard by year end. Following COVID routine elective activity has had to be scaled down;

- An achievement of 99.05% for diagnostic 6 week was reported against a target of 99% for February 2020 which presented an improvement from the January 2020 position;

- All 31-day nationally reported Cancer targets were achieved for January 2020,

however none of the 62-day nationally reported measure were achieved;

- The Trust delivered 85.43% against a national target of 95% for 4-hour access

during February 2020, which continued to be a challenge;

- A 17% decrease in ED activity had been noted for March 2020 reflecting the impact

of COVID.

It was noted that the reconfiguration to Cancer Services throughout the pandemic was working well for patients. A protected facility at Park Hill Hospital was being utilised for protected inpatient elective work and cancer patients. To avoid these patients waiting in waiting areas, they contact reception when on site in their car, where their pathway into Park Hill Hospital was managed to avoid contact with others. Rebecca Joyce was meeting with the Cancer Management Team on a weekly basis to review this services for cancer patients throughout the pandemic. The main challenges presented were the achievement of the 62-day pathway, however this was due to the complex pathways of patients that require treatment from more than one organisations. David Purdue noted that national guidance had been received on discharging of patients into social care. Changes had been made to allow for single point of access. To date there had been 104 patients discharged through the single point of access route, with only two patients being moved twice, therefore the changes were proving successful. Kath smart asked whether Safer Staffing standards had been maintained during this period. David Purdue confirmed that external reporting had been temporarily stood down, however the organisation was better staffed that under normal circumstances, as two wards at DRI, and one ward at Bassetlaw Hospital had been closed These staff are redistributed to other areas on a daily basis. The current nurse to patient ratio was 1:1 or 1:2 in Critical Care. Richard Parker advised that the Executive Team took a difficult decision to cancel all annual leave during April and May, however this would be reviewed by observing the number of patients and the predicted trends to ensure that areas are safely managed. It was confirmed that the Trust was asked to send 19 staff members to the Nightingale Hospital: four medics, three ITU nurses, four general nurses, four healthcare assistants,


two radiographers, one physiotherapist, two pharmacy staff with the remaining being form HR Support and General Management. Fourteen had been for an induction at the Nightingale Hospital, however it had not yet been opened for patients. It may be required that more staff are released if the hospital was open, however there were no current plans for the hospital to open. David Purdue noted that an issue raised by staff was the lack of visitors for end-of-life patients and therefore the restriction for these patients had been changed to one visitor permitted, with the exception of Covid-19 positive patients who were unable to have any visitors. Tablets/iPads had been given to staff to allow patients to video call relatives, and letters were being printed for patients to read. It was noted that staff were being innovative to find ways to support patients and their relatives at the end-of-life stage. It had been particularly hard on the staff. The Board collectively passed on their thank you to these members of staffing dealing with these challenges.

The Board:

- Noted the Operational Update.

P20/04/F1 Finance Update 2019/20 (Enclosure F1)

Jon Sargeant provided an update on year-end, which highlighted:

- An amendment to enclosure F1, highlighting an expected surplus of £260k at year-end. A decision was taken at year-end to allow annual leave accrual into the new financial year which would be a loss of £637k. The organisation reported an adverse variance of £376k, which was a loss against a turnover of £408m. Jon Sargeant confirmed that the Trust had achieved the plan and would be paid the bonus, MRET and FRF;

- The Trust delivered £11.2 cost improvement versus a plan of £13.2, an under-

delivery of £2 for the year 2019/20;

- The Trust delivered £1,919k CIP, against a plan of £1,911k, an overachievement of £8k in month;

- The cash balance at year-end was £30.8m;

- Capital expenditure was £741k behind forecast for year-end. This was a known circumstance due to Covid-19 where work had been postponed.

The Board commended the Finance Team in achieving the target at year-end.

The Board:

- Received and noted the Finance Update 2019/20

P20/04/F2 Finance Update 2020/21 (Enclosure F1)

Jon Sargeant provided a financial update for 2020/21, which highlighted a significant number of national changes to financial arrangements and cost reimbursement for the period 1 April – 31 July, and included:


- Normal business was currently suspending, which would mean that Commissioners would have a block contract with NHS Providers for the period 1 April to 31 July, however it was expected that this may last the entire year;

- The first payment highlighted a significant gap of £695k per month, which would be challenged;

- The Trust had received a £15m limit for Covid-19 related expenses. Any Covid-19 related financial requests over £250k for any one scheme, would require a case put forward to a central team. A response would be received within 48-hours;

- The Trust received written guidance the previous week that all suppliers must be paid upon receipt of an invoice to support the economy;

- A Covid-19 budget plan would be produced for a period of four-months, which would be approved at the Finance and Performance Committee. Work was underway with Divisions to undertake a detailed forecast of the next four-months to understand what extra costs would be incurred;

- Capital spend had been approved at Executive Director Level for Covid-19 response items such as ventilators, oxygen and gowns.

Jon Sargeant noted that the Trust had gratefully received a donation of three-year old laptops from KPMG. The market value of the laptops was low and it was proposed that the detail be reported to the Finance and Performance Committee. Richard Parker noted that the capital programme had been disrupted by the Covid-19 planning process. It was agreed that with immediate effect, Kirsty Edmondson-Jones, Director of Estates and Facilities and Ken Anderson, Chief Information Officer report directly to Jon Sargeant, Director of Finance as the majority of capital spend was linked to these two services.

The Board:

- Received and noted the Finance Update 2020/21; - Agreed that the report on donated laptops be received at the Finance and

Performance Committee.

P20/04/F2 Going Update (Enclosure F3)

Jon Sargeant informed the Board that this item had been presented to the Finance and Performance Committee meeting on 31 March 2020. International Accounting Standard (IAS) 1 requires the management of all entities to assess, as part of the accounts preparation process, the bodies’ ability to continue as a going concern. This was further enforced by Department of Health requirements to review the trust’s going concern basis on an annual basis. The going concern principle being the assumption that an entity would remain in business for the foreseeable future. This was to facilitate the accounting basis to be used in the preparation of the Trust’s annual accounts. Should an assessment be made that an entity was not a going concern then the year-end balance sheet should be prepared on a ‘disposals’ basis. Jon Sargeant recommended that the Board of Directors agreed to produce the accounts on a going concern basis. The principal was approved at the Finance and Performance


meeting, however the draft accounts would be presented to the Audit and Risk Committee Year-End meeting early June 2020.

The Board:

- Supported the recommendation to produce the annual accounts on a going concern basis;

- Noted the information in the Going Concern paper.

P20/04/G1 Major Incident Plan Policy Update (Enclosure G1)

Rebecca Joyce presented to the board an updated Major Incident Plan policy to be formally ratified. Major changes include the reference to Care Groups, which changed to Divisions approximately 12-months ago. Training had taken place with senior colleagues on the updated plan that are within the Command and Control Structure in response to Covid-19. It was clarified that further amendments wouldn’t be made based on lessons learned from the Covid-19 pandemic as this was a broad plan of management principals in place to cover a range of potential major incidents. Specific plans in response to a major incident would be adopted accordingly. Kath Smart noted that on page 16 of the page, it stated ‘There was a requirement for the AEO to be supported by a non-executive director,’ and asked for clarification on who this was. It was confirmed that this was Neil Rhodes. Neil advised that he had reviewed the major incident plan in depth when it was last updated several years ago. Richard Parker added that during a major incident rapid decisions are required and therefore these are managed through the specific plan produced during a major incident. It would not be expected that staff relearn or change the way they work. The Major Incident Plan was the overarching framework. Lessons learned would be identified throughout the review process that Marie Purdue and Jon Sargeant were undertaking, and would include structural and operational changes, risk management and lessons to be learned.

The Board:

- Formally ratified the updated Major Incident Plan Policy.

P20/04/G2 Business Continuity Terms of Reference (Enclosure G2)

Fiona Dunn presented the Business Continuity Terms of Reference for approval, following the agreement at the previous Board of Directors meeting to suspend the Trusts current standing orders relating to Board and Board Sub-Committee meetings normal terms of reference, with a proposal to invoke section 6.2 of the standing orders emergency powers. A focus was taken on section 5.4 of the standing order which sets out the requirements of suspending any standing orders. It was noted that the Business Continuity Terms of Reference do not replace, but would add as an addendum to the current standing orders.


The Board:

- Approved the Business Continuity Terms of Reference.

P20/04/G3 Chairs’ Assurance Logs for Board Committees (Enclosure G3)

Finance and Performance Committee – 31 March 2020 The Chairs Assurance Log for the Finance and Performance Committee was received by the Board. Quality and Effectiveness Committee – 31 March 2020 Pat Drake advised that the meeting for 31 March 2020 was stood down due to clinical Executive’s involvement with the response to Covid-19, however a number of papers were collated to support the Assurance Log. Any items planned for the 31 March 2020 meeting had been deferred on the work plan. There was one paper received that had been highlighted as red: Complaints Update, as Pat Drake was not assured due to key gaps. Pat Drake had liaised with David Purdue regarding this paper. David Purdue had taken over as lead on the issue and noted that a simplified process had been introduced within the Patient Advice and Liaison Team during the pandemic. National guidance stated that response to complaints could be stood down for three-months however the Trust had decided not to follow this guidance in the interest of patients. The interim process continues the management of complaints made to the Trust. Charitable Funds Committee – 17 March 2020 The Chairs Assurance Log for the Charitable Funds Committee was received by the Board. Audit and Risk Committee – 23 March 2020 Kath Smart advised that KMPG had given the Head of Internal Audit draft year end assurance as "Significant Assurance with improvements required" which was a good outcome for the Trust, although this was taken in the context there were still audits with only partial assurance which have action plans. The two recent Internal Audit Reports – a) WHO Checklist and b) Referral to Access reports had not yet been not been finalised, although their outcomes were only Partial Assurance. They had not been finalised due to Covid-19 preparations. The Declaration of Interests, Gifts and Hospitality issue had been flagged as amber, and a further update was due mid-year.

The Board:

- Noted, and were assured by the update from the: Finance and Performance Committee on 31 March 2020 Quality and Effectiveness Committee on 31 March 2020 Charitable Funds Committee on 17 March 2020 Audit and Risk Committee on 23 March 2020


P20/04/G4 Charitable Funds Terms of Reference

The Terms of Reference for Board Committees had been reviewed by the Committees respectively. The Chair of the following Committees were asked to recommend the Terms of Reference for each Committee:

- Charitable Funds Committee The Board noted the recommendations and approved the Board Committee Terms of Reference.

The Board:

- Received and noted the Terms of Reference for the Charitable Funds Committee.

P20/04/H1-H4

Information Items (Enclosures H1 – H4)

The Board:

- Noted the minutes of the Finance and Performance Committee meeting held on 25 February 2020;

- Noted the minutes of the Charitable Funds Committee meeting held on 17 December 2019;

- Noted the minutes of the Audit and Risk Committee meeting held on 6 February 2020;

- Noted the Board work plan.

P20/04/I1 Minutes of the Meeting held on 17 March 2020 (Enclosure I1)

The Board:

- Received and Approved the Minutes of the Public Meeting held on 17 March 2020

P20/04/I2 Any Other Business (Verbal)

No other items of business were raised.

P20/04/I3 Governor Questions Regarding the Business of the Meeting (Verbal)

P20/04/I3(i) Hazel Brand Hazel Brand extended her thanks on behalf of the Governors to all within Team DBTH for their remarkable efforts. A question was raised that there was no mention about a communications strategy within the updated Major Incident Plan, in particularly in keeping Governors and others informed of what had happened.


Post Meeting Note: The Communications and Engagement Department confirmed that sharing information with employees and Governors formed part of their departmental response to major incidents. A specific communication plan for COVID-19 had been produced and was in use, which included that regular contact be made with the Council of Governors to keep them informed of events. Hazel Brand also referenced Operation London Bridge which was an operation that would be activated in the event of a member of the monarch passing away as this would have implications on the health service with an expected outpouring of grief. All Governor activity was stood down during the Covid-19 Pandemic, and Hazel Brand asked if the return to Governor meetings would be a gradual one. It was noted that the pre-organised timetable would be reviewed, however it was agreed that Governors should not assume that the current timetable was in use going forward, and a communication would be sent once a timetable had been confirmed. A discussion took place about the potential of holding the Council of Governor meetings virtually, however it wasn’t known what the required bandwidth was for the software and what the maximum number of people could dial into one meeting. Jon Sargeant would liaise with Ken Anderson to identify if it was a possibility for a large number of people to dial into one meeting.

Action: Governors would be informed of a timetable of meetings once they have been agreed, once normal business resumes.

FD

Action: Jon Sargeant would liaise with Ken Anderson to identify if it would be possible for a large number of people to dial into one meeting for the Council of Governors meetings.

FD

The Board:

- Noted the comments raised, and information provided in response.

P20/04/I4 Date and Time of Next meeting (Verbal) Date: Tuesday 19 May 2020 Time: TBC Venue: TBC

The Board:

- Noted that the time and venue would be confirmed prior to the meeting on 29 May 2020.

P20/04/I5 Withdrawal of Press and Public (Verbal)

The Board:

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


P20/04/J


The meeting closed at 13:30.

Suzy Brain England Date Chair of the Board 12 May 2020