no time item lead enc patient story standing items …...social care. the board of directors noted...
TRANSCRIPT
No Time Item Lead Enc
1 9.00 Welcome
LP
2 Apologies for Absence (Dr Ahluwalia)
3 Declarations of Interest A
PATIENT STORY
4 9.05 Doncaster Adult Mental Health Community Services DW Pres.
STANDING ITEMS
5 9.40 Minutes of the Board of Directors held in public on 27 July 2017
LP
B
6 Matters Arising and Follow up action list C
7 Chairman’s Report and Council of Governors update D
8 Chief Executive’s Report KSi E
QUALITY
9 10.00 Report from the Quality Committee AP / DW F
10 Safer Staffing Declaration DW G
11 Report from the Mental Health Legislation Committee JM / DS H
FINANCE
12 10.30 Report from the Finance, Performance and Informatics Committee (FPIC) TS / SH I
13 Report from the Charitable Funds Committee
Charitable Funds Annual Report and Accounts 2016/17 JM / SH J
GOVERNANCE
14 Extreme Risks PG K
BOARD OF DIRECTORS Thursday 31 August 2017 at 9am in the RED Centre, Tickhill Road Hospital, Doncaster DN4 8QN
No Time Item Lead Enc
15 Any Other Business (to be notified in advance to the Chair)
LP Verbal 16 11.00 Public questions *
17 Chair to resolve that because publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted, the public and press be excluded from the meeting.
* PUBLIC QUESTIONS:
The Board welcomes questions from members of the public at the appointed time during the agenda and offers the following
guidance.
• Questions at the meeting should relate to papers being presented on the day
• Members of the public and Governors are very much welcome to raise questions at any other time, on any other matter,
through the office of the Chair and Chief Executive or other contact points
• There is no need for questions to be submitted in advance, although this may mean that it is not always possible to provide an
answer at the meeting. In that case, the questioner’s contact details will be requested for response.
• Questions will be taken in rotation, to ensure those wishing to raise questions have equal opportunity, within the limited time
available
Next meeting:
Thursday 28 September 2017 at 9am – RED Centre, Tickhill Road Hospital, Doncaster, DN4 8QN
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Committee Name
Board of Directors
Agenda Item
A Date 31 August 2017
Title of Paper
Declarations of Interest
Action Required
Decision Assurance Information
Prepared by
Philip Gowland, Board Secretary/Director of Corporate Assurance
Presented by
Lawson Pater, Chairman
Delivery against
Strategic Goal(s) Strategic Risk(s) CQC Domain
Financial/Budget
No financial implications
Equality & Diversity
No E&D implications – the requirement to make declarations is applicable to all Directors.
Previously
Presented to
N/A
Background /
Key Points /
Outcome
1. The Board of Directors to note the Register of Interests and to consider any conflicts of interest arising from the agenda items.
2. The Register is presented as attached and Directors are asked to confirm
at the meeting that this register is accurate.
Declarations are made to the Board Secretary as they arise, recorded on the public register and formally reported to the Board of Directors at the next meeting. To ensure openness and transparency during Trust business, the Register has, from September 2012, been included in the papers that are considered by the Board of Directors each month. Updates are shown in
bold.
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST BOARD OF DIRECTORS – REGISTER OF INTERESTS
Name / Position
Interests Declared
Lawson Pater Chairman Trustee of Doncaster Community Arts, a registered charity
Trust Associate Manager at RDaSH
James Marr Non-Executive Director
Managing Trustee of the Barton and Brigg Methodist Circuit
Daughter is a Pharmacist with Boots in Scunthorpe.
Volunteer Manager at Brigg Job Club
Trust Associate Manager at RDaSH
Kathryn Smart Non-Executive Director
Independent member of the Doncaster Metropolitan Borough Council Audit Committee
Board member Independent Audit Committee member of a social housing provider (ACIS,
based in Gainsborough)
Court Secretary for Foresters Friendly Society (Sheffield court) (from Jan 2017)
Director of Flourish (from Jan 2017)
Trust Associate Manager (TAM) - RDaSH
Volunteer member of the Friends of Town Fields (charity)
Volunteer at Town Fields Primary School (from Jan 2017)
Tim Shaw Non-Executive Director Trust Associate Manager at RDaSH
Chair of Doncaster Business for the Community
Alison Pearson Non-Executive Director Husband’s daughter works at Doncaster Rape Crisis and Sexual Abuse Counselling Service
Chair of Stillingfleet Village Institute
Trustee for the Two Ridings Community Foundation
Independent Member of the Parole Board
Trust Associate Manager at RDaSH
Dawn Leese, Non-Executive Director Daughter works for Price Waterhouse Coopers (PWC) (the Trust’s previous external audit providers) – her role does not involve work within the NHS sector.
Occasional consultancy work for NHSE Central Midlands (March 2017 / July 2017) - no conflict with RDaSH duties.
Justin Shannahan, Non-Executive Director Head of Finance Strategy and Processes, Derbyshire County Cricket Club
Ad hoc consulting work for GLG (Gerson Lehrman Group, Inc.)
Kathryn Singh Chief Executive Husband is Chair of Derbyshire Community Health Services NHS FT
Husband is MD of PMS Consulting Ltd (provides consultancy support to NHS organisations and individuals)
Kathryn Singh Chief Executive Husband is Chair of Derbyshire Community Health Services NHS FT
Husband is MD of PMS Consulting Ltd (provides consultancy support to NHS organisations and individuals)
Dr Nav Ahluwalia Executive Medical Director Chair Y&H RO/Appraisal Leads network
Research Lead for the South Yorkshire Specialist Higher Trainees in Psychiatry
Member of the Y&H National Clinical Excellence Awards Committee
RCPsych Trent Division Regional Representative in Addictions
RCPsych Trent Division Regional Representative for Workforce
RCPsych Membership CASC (Clinical Examination): member of Examination panel, run examination circuits, train new examiners
Richard Banks Director of Health Informatics Nil
Steve Hackett, Executive Director of Finance and
Performance None
Rosie Johnson Executive Director Workforce and Organisational Development
Nil
Deborah Smith Chief Operating Officer Director of Flourish Enterprises Community Interest Company
Dr Deb Wildgoose Executive Director of Nursing and Quality
School Governor of South Axholme Academy
Son is a volunteer within Flourish Enterprises Community Interest Company
Philip Gowland Board Secretary/Director of Corporate Assurance
Partner is employed by RDaSH as a Membership & Engagement Facilitator (working in Nursing & Quality Directorate)
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Committee Name
Board of Directors
Agenda Item
B Date 31 August 2017
Title of Paper
Minutes from the public Board of Directors meeting held on 27 July 2017
Action Required
Decision Assurance Information
Prepared by
Diane Jeavons, PA to Chief Executive
Presented by
Lawson Pater, Chairman
Delivery against
Strategic Goal(s) All Strategic Risk(s) CQC Domain
Financial/Budget
The financial implications of the matters discussed are recorded as appropriate in the minutes and are within the original supporting paper.
Equality & Diversity
The Equality and Diversity implications of the matters discussed are recorded as appropriate in the minutes and are within the original supporting paper.
Previously
Presented to
N/A
Background /
Key Points /
Outcome
The Board of Directors is asked to consider whether the attached minutes are a true record of the Board of Directors meeting held in public on 27 July 2017.
The Chairman will sign a copy of the ratified minutes.
1
ROTHERHAM DONCASTER AND SOUTH HUMBER
NHS FOUNDATION TRUST
PRESENT Lawson Pater Chairman Dawn Leese Non-Executive Director Jim Marr Non-Executive Director (Vice Chair/SID) Alison Pearson Non-Executive Director Justin Shannahan Non-Executive Director Tim Shaw Non-Executive Director Kathryn Smart Non-Executive Director Kathryn Singh Chief Executive Dr Navjot Ahluwalia Executive Medical Director Steve Hackett Executive Director of Finance and Performance Rosie Johnson Executive Director of Workforce and Organisational Development Deborah Smith Chief Operating Officer
IN ATTENDANCE Philip Gowland Board Secretary/Director of Corporate Assurance Lynn Hall Head of Communications Diane Jeavons Personal Assistant (minute-taker) Wendy Joseph Deputy Director, Nursing and Quality Joanne McDonough Deputy Chief Operating Officer, Doncaster Care Group Director Anthony Fitzgerald Chief of Strategy and Delivery, Doncaster CCG (up to and including
Item 10 on the agenda)
APOLOGIES Richard Banks Director of Health Informatics Dr Deborah Wildgoose Executive Director of Nursing and Quality Members of the public in attendance: A total of seven members of the public attended, which included the following governors:- Mike Young Partner Governor, Doncaster CCG Richard Rimmington Doncaster Public Governor Mohammad Ramzan Rotherham Public Governor Brendan Fox Community Services, Service User Governor
ACTION
110A/17 Mr Pater opened the meeting, welcoming everyone and explaining the format of the meeting.
111A/17 APOLOGIES FOR ABSENCE Apologies had been received from Mr Banks and Dr Wildgoose.
112A/17
DECLARATIONS OF INTEREST
MINUTES OF THE BOARD OF DIRECTORS MEETING – held in PUBLIC
ON THURSDAY 27 JULY 2017
AT
THE RED CENTRE, TICKHILL ROAD SITE, DONCASTER, DN4 8QN
2
Given the topic of agenda item 10, Mrs Smart declared her role on DMBC Audit Committee but stated there was no conflict of interest to be recorded. There were no other declarations of interest received for the meeting today.
The Board of Directors received and noted the Register of Interest report.
PATIENT STORY
113A/17
DONCASTER CARE GROUP – EARLY PATIENT OUTCOMES FROM
TRANSFORMATION Mrs McDonough gave a presentation on the early patient outcomes since the launch of the Doncaster Care Group. The outcomes were recently showcased at an event held at St Catherine’s House where over 250 people attended. The work is focusing on the ongoing aspects of transformation and turning these outcomes into sustainable ways of working. Early examples where staff are working together in an integrated way is showing evidence of improved outcomes for patients and some of these examples were aired through a podcast at the meeting today. Mrs McDonough mentioned the Doncaster Place Plan, which a presentation was given later in the meeting and highlighted the integrated work that is currently underway, one area being is to have a single point of access for both health and social care.
The Board of Directors noted the presentation.
STANDING ITEMS
114A/17 MINUTES OF THE BOARD OF DIRECTORS HELD IN PUBLIC ON 29 JUNE
2017
The minutes were agreed as an accurate record of the meeting subject to the following amendments:-
Item 97A/17 – STP Update The document referred to by Mr Shaw – the 5 year forward view should have been noted as the NHS Five Year Forward View.
Item 104A/17 – Finance Performance and Informatics Committee (FPIC) It was Mr Shaw that had highlighted the salient points from the report and not Mr Hackett as noted.
115A/17 MATTERS ARISING AND FOLLOW UP ACTION LIST
The previously circulated paper informed the Board of Directors of the completed action and progress update. A correction was made to item 101A/17, Report from the Quality Committee - the annual report referred to was the Infection Prevention and Control report and not the Safeguarding report as stated, therefore, this item was changed to green. Mr Pater made reference to items 93A/17 and 99A/17 where the progress reported that the Board would discuss the Trust’s strategy/business plan at the next Board Development session. This session scheduled for 18 July 2017 was cancelled, therefore, the work would be carried forward to a future development session and the actions would remain at amber.
3
Item 103A/17 – Guardian of Safe Working Hours quarterly report. Dr Ahluwalia reported that EMT had discussed this at the meeting held on 26 July 2017 and from this Ms Marsh, Head of Financial Management would be producing a draft set of proposals.
116A/17 CHAIRMAN’S REPORT AND COUNCIL OF GOVERNORS UPDATE
Mr Pater’s activities at the Trust were detailed in the paper and he also highlighted the Council of Governor’s update which included the details of the 13 newly elected Governors. He would complete the introductory meetings with each governor in the next week. Mr Pater also made reference to the STP presentation which was given at the recent Governor Information and Discussion Group meeting, along with his attendance at the South Yorkshire and Bassetlaw Accountable Care System (the new designation for the STP) meeting. Mrs Smart also reported that the Chairs of the Audit Committees are going to be invited to a STP meeting possibly in early September. The NED activities included within the report were noted with the following change:- Mr Shannahan did not attend the Doncaster Care Group showcase event and Mr Shaw attended the Doncaster Nursing Conference.
The Chairman’s Report was noted.
117A/17 CHIEF EXECUTIVE’S REPORT Mrs Singh presented the Chief Executive’s report highlighting the successful Nursing Conference held on 30 June 2017, attended by almost 250 people. The key note speakers were Dr Ruth May from NHS Improvement, Corinne Harvey from Public Health England and Kath Evans and Lorraine Wolfenden from NHS England. Mrs Singh highlighted LiA, reporting that the year 2 pulse check results were lower than the previous year but had still exceeded the national results. However, it was acknowledged that a different set of questions was used for year 2 to gain additional insight and identify areas for further work. Mrs Singh highlighted the NHS Improvement launch of the national programme for improving staff retention across the NHS. The Trust has been included in the first cohort of work. The programme launched in June 2017 is set to run until 2020 and is focussed upon firstly stabilising leaver rates, which are acknowledged as rising throughout the NHS and then reducing leaver rates as the programme progresses. Ms Johnson confirmed to Mr Shaw that exit interviews are undertaken and all collated centrally, with information shared with service managers. There are however, occasionally ‘hotspot’ areas or clusters of staff that leave where more focused attention is given. Mrs Smart noted a reference in the programme which referred only to ‘non-medical staff’ and enquired how this would fit with medical staff. Ms Johnson stated the Trust would be looking at the workforce as a whole. Dr Ahluwalia went on to explain that his approach to exit interviews for doctors was slightly different and allowed for a period of reflection post-exit.
4
Contained within the national publications Mrs Singh made reference to the report titled “The state of care in mental health services 2014 – 2017”, indicating the detailed report includes the full inspections of the 54 mental health trusts around the country. Mrs Leese also asked about locked rehabilitation referred to in the report and how as a Trust this was being picked up. Mrs Singh commented that an executive lead (Executive Director for Nursing and Quality) has been assigned to this area and it will be picked up through EMT. Mrs Smart referred to the Quality Improvement in Mental Health report and the skill set that is required to deliver the methodology. Mrs Singh noted the recent appointment of the Deputy Director for Quality Improvement who will lead a new centralised quality team. In response to Mr Marr’s question, Mrs Singh confirmed that the media statement issued regarding the paranormal night was to ensure there was no inappropriate misrepresentation of St Catherine’s House in the related publicity for such events taking place within the Flourish, social enterprise.
The Board of Directors received and noted the Chief Executive’s Report.
STRATEGY
118A/17 STP UPDATE
The South Yorkshire and Bassetlaw STP Collaborative Partnership Board minutes from the meeting on 14 July 2017 were presented for information. Mrs Singh reported that NHS England and NHS Improvement have issued aggregated performance review scores for STPs, where 1 is outstanding and 4 is needs improvement and the South Yorkshire and Bassetlaw STP had been identified as outstanding scoring 1. Only 1 in 5 of the 44 STPs that has been given this rating. It was noted that Humber Coast and Vale STP were given a rating of 4. Mr Shaw asked what this meant for RDaSH as services are covered in both of these STPs and Mrs Singh stated that time would be allowed to discuss this at the next Board Development session. Mrs Smart asked how vocational services will fit into the health led IPS employment services. Mrs Singh stated there would be a procurement process which they will be able to apply a bid to.
The Board of Directors noted the South Yorkshire and Bassetlaw STP
Collaborative Partnership Board minutes from the meeting held on 14 July
2017.
119A/17 DONCASTER PLACE PLAN – IMPLEMENTATION UPDATE
Mr Fitzgerald presented the draft Doncaster Place Plan – Implementation Update. The plan itself was approved by the Governing Body of Doncaster CCG and is a joint vision for Doncaster to help maximise the health and wellbeing and independence for Doncaster residents. Ernst and Young the strategic partner were commissioned in January 2017 to assess the implementation of the plan and their report includes an assessment of readiness state across 6 key areas and also describes the key areas of focus for phase 2.
5
The 6 key areas are:- 1. Leadership 2. Culture 3. Governance 4. Services 5. Finance 6. Operational and commercial
Mrs Singh stated that jointly with local CEO providers, including, Doncaster MBC, Doncaster and Bassetlaw NHS Foundation Trust, Doncaster Children’s Services Trust and Fylde Coast Medical Services (FCMS), an agreement had been reached to test two of the key areas of focus, these being vulnerable adolescents and dermatology. Mr Shannahan highlighted the reference within the finance section “no group approach to accounting” – this term had a specific meaning and he suggested it was queried in order to clarify the context in which it was used.
The Board of Directors noted the phase 1 state of assessment and the
recommendations and work programme for phase 2 of implementation.
KSi
QUALITY
120A/17 REPORT FROM THE QUALITY COMMITTEE
Mrs Pearson referred to the previously circulated report and highlighted key areas contained within the report, which included highlights and opportunities, assurances, gaps and risks
The patient safety dashboard shows that the number of incidents in quarter 1 this year was 2,324 compared to 2,831 last year, with 95% of these being classed as minimal harm
Serious incidents show a 25% reduction in quarter one this year compared to the previous year. However, 30 of the serious incidents are proceeding to a full investigation which is up by 15% compared to last year for the same quarter
There has been a reduction in complaints
Medicine related errors are up by 20%, although it was noted that the trend in harmful incidents remains very low with 5 over the year and none in the last 3 months
There are currently no extreme risks aligned to the Quality Committee
Safer staffing had 10 red rated shifts on inpatient wards in May 2017 with Skelbrooke ward showing a significant increase from 2 in April to 9 in May.
Mrs Singh spoke of safer, stating that sickness absence, demands of patients, section 136 demands all contribute to pressures on the inpatient ward. Ms Smith also commented that immediate steps have been put in place which includes additional staff in the section 136 suite, along with medium term steps. Information is being gathered and updates are being produced to the Operational Management Meeting, which will feed up to the Executive Management Team and subsequently into the Quality Committee.
In response to Mrs Smart, it was confirmed that the lead Director for Health and Safety was Mr Hackett, who confirmed that a Health and Safety Report was being produced and will be presented to the Board in September.
The Board of Directors noted the update from the Quality Committee.
SH
6
121A/17 ANNUAL REPORTS 2016/17
Safeguarding The Safeguarding Annual Report for 2016/17 provides a combined review for the first time of the work by the safeguarding adults and children’s teams. Mrs Smart asked about modern slavery and the rollout of training. Mrs Joseph commented that a training package has been devised which is competency based and has been incorporated into the existing training programme. It was also reported that a working group across Doncaster had been established to look at aligning safeguarding as a whole across Doncaster for 2017/18. The group includes representation from Doncaster CCG and Doncaster and Bassetlaw NHS Foundation Trust. Initial scoping work has commenced and includes looking at changing the pathway using access to expertise in this area. The next step will be to engage the Local Authority after which an options paper will be developed. Mr Marr asked about the self-neglect policy covering all geographical areas and Mrs McDonough confirmed this was being developed and once ratified would be adopted by the Doncaster Care Group following which it will then be developed in Rotherham and North Lincolnshire. In the meantime, the principles in the policy can be utilised in all these areas.
Infection Prevention and Control
Mrs Joseph highlighted the well-attended IPC conference held in October 2016.
The Board of Directors noted the Safeguarding and Infection Prevention and
Control Annual Report for 2016/17.
122A/17 MEDICAL REVALIDATION
Dr Ahluwalia highlighted the main points within the report which were that:-
50 out of 55 doctors had a revalidation ready appraisal.
8 doctors were considered for revalidation with 7 having a positive recommendation to the GMC and 1 recommendation for deferral. This was accepted by the GMC.
Mr Shaw made reference to the audit of the missed or incomplete appraisals within the report. Dr Ahluwalia stated that an audit of all appraisals was being carried out. Mr Pater asked about the audit of concerns about a doctor’s practice within the last 12 months, with two of these being at the medium level. Dr Ahluwalia stated that as the Responsible Officer, he determines the nature and degree of concerns about a doctor and categorises them. Usually only the serious concerns about a doctor’s conduct and/or performance results in a Maintaining Higher Professional Standards (MHPS) investigation.
The Board of Directors noted the Medical Revalidation Annual Report.
7
FINANCE PERFORMANCE AND INFORMATICS
123A/17
REPORT FROM THE FINANCE PERFORMANCE & INFORMATICS COMMITTEE
(FPIC)
Mr Shaw commented on the highlights from the Finance, Performance and Informatics Committee (FPIC) in June. Assurances
Achievement of the financial target for month 3 of the financial year 2017/18. Retaining a risk rating of 1
Achievement of the Single Oversight performance requirements.
Cash balances being slightly ahead of target
Capital expenditure ahead of spend profile
Risks
The performance hotspots are identified as CAMHS waiting time in Rotherham and ADHD waits. Ms Smith reported that engagement was being sort with Meridian to look at completing work in these areas. Mrs Leese stated it would be helpful to have sight of the key milestones and for a narrative to be included.
Agency cap is 22% below the target. Medical agency is 59% of the budget
Mr Hackett highlighted the work being done by the Project Management Office and made reference to the QIPP target which at the moment will be around £1m undelivered at the end of the financial year. A mitigation plan is being produced.
Mr Shaw also highlighted that the Flourish Enterprise annual accounts had been received and the financial performance was ahead of the original plan. Mr Pater stated that the new table in the report summarising the financial information was very clear and helpful. Mrs Singh stated it would be helpful to have reports for the key performance contractual activity in order to identify any risks. Mr Hackett and Ms Smith agreed to take this action.
The Board of Directors noted the update from the Finance Performance and
Informatics Committee.
SH/DS
124A/17 DONCASTER CARE GROUP – PERFORMANCE OVERVIEW
Mrs McDonough gave an overview of the Doncaster Care Group and its current performance across finance, workforce, quality and performance. Referring to the balanced scorecard and highlighting the mandatory and statutory training, where the current performance stands at 82%, Mrs McDonough stated work to improve this compliance to the required 90% was ongoing.
The Care Group has 68 key performance indicators and 53 are being delivered including all 18 week waiting time targets. Waiting times in other areas were being monitored and action taken to improve, including the ADHD Service, Speech and Language Therapy and stretch targets for response to unplanned nursing calls via the Single Point of Access.
8
Mr Shannahan made reference to the current vacancies being 14% below the required Whole Time Equivalent (WTE) and asked if this implied they were not affordable within the budget. Mrs McDonough responded by saying a deep dive was being undertaken which will determine affordability.
Mr Hackett stated also that a sizeable and sensitive piece of work was underway looking at pay versus non-pay and this would feature in the plan for next year.
The Board of Directors noted the presentation.
GOVERNANCE
125A/17 BOARD ASSURANCE FRAMEWORK – OVERVIEW
Mr Gowland presented the overview for the Board Assurance Framework for 2017/18. He highlighted the current position along with the next steps which will continue to evolve over the next few months and will be presented to the lead committees. Mr Shannahan provided positive feedback on the overview and suggested the risk scoring could be refined with further reference to the stated risk appetite. Mrs Smart suggested there were further gaps in assurance to be detailed on the framework and in particular referenced strategic goal 2. Sub-committees would need to look at these gaps and populate them where necessary. Mr Marr stated that the Mental Health Legislation Committee should identify key sources for controls and assurance relevant to the BAF and the Terms of Reference of the Committees should refer to key sources of assurance.
The Board of Directors approved the 2017/18 Board Assurance Framework
and supported the next steps and reporting process as outlined in the report.
PG
126A/17 EXTREME RISKS
Mr Gowland presented the extreme risks report stating there are currently 3 extreme risks on the register. He made reference to the new risk that was added around the capacity in the data warehouse. One element of this was linked to the new IR35 HMRC rules but this had been since resolved, although other capacity challenges remain.
Mr Pater made reference to the timeline for the implementation of the new EPR system and whether this was on track. Mrs Singh commented that discussions are continuing with Channel 3 regarding the implementation of the timeline.
The Board of Directors noted the Risk Register Update Report.
127A/17 ANNUAL REPORT AND ACCOUNTS 2016/17
Mr Gowland informed the Board that the Annual Report and accounts were presented to parliament on 6 July 2017 and these were now available on the website. Limited numbers of copies are available and the Report would be the focus of the Annual Members Meeting being held on 10 August 2017.
The Board of Directors noted the completion of the work to produce the
Annual Report.
9
128A/17 ANY OTHER BUSINESS
There was no other business.
129A/17 PUBLIC QUESTIONS Mr Ramzan asked what QIPP stood for this was confirmed as Quality, Innovation, Productivity and Prevention. Mr Fox asked if the Flourish Directors are paid a salary in addition to their current salary, it was confirmed they are not. Mr Fox asked what MAST stood for it was confirmed as Mandatory and Statutory Training. He also asked what MHPS stood for, this was confirmed as Maintaining Higher Professional Standards Mr Fox asked how many contracts were losing money. Mr Hackett responded by saying that work was ongoing looking at all contracts and individual service level agreements contained within the contracts, several of which are ‘block’ contracts and therefore varying activity was not always reflected in the amounts paid. Mr Rimmington asked what percentage of staff from the EU would be affected by Brexit. Ms Johnson replied by saying that a review of staff was under way not only of staff from the EU but from other countries and once this was complete the exact number would be known, although it was anticipated this would not be high. Mr Rimmington also asked if incentives were available for staff to help in the reduction of the sickness absence rate. Ms Johnson replied by saying that the Trust follows national pay and conditions and adheres to a robust sickness policy in place. Health and wellbeing initiatives for staff are currently being reviewed.
Mr Pater thanked all for their attendance and read the following statement as the
Board of Directors meeting moved to private session. “To resolve that because
publicity would be prejudicial to the public interest by reason of the
confidential nature of the business to be transacted, the public and press be
excluded from the meeting.”
DATE, TIME AND VENUE OF NEXT MEETING Thursday 31 August 2017 at 9 am at the RED Centre, Tickhill Road Site, Doncaster DN4 8QN
1 Key to ‘Status’ column: Action complete Action started but not complete Action outstanding Green Amber Red
The statements below provide assurance that the actions have been completed and / or provide an update on the progress to date.
Follow up actions from the Board of Directors meetings held in Public on 29 June 2017
Minute Item Lead Director
Progress Status
93A/17 Minutes of the previous meeting Mr Pater agreed there is further work to do from a strategic and timeline point of view regarding the links between work programmes and that a wider debate would be held during the Board development session on the afternoon of 29/06/17.
LP
July Update: The links between work programmes and the delivery against the Trust’s strategy / business plan will be discussed during the next session for the Board on the development of the forward strategy in September 2017.
Am
be
r 99A/17 Strategic Direction Mr Shannahan sought confirmation about the business plan deployment to ensure that there was clarity about what was expected and how the Board of Directors could monitor progress.
RJ
102A/17 PPEE Quarterly Update Agreement to review the action plans referred to in the paper. A common approach to RAG ratings was suggested
DW / RJ
RJ
July Update: EMT discussed the need for a consistent RAG rating process and this has been shared with Non-Executive Directors. Once feedback is received a standard approach will be adopted and the action plans, including those linked to the delivery of the PPEE Strategy will be updated. August Update: Final version distributed 24 August 2017. Copy attached.
Gre
en
103A/17 Guardian of Safe Working Hours Quarterly Report The issue of potential fines was to be discussed by EMT
NA
July Update: Discussed at EMT on 26 July and Ms Marsh, Head of Financial Management is producing a draft set of proposals. August Update: Work underway on the proposals and a further update will be provided at the meeting.
Am
be
r
Paper C
2 Key to ‘Status’ column: Action complete Action started but not complete Action outstanding Green Amber Red
Follow up actions from the Board of Directors meetings held in Public on 27 July 2017
Minute Item Lead Director
Progress Status
119A/17 DONCASTER PLACE PLAN - IMPLEMENTATION Mr Shannahan highlighted the reference within the finance section “no group approach to accounting” – this term had a specific meaning and he suggested it was queried in order to clarify the context in which it was used.
KSi
KSi will discuss at the Doncaster Place Group meeting in September (not present at the August meeting)
Am
ber
120A/17 REPORT FROM THE QUALITY COMMITTEE In response to Mrs Smart, it was confirmed that the lead Director for Health and Safety was Mr Hackett, who confirmed that a Health and Safety Report was being produced and will be presented to the Board in September.
SH
As agreed at the last meeting, the report will be included in the agenda for the September Board of Directors meeting.
Am
be
r
123A/17 REPORT FROM THE FINANCE PERFORMANCE AND INFORMATICS COMMITTEE (FPIC) Mrs Singh stated it would be helpful to have reports for the key performance contractual activity in order to identify any risks. Mr Hackett and Ms Smith agreed to take this action.
SH / DS
As part of a review of performance reporting, material contractual performance will be included. In advance of the overall performance report development FPIC will receive a dashboard on contractual performance and delivery of national targets, this will be in place for September FPIC.
Am
be
r
125A/17 BOARD ASSURANCE FRAMEWORK - OVERVIEW Mr Shannahan provided positive feedback on the overview and suggested the risk scoring could be refined with further reference to the stated risk appetite. Mrs Smart suggested there were further gaps in assurance to be detailed on the framework and in particular referenced strategic goal 2. Sub-committees would need to look at these gaps and populate them where necessary.
PG
The BAF Overview has been developed with the lead Directors. Individual strategic risks have been reviewed in greater detail and the respective controls, assurances and gaps identified and recorded. Relevant parts of the BAF were presented and discussed at the Quality Committee and at Finance, performance and Informatics Committee in August and further feedback received. The BAF will be presented to the Board of Directors next in October 2017.
Gre
en
Version 1 – August 2017
RAG RATING GUIDANCE SHEET
Green Amber Red
Finance Financially stable position
Minor overspend from budget within defined tolerance < 1% of budget value
Major overspend from budget above defined tolerance >1% of budget value
Quality & Patient Care
Acceptable quality standard
Minor quality concerns Slight deviation from acceptable Do not create risks to patients or registration
Major quality concerns Deviation from acceptable Adverse patient harm or registration impact
Workforce Safe and stable workforce
Minor concerns in stability of workforce Slight recruitment and/or retention increase (5%) Known expertise shortage in the market
Major concerns in stability of workforce Significant recruitment and/or retention increase (>5%) Known long-term expertise shortage in the market
Risks No material risks known
Risks identified but with appropriate mitigation plan in place to limit /remove risk impact
Risks identified that are extreme Risks with unidentified mitigation plan in place
Project & Performance
On track against target /plan
Minor deviation from target/plan within defined tolerance 5% off target 1 month slippage
Major deviation from target/plan above defined tolerance >5% off target >1 month slippage
N.B. Other sensitivities can be used to assess RAG status but where this influences the RAG rating, this detail must be explained
1
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Committee Name
Board of Directors
Agenda Item
D Date 31 August 2017
Title of Paper
Chairman’s Report
Action Required
Decision Assurance Information
Prepared by Lawson Pater, Chairman
Philip Gowland, Board Secretary / Director of Corporate Assurance Diane Jeavons, Personal Assistant
Presented by
Lawson Pater, Chairman
Delivery against
Strategic Goal(s) 1 2 4 5
Strategic Risk(s) 1.4 2.1 4.2
CQC Domain WL
Financial/Budget
There are occasional costs associated with attendance at some of the events recorded in the report (for example conference fees).
Equality & Diversity
N/A
Previously Presented to
N/A
Background / Key Points / Outcome
The Board of Directors is asked to receive and note the Chairman’s Report including the report of NED activities and the Council of Governor’s update.
2
Chairman’s Report to the Board of Directors This report includes background notes indicating the rationale for the various activities undertaken by the Chair since the last meeting, which include the following attendances and engagements, in addition to regular meetings with the Chief Executive and other Trust staff. RDASH
One to One meetings with Governors
Council of Governors
Governor Induction Briefing
Annual Members Meeting
Quality review visit to New Beginnings Detox Unit
Attendance at the service user art exhibition
Attendance at Sandfield House Garden Party (North Lincs)
Attendance at the Recovery Games I attend board committees and other meetings to contribute to Trust decision making and to observe their operation and contribution to the effectiveness of Trust Governance systems. I take the opportunity to visit services and internal events to engage with and learn from patients, staff and other stakeholders. EXTERNAL
Introductory meeting with Deloittes, external auditors
Meeting with Suzy Brain England, Chairman, Doncaster and Bassetlaw Hospitals NHS Foundation Trust
Meeting with Martin Havenhand, Chairman, The Rotherham Hospital Foundation Trust
Attendance at Rotherham Together Partnership Meeting
The purpose my engagement with external organisations is to promote partnership working, to learn from service users and their representatives, to act as an ambassador for the Trust, assist in building strong relationships, and facilitate the resolution of problems and development of opportunity. Non-Executive Director activities Non-Executives chair (C) / are members (X) of the six Board Committees as per the table below. The Committees that have met in the month are shaded. Apologies are noted with ‘a’ and details of attendance are recorded and included for the full year in the Trust’s Annual Report.
COMMITTEE LP JM KS TS AP JS DL
Remuneration X X X X X X C
Quality X C X
Finance, Performance and Informatics X C X
Audit C X X X
Mental Health Legislation C X Xa X
Charitable Funds * C X
Lawson Pater (LP) Jim Marr (JM) Kath Smart (KS) Tim Shaw (TS) Alison Pearson (AP) Justin Shannahan (JS) Dawn Leese (DL)
* also attended as part of handing over the Chairing of the Committee In addition, over the last month the Non-Executives attended:
Meeting with Heather Rice, Assistant Director of Research (Mr Shannahan)
Annual Members' Meeting (Mr Shannahan, Mrs Pearson, Mr Marr, Mr Shaw, Mrs Leese)
Council of Governors (Mr Shannahan, Mrs Pearson, Mr Marr, Mr Shaw, Mrs Leese)
One to One with the Head of Nursing (Mrs Pearson)
Meeting with Dr Ian Brown, regarding quality improvement (Mr Marr)
Governors Induction meetings (Mr Marr)
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Meeting with Dr Deborah Wildgoose and Helen Moran regarding handover of the Mental Health Legislation Committee (MHLC) (Mr Marr)
One to One meeting with Steve Hackett, Executive Director of Finance and Performance (Mr Shaw, Mrs Smart)
Service User Art Exhibition: Shine a Light (Mr Shaw)
One to One meeting with the Chairman (Mrs Smart)
Flourish Board meeting (Mrs Smart)
One to One meeting with the Executive Director of Nursing and Quality (Mrs Leese)
Service visit to Amber Lodge (Mrs Leese) Council of Governors The Council of Governors held its most recent quarterly meeting on 10 August 2017 immediately following the Annual Members Meeting. The Annual Members Meeting provided a showcase of services from the Care Groups and a number of corporate services and it was very pleasing to see the number of staff, FT members and members of the public that came along to engage and to learn more about the Trust. At the CoG several of the most recently elected new governors attended their first formal meeting and as well as receiving the latest performance, finance and HR data the Governors also received the audit reports from the External Auditors – PWC. During the month we have welcomed the new governors to attend the first two parts of the revised four-part induction Programme. The focus of these sessions has been ‘The Trust’ – providing a range of background information about the Trust; and ‘The Council of Governors’ – a session that focused on the role of the Council, its composition and meeting structure. The final two parts will be delivered in September and will focus on ‘The Board of Directors’ and ‘Putting it into practice – how to undertake the role of a governor’. The Trust is also supporting a number of Governors to attend national training sessions run by GovernWell (part of NHS Providers).
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ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Committee Name
Board of Directors
Agenda Item
E Date 31 August 2017
Title of Paper
Chief Executive’s Report
Action Required
Decision Assurance Information
Prepared by Kathryn Singh, Chief Executive Philip Gowland, Board Secretary/Director of Corporate Assurance Diane Jeavons, Personal Assistant
Presented by
Kathryn Singh, Chief Executive
Delivery against Strategic Goal(s) 1 2 4 5
Strategic Risk(s) 2.3 CQC Domain WL
Financial/Budget
The financial implications of any item in the report are included as appropriate.
Equality & Diversity
Not applicable
Previously Presented to
Not applicable
Background / Key Points / Outcome
The Chief Executive’s Report provides the Board with information about policy, legislative and developmental issues and changes that affect the Trust and local initiatives across the Trust in the last month. Further information can be gained from the relevant lead director. This month’s report contains the following:
RDaSH News National / Regional Update RDaSH Summary Information
o Media coverage o Freedom of Information (FOI) Requests
2
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
CHIEF EXECUTIVE REPORT 31 AUGUST 2017
RDaSH
LiA Update After providing the extended summary of our second 20 LiA teams in my June board report I am happy to share the progress of our next operational teams, which cover all of our frontline services. The reason we have spread our LiA approach to all RDaSH clinical services is that it is an evidenced based model that has worked not only for other NHS Trusts but for many of our RDaSH teams shown throughout their 2016 work, and it links to our wider focus upon organisational leaning and development. Using LiA ensures a consistent leadership approach that ensures solutions and service change are coproduced with staff, patients and carers via big conversations and ensures frontline staff engage in and implement change. Connecting with our Trust wide quality priority on “safe care” all our teams have patient safety focussed missions which are listed in the table below. Although many of them have now conducted their Big Conversations with their clinical and professional leads, they would love to hear from you if you have interest, experience or examples of practice that may help their focussed mission:
Team Operational
Lead Focus
DONCASTER
Access & Liaison Team
Paula Thompson
Develop and implement concepts linked with ‘Psychiatric Decision Unit’s’ in order to minimise risk for those presenting in crisis.
Acute All Age Mental Health
Sue Halder Develop an all-age care pathway for those experiencing non-organic mental illness requiring acute services: Right Patient, Right Place, Right Care at the Right Time.
Mental Health Rehab
Tania Linden
‘One person one plan’ – focussed upon the development for a single care plan so no matter which, or how many services a patient uses, and which funding streams are sourced, an individual has one care plan, which covers all domains, and meets all requirements.
Rapid Response
Melanie Gibbons
To focus upon leadership at all levels of the team – ensuring all delivering front line care are involved in deciding on changes that affect the work area.
North Locality
Chris Eastwood The turnover rate for District Nursing is higher than many other teams
in RDaSH. The team have identified this as one of the largest risks in terms of care delivery and therefore will be focussing upon this issue jointly between the North and Central locality.
Central Locality
Samantha Butcher
South Locality
Claire Wagstaff
To work together to enable cohesive leadership within the Doncaster Locality. This mission recognises the difficulty that can form in regards to boundaries between teams, based upon feedback from patients and staff. This is a joint focussed mission between the East and South localities which should generate outcomes which maybe applicable for the wider care group and organisation.
East Locality
David Smith
Rehabilitation
Cora Turner To improve the safety of Magnolia Ward – neurological rehabilitation in patient environment.
Drug & Alcohol Services
Stuart Green
To enable service users to experience seamless care with no gaps during transitions between drug and alcohol services and RDaSH mental health services.
Palliative & Long Term Conditions
Andrew Brankin
To develop an integrated palliative care pathway with wider locality services to safely and appropriately support and manage patient and carer needs
Intermediate Care & Frailty
Dave Wragg To explore and focus upon the risk related to excessive alcohol use in older adults, specifically exploring the experience and care pathways in place in the Community & Intermediate Care Pathway in Doncaster.
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Forensic LD Pathway
Andrea Vincent
To explore issues and plan interventions related to the subject of “relational security” within the inpatient forensic environment.
LD Community/ Psychology/ ADHD / ASD
Alison Courtney To identify if RDaSH can deliver a commissionable safe service for
ADHD in Doncaster
ROTHERHAM
Borough Wide
Michaela Bateman
This care group have agreed to take a joint focus upon carer Engagement and Risk Reduction in Rotherham within each of their separate services. Their actions and conversation will be focussed upon areas identified as having risks through a review of past: service complaints, serious incidents, investigations and audit. The information from the carers forum and also the friends and family test will also inform their actions.
North Locality
Kerri Booker
South Locality
Matt Pollard
Inpatients
John O’Grady
NORTH LINCS
Acute Services
Joanne Lloyd
To improve the environmental safety of the building and ward areas on Great Oaks mental health unit. Specifically concentrating upon both physical safety mechanisms and behaviours and actions that promote a safety culture.
CHILDREN’S
CAMHS
Barbara Murray
To reduce risk by promoting active engagement in ‘Early Help Services’ across 3 localities providing child and adolescent mental health services.
0-5 & Long Term Conditions
Kate Watkins
To reduce risks related to patient health focussed upon the concept of prevention and ‘early help’ within the 0-5 and long terms conditions services for children in RDASH.
5-19 & Tri-health
Heather Murphy
To reduce risks related to patient health focussed upon the concept of prevention and ‘early help’ within the 5-9 and tri-health services for children in RDaSH.
Alongside the teams working above, during September and October we will be focussed upon how support services and teams, such as informatics and health and safety teams, could also make changes which in turn support the risk reduction interventions that are developing in the clinical teams above. #FabChangeWeek RDaSH like many other health organisations in the country will be taking part in NHS Change Week, branded: #FabChangeWeek. This will take place between 13th – 17th November 2017. This year we would like the change pledges to focus upon “reducing risk” and “reducing waste”. We know that wastefulness can be considered a risk to the optimal use of resources and could impact adversely on patient care. So we are keen to encourage people to pledge to do something positive about eliminating waste. For example, by doing some litter picking as they walk around our sites, removing broken furniture from rooms and challenging why we are doing some activities that are either not adding value or that are no longer required. In terms of our continued commitment to quality improvement and using LiA, we would like everyone in the organisation to take part in considering what they could do to reduce waste and reduce risk. All you have to do to take part is:
Decide what it is that YOU want to change
Write this on a pledge sheet (available from the communications team or from [email protected] )
Take a picture
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Either email your picture to Judith Graham or upload it onto the change week site. Further details can be found here: https://fabnhsstuff.net/ Organisational Development The LiA approach can be summarised as an organisational development approach to quality improvement. Over the coming months Judith Graham (Deputy Director for Organisational Development) will be working with the teams from RDaSH to evaluate the LIA work conducted over the past 18 months to form part of the foundations in developing an Engagement and Organisational Development strategy for the Trust. The Organisational Development strategy will describe and plan for our short and long term systematic approach which aligns strategy, processes and workforce to improving our overall organisational effectiveness. Alongside the progress of the Organisational Development strategy Ian Brown (Deputy Director for Quality Improvement) will analyse the quality improvements made via the LiA process to incorporate into a larger vision for quality improvement within the Trust.
Visit from Jim Mackey NHS Improvement Chief Executive On 18 August 2017, I had the pleasure of accompanying Jim Mackey, Chief Executive of NHS Improvement to a visit to our inpatient unit at Great Oaks in Scunthorpe. Jim came along to meet and thank staff for their bravery in handling a very dangerous situation at the unit back in November 2016. It was great for them to meet with Jim and receive his praise and thanks. It was also a timely opportunity to highlight the issues that staff working in high pressure environments have to sometimes deal with, and to show case their exceptional skills. During the course of the day we also called into the 6th annual Recovery Games. Once again this event was a huge success and had an even greater level of attendance than in previous years.
Service User Art Exhibition On 16 August 2017 our Occupational Therapists from across RDaSH held an art exhibition showcasing the work of service users and patients entitled “shine a light on mental health”. The event was a great opportunity to display the creative art from our service users and to bring attention to the various forms of OT and art therapy available for use with our patients.
Annual Members Meeting Our Annual Members meeting took place on Thursday 10 August in Rotherham. A market place event prior to the meeting gave an opportunity for our members to see the showcase work of our 4 Care Groups along with being able to visit stalls from Listening into Action, Patient Advice and Liaison Services, Membership and Recruitment. There was also an opportunity for members to meet the Governors and Non-Executive Directors.
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Highlights from the month of August
Service visit to Skelbrooke adult inpatient ward, Doncaster
Introductory meeting with Deloittes, external auditors
Meeting with the Chief Executive of North Lincolnshire CCG
Meeting with Doncaster PFG
Meeting of the South Yorkshire and Bassetlaw Mental Health & Learning Disabilities Workstream Steering Group
Meeting of the Council of Governors
Quarterly meeting with Rotherham health providers
Meeting with the Chief Executive of Primary Care Doncaster
Meeting with the Chief Executive of Humber NHS Foundation Trust
National / Regional / Local Announcements and Publications
National Publications and Guidance Listed below are the key publications and guidance issued in the last month which are received within the Executive Management Team and incorporated / referred to in the ongoing relevant pieces of work at the Trust. A Lead Director has been identified against each item to take forward the work on understanding implications for our organisation. 1. Stepping Forward to 2020/21: The mental health workforce plan for England
Lead Director: Rosie Johnson/Kathryn Singh Stepping Forward to 2020/21: the mental health workforce plan for England sets out a high level road map and reflects the additional staff required to deliver the transformation set out in the Five Year Forward View for Mental Health based on best evidence to date. Health Education England are working with NHS England, other arms length bodies (ALBs), and local service providers to trial essential components of this programme (including, for example, integrated IAPT services, perinatal care and an expansion of liaison services) to identify the best skill mix to deliver evidence-based care in the optimal way and test innovations (e.g. increasing use of digital services) designed to improve productivity. Findings from these workstreams will be used to refine this model. https://www.hee.nhs.uk/sites/default/files/documents/CCS0717505185-1_FYFV%20Mental%20health%20workforce%20plan%20for%20England_v5%283%29.pdf?utm_source=The%20King%27s%20Fund%20newsletters&utm_medium=email&utm_campaign=8521695_NEWSL_HMP%202017-08-01&dm_i=21A8,52NDR,PGMKDX,JG5LT,1 2. Delivering high quality end of life care for people who have a learning disability
Lead Director: Dr Deb Wildgoose NHS England published their ‘top tips’ guide which aims to support commissioners, providers and clinicians to reduce inequalities in palliative and end of life for people with a learning disability, focusing on ‘The Ambitions for Palliative and End of Life Care’1 . The 6 ambitions provide a framework for national and local health and care system leaders to take action to improve palliative and end of life care.
https://www.england.nhs.uk/wp-content/uploads/2017/08/delivering-end-of-life-care-for-people-with-learning-disability.pdf 3. Updating the Single Oversight Framework 2017/18
Lead Director: Philip Gowland
NHS Improvements are now updating the Single Oversight Framework to reflect changes in national policy priorities and developments in their approach to provider oversight. Details of the draft framework is available using the below link. The consultation closes on 18 September 2017. https://improvement.nhs.uk/resources/updating-single-oversight-framework-share-your-views/
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4. Specialised Services Quality Dashboards – Mental Health metric definitions for 2017/18 Lead Director: Dr Deb Wildgoose
NHS England published on 20 August 2017 their Specialised Services Quality Dashboards (SSQD) which are designed to provide assurance on the quality of care by collecting information about outcomes from healthcare providers. SSQDs are a key tool in monitoring the quality of services, enabling comparison between service providers and supporting improvements over time in the outcomes of services commissioned by NHS England. https://www.england.nhs.uk/publication/specialised-services-quality-dashboards-mental-health-metric-definitions-for-201718/?utm_source=The%20King%27s%20Fund%20newsletters&utm_medi 5. Use of Resources
Lead Director: Steve Hackett Published on 8 August 2017 NHS Improvement’s Use of Resources assessments aim to help patients, providers and regulators understand how effectively trusts are using their resources to provide high quality, efficient and sustainable care in line with the recommendations of Lord Carter’s review of Operational productivity and performance in English NHS acute hospitals. They will do this by assessing how financially sustainable trusts are, how well they are meeting financial controls, and how efficiently they use their finances, workforce, estates and facilities, data and procurement to deliver high quality care for patients. https://improvement.nhs.uk/resources/use-resources-assessment-framework/
RDaSH Summary Information
Media Coverage – 18 July – 11 August 2017 18 releases, statements, interviews and information supplied 18 taken up Plus 710 Tweets only 10 positive press hits 3 neutral press hits 1 negative press hit Twitter positive 1,145 Twitter Impressions 106,637 Facebook reach 38,026
Press release – Board meeting (Corporate) Press release – new recruits join local health trust (CAMHS) Diary date/events page – 25th birthday of Hospice (Trax FM web) Press release – Summer Fayre in Ashby (Sandfield House) Look North enquiry - Regarding the Hull trial any update to the statement issued about the investigation Press release – Jump on board for your child’s vaccinations (Children’s) Press release: Supporting people with cancer (DCIS adults) Media enquiry – Health Service Journal – quarter 1 finances Nursing Times request for interview with school nurse regarding conference and e-Clinics BBC Radio Sheffield– Stuart Green, Aspire Manager on Rony Robinson ‘My life’ show http://www.bbc.co.uk/programmes/p057wrl3 Trax FM pre-record: World Breastfeeding Week HSJ enquiry – Cost Improvement Plans 2017/18 Press enquiry: Gareth Denninson Rotherham Advertiser regarding Margaret Denise Appleby Press enquiry – Kevin Larkin, BBC Radio Sheffield regarding Safe Haven Statement – Safehaven bus for BBC Radio Sheffield (Children’s) Press release - ‘Growing the therapeutic benefits down on the allotment’ as part of National Allotment Week (14-20 August) Press Release – RDaSH more than doubles its number of clinical research studies (Corporate) Press release – Doncaster mums celebrate world breast feeding day (Children’s)
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Freedom of Information (FoI) Requests – 17 July – 16 August 2017
FOI 1687 – Asking whether the Trust provides insulin pumps to diabetes patients and what kind.
FOI 1688 – Questions around the Trust’s contracts for printers/multi-functional devices.
FOI 1689 – Questions around private input into the Trust’s pharmacy provision.
FOI 1690 – Questions around the Trust’s procurement of labels.
FOI 1691 – Request for copies of all emails sent by the Trust between 050717 and 150717 relating to the Safe Haven project.
FOI 1692 – Questions around staff sickness and departures from the Trust due to mental health problems.
FOI 1693 – Asking whether the Trust uses an integration engine and what kind.
FOI 1694 – Asking about the Trust’s repairs and servicing of faulty mattresses.
FOI 1695 – Questions around CAMHS services – accepted and rejected referrals, expenditure and waiting times.
FOI 1696 – Questions around the Trust’s IT expenditure.
FOI 1697 – Asking how many cases of carbon monoxide poisoning the Trust has treated in A&E.
FOI 1698 – Asking for staff contact details for the following job titles: o Director of Medical Education o Head of Education and Training o Quality Improvement manager
FOI 1699 – Questions around the Trust’s overall expenditure and IT expenditure.
FOI 1700 – Asking for staff contact details in IT and IG, and for the number of contractors we employ in these areas.
FOI 1701 – Asking for the Trust's total recruitment advertising expenditure for calendar year 2016.
FOI 1702 – Questions around the Trust’s server IT contracts.
FOI 1703 – Questions around the Trust’s use of internal staff banks.
FOI 1704 – Asking what proportion of cataract surgery procedures are performed without an anaesthetist.
FOI 1705 – Questions around the Trust’s use of complementary therapies.
FOI 1706 – Questions around the Trust’s use of British Sign Language interpreters in both emergencies and general treatment of deaf patients.
FOI 1707 – Questions around the Trust’s expenditure on psychological therapies.
FOI 1708 – Questions around the Trust’s purchasing arrangements for arboriculture/tree surgery.
FOI 1709 – Questions around seconded staff and expenditure for the Trust’s STP programme.
FOI 1710 – Asking for staff contact details for the following job titles: o IT Director o Head of Compliance o Director of Transformation
FOI 1711 – Asking for the number of HIV patients the Trust has treated with antiretroviral therapy.
FOI 1712 – Asking for the number of hours mandatory/statutory training required for the following job titles:
o Band 6 CMHT Community Nurse o Band 5 Inpatient Nurse o Band 3 Inpatient Healthcare Assistant o Ward Manager
FOI 1713 – Questions around Trust car parking charges for staff, the wages and roles of the five highest paid staff, and Trust spend on PR and marketing.
FOI 1714 – Questions around the Trust’s recovering debts from chargeable overseas NHS patients.
FOI 1715 – Questions around serious incidents in the Trust involving physical restraint.
FOI 1716 – Request for a list of all inpatient mental health wards in the Trust.
FOI 1717 – Request for information around losses and special payments for the last two financial years.
FOI 1718 – Request for information regarding the Trust’s contracts for ophthalmology services.
FOI 1719 – Questions around the Trust’s Early Intervention in Psychosis (EIP) services.
FOI 1720 – Asking how many intersex babies the Trust has performed surgery on in the last five calendar years.
FOI 1721 – Questions around staff headcount, staff cost and agency hours/spend.
FOI 1722 – Request for information concerning overseas trips taken by Trust staff.
FOI 1723 – Questions around off-payroll staff working for the Trust.
FOI 1724 – Request for the Trust’s IG structure and key policies, and information on our SAR and
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FOI requests for the last three financial years.
FOI 1725 – Request for information on cataract operations and provision of toric intraocular lenses in the Trust.
FOI 1726 – Questions around the Trust’s use of server farms.
FOI 1727 – Questions around the Trust’s provision of mobile devices/smartphones.
FOI 1728 – Questions around the provision of Naloxone in the Trust’s drug and alcohol services in Doncaster.
FOI 1729 – Questions around the Trust’s contracts for printers/multi-functional devices.
FOI 1730 – Questions around general procurement, contracts, and IT procurement in the Trust.
FOI 1731 – Questions around the closure of children’s inpatient units in the Trust since 2010.
FOI 1732 – Questions around vacancies, agency staff and hard to recruit areas in the Trust.
FOI 1733 – Request for information about the Trust’s Estates and Facilities department.
FOI 1734 – Questions around waiting times for mental health services in the Trust.
Kathryn Singh, Chief Executive August 2017
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Committee Name
Board of Directors
Agenda Item
Paper F Date 31 August 2017
Title of Paper
Report from the Quality Committee – August 2017
Action Required
Decision Assurance Information
Prepared by
Dr Deborah Wildgoose, Director of Nursing and Quality
Presented by
Alison Pearson, Non-Executive Director
Delivery against
Strategic Goal(s) 1
2
5
Strategic Risk(s) 1.1-1.5
2.1-2.3
5.1-5.3
CQUALITY
COMMITTEE
Domain
S
E
C
R
W
Financial/Budget
Financial implications are considered as part of the individual actions.
Equality & Diversity
The Quality Committee whilst undertaking its purpose considers matters relating to equality and diversity. All relevant issues are identified though supporting documents, therefore no additional areas are highlighted through this report.
Previously
Presented to
Not applicable.
Background /
Key Points /
Outcome
The last meeting of the Quality Committee was held on 10 August 2017. A summary of discussion and key highlights, assurances, risks and gaps are detailed in the attached paper. Key areas identified are:
The Freedom to Speak Up quarterly update was received, 6 concerns were raised across all localities, with 3 investigated and concluded. None were classified as whistleblowing.
The statutory safe staffing six month review and declaration was received. No patient safety/serious incidents occurred as a result of staffing issues since the last declaration in January 2017. This is included in Paper H to this Board of Directors meeting.
The Serious Incident report for July 2017 was reviewed. There have been 5 new serious incidents logged. This is a reduction in the number of SIs from July 2016 of 3 and a reduction of 4 SIs year on year when compared to cumulative position.
Magnolia Lodge, Significant assurance was received on the progress of the improvement plan. This was evidenced and supported by the outputs of the Quality Summit Review in July 2017.
The collation of Workforce Race Equality Standard (WRES) data. The 2016 RDaSH data has been compared to national benchmark data for MH/LD/Community Trusts. The report will enable identification of focused action. The RDaSH 2017 WRES data submission was submitted on schedule on 1 August 2017.
The Annual report 2016-17 for the Accountable Officer for Controlled Drugs was not presented and the Quarterly report for Medicines management, due July 2017, will now be presented in September and the period of coverage extended as a result.
The Board of Directors is asked to note the update from the Quality Committee on 10 August 2017.
Alison Pearson Non-Executive Director
Chair, Quality Committee
Dr Deborah Wildgoose Director of Nursing and Quality
Report from the Quality Committee
Held on 10 August 2017
August 2017
Nursing and Quality
1. Introduction
This paper is a summary report that captures key messages from the meeting of the Trust Quality Committee (QC) held on 10 August 2017 and is framed around:
Highlights and opportunities
Assurance
Gaps
Risks
2. Highlights and Opportunities
The Clinical Effectiveness and Professional Leadership Dashboard for Quarter 1 2017-18 was reviewed with the following areas highlighted:-
- 42 items of NICE guidance issued in Quarter 1 and all assessed. No risks identified for NICE compliance.
- 7 clinical audits took place with 13 reports produced by Care Group. 9 rated as Good and 4 rated as Requires Improvement – see risks.
- The Trust has 11 referrals open with NMC, 5 of which relate to staff in Trust employment – there are no organisational concerns about the fitness to practice of these employees.
The Infection Prevention and Control (IPC) Quarter 1 update was reviewed and indicated good controls in place, with 3 outbreaks of Clostridium difficile infection in the Doncaster Care Group (no lapse in care noted), 3 cases of E. coli bacteraemia across the Trust (some lessons identified). 10 inpatient audits undertaken and actions shared. The 80 link champions across Trust continue to be supported. IPC training compliance currently stands at 82.69%.
The collation of Workforce Race Equality Standard (WRES) data is a mandatory NHS Trust requirement since 2015. The 2016 RDaSH data has been compared to national benchmark data for MH/LD/Community Trusts and compares favourably for Bullying and Harassment, career progression, discrimination and Board composition. The report will enable identification of focused action. The RDaSH 2017 WRES data submission was submitted on schedule on 1 August 2017.
The Freedom to Speak Up (F2SU) quarterly update was received; 6 concerns were raised across all localities, with 3 investigated and concluded. None were classified as whistleblowing. Across site themes were identified as linked to transformation and Health & Safety advice/equipment. F2SU advocates are now in place.
The Quality and Safety Impact Assessment (QSIA) process update was received – there are 37 identified change schemes at various stages. The Quality Committee requested further clarity regarding the cumulative effect, and the associated risks, of the projects deployed, as well as details of the schemes that did not progress.
The Quality Review quarterly update was received – to date 33 reviews have been undertaken, with 21 concluded and each showing improvement. 5 reviews commenced in Quarter 1 2017/18 and a further 5 are planned for Quarter 2 2017/18. Themes emerging from more than one review were shown against CQC domains. The Quality Committee questioned how this information would be used to inform further work, through cross-reference to other intelligence and lead through to challenge at Care Group level.
The CQC Must Do and Should Do action plan and the revised process for action plan review through the Care Groups, and the quality OMM with exception reports to the EMT and Quality Committee on a quarterly basis was noted.
At the end of Quarter 1 2017/18 there were 181 whole time equivalent (wte) vacancies; this represents a decrease of 10 wte since the last report. 57wte are on hold pending service re-design. The majority of vacancies are in nursing (92wte) with most being in Doncaster Community Services. The current Trust turnover rate is 12.5%. Recruitment and retention action plan is under development and will focus on community nursing and adult/older people MH roles, plus medical. A recruitment timeline tracking process was deployed in June and indicates that the average recruitment time has reduced. The Quality Committee
welcomed the transparency but challenged the ambition and requested the tracking from the vacancy occurring to role fulfilment to be monitored.
Mandatory and statutory training compliance maintained at 89.48%.
Agency spend at month 3 is £311k (22%) under the NHSI ceiling target.
3. Assurances
The statutory Safe Staffing Six Month Review and Declaration was presented to the Quality Committee. No patient safety/serious incidents occurred as a result of staffing issues since the last declaration in January 2017. A detailed establishment review has been undertaken to support the declaration. The Quality Committee noted this robust piece of work and the identified actions required to mitigate any risks. This is included in Paper H to this Board of Directors meeting.
Magnolia Lodge – Significant assurance was received on the progress of the improvement plan. This was evidenced and supported by the outputs of the Quality Summit Review that took place in July 2017. The Quality Committee noted the closure of the plan with on-going monitoring to be undertaken by the Doncaster Care Group.
The inpatient staffing report for June 2017 was shared; there were no incidents of patient harm reported as a result of staffing levels. Limited Assurance received as the staffing levels on certain Adult Mental Health wards was too low on some shifts should an incident have occurred. There were 6 Red rated shifts on inpatient wards in June 2017, as opposed to 10 in May (using local reporting v. occupancy & acuity criteria). There was an increase in the number of red rated shifts on Brodsworth ward in Doncaster from 0 in May to 5 in June 2017.
The Serious Incident report for July 2017 was reviewed – 5 new serious incidents were logged. There was a reduction in the number of SIs from July 2016 of 3 and a reduction of 4 SIs year on year when compared to cumulative position. Information was provided to demonstrate investigation, extraction of learning and the tracking of actions by Care Group. The provision of data to commissioners was improved compared to last month. Risk assessment and management has been highlighted as a key action in the North Lincolnshire and Rotherham Care Groups.
4. Gaps
The Community Clinical Staffing Trust-wide review is waiting for the establishment of the community teams and pathways. The Quality Committee noted that the reporting will commence in December 2017. In the interim the community caseloads are monitored and reviewed at Care Group level.
Clinical Care Records Audit 2016-17 action plan update – of the 82 local actions generated, 73 are complete. Evidence against remaining 9 actions demonstrated work underway but clarity required on implementation dates.
The Internal Audit (360 Assurance) action update was received – progress noted but the Executive responsible and level of associated risk to be specified in future reports.
The Sign up to Safety 2015-18 paper was not presented to Quality Committee in July 2017 and August 2017 due to illness and annual leave. This will be presented to the September 2017 Quality Committee.
The Annual report 2016-17 for Accountable Officer for Controlled Drugs was not presented.
The Quarterly report for Medicines management due July 2017 will now be presented in September and period of coverage extended as a result.
PDRs – level of completion has dropped 2% to 73%.
5. Risks
The Safe Staffing 6 Month Declaration identified that 4 inpatient wards require significant intervention. This is being progressed by the EMT. Immediate action underway to ensure staffing reviewed on a daily basis. The Quality Committee requested assurance in relation to risk mitigation for these wards.
The Safe Staffing report for June 2017 identified continued pressure in relation to staffing levels on adult mental health wards across the Trust. The staffing of 136 suites, capacity issues on nights, periods of seclusion and issues with the E-rostering of Bank staff have led to staffing levels that are too low. In mitigation the escalation process within Operations has been reviewed with the matrons, and use of the E Bank rostering system has been suspended with the previous methodology reinstated. The EMT were asked to expedite the risk assessment and mitigation plan, particularly for the acute mental health pathway.
Staffing levels in the Doncaster community nursing service are a concern with a high number of vacancies and difficulties in recruitment. The Quality Committee have asked for assurance that the risk is being mitigated.
Clinical Audits – the following Care Groups were rated as requiring improvement with actions underway: o Doncaster – Pressure ulcer management and Pressure ulcer prevention plan re-audit. o North Lincolnshire - Pressure ulcer prevention plan re-audit. o Trust wide – audit of early warning score and neurological observations.
There are currently no “Extreme” risks aligned to Quality Committee. The EPR (Unity) extreme risk (H12/16) is being monitored by FPIC but was noted by the Quality Committee due to potential quality impact.
Sick absence rates were 5.1% in June 2017 (note May 5.2%, Apr 5.1%, Mar 5.1%, Feb 5.7%, Jan 6.3%), with the cumulative position at 5.15% against the Trust target of 4.8%. Existing policies will continue to be rigorously pursued.
The Study Leave policy is under review due to a 55% reduction in funding from Health Education England over the last 2 years; this is a potential emerging risk.
From 1 August 2017 new students in England on nursing, midwifery and allied health professions pre-registration courses will access standard student support package of tuition fee loans instead of NHS grants; this is a potential emerging risk.
The following areas have been identified for risk assessment and action:
Medicines management and pharmacy - the Quality Committee is concerned about the lack of assurance provided to date and requested that the reports are produced for September 2017.
The following potential risks were identified last month and will remain listed until an EMT review has taken place.
The Quality Committee has requested a review of the current risks and mitigations associated with a high proportion of incidents are not closed within 10 working days and narrative is often insufficient.
The Quality Committee was informed that additional capacity will be in place to support the SI process by the end of Quarter 3 2017-18.
A range of issues have been identified in relation to the capacity to provide, analyse and act on quality and safety data within the organisation. The executive team agreed to review the risks associated with this and action required to mitigate them.
6. Clinical Policies, Standard Operating Procedures and Patient Group Directions
Approved by Sub-Committees
The Quality Assurance Sub-Committee (QASC) scheduled for 31 July 2017 was not quorate. Therefore the clinical policies and standard operating procedures needing approval were circulated electronically (via email dated 1 August 2017) after the meeting. The following members of the QASC responded to provide quoracy for the decisions taken:
Wendy Joseph, Deputy Director of Nursing and Quality
Dr Ian Brown, Deputy Director of Quality Improvement
Rachel Millard, Associate Nurse Director, Rotherham Care Group
Lisa Connor, Associate Nurse Director, Doncaster Care Group
Wendy Fisher, Associate Nurse Director, North Lincolnshire Care Group
Gavin Portier, Head of Quality, Compliance and Assurance
Sue Sparks, Head of Education
Dianne Graham, Rotherham Care Group Director
Christina Harrison, Children’s Care Group Director
Policies approved:
Meticillin Resistant Staphylococcus Aureus (MRSA) Procedural Document
Mobile Phone and other Handheld Technology within Adult Mental Health Inpatient Services Standard Operating Procedure.
Physical Health Policy
Requesting a Second Opinion Policy
Verification of Expected Death Policy (Adults), Version 2
Visiting RDaSH Services and Facilities (VIP/Celebrity/Governor) Policy
Extensions to the following policies approved:
Copying Letters to Patients/Service Users Policy – extension until September 2017
Eating Disorder: Care and Treatment Policy – extension until August 2017
Management of Pornographic and Sensitive Material Standard Operating Procedure – extension to August 2017
Transfer of the Deceased into the care of another Service Provider (expected and unexpected deaths) Policy – extension to September 2017
Transitional Protocol: Adult Mental Health to Older People’s Mental Health Services – extension to January 2018
Removal from clinical policy suite approved:
Health Bus: Operational Guidance Standard Operating Procedure
The Quality and Safety Sub-committee has been made aware that review dates for the following policies are overdue, but escalation processes have been put in place with the relevant leads:
Contacting the On-Call Training Doctor/GP (Mental Health and Learning Disability Services)
Planned Discharge/Transfer of Patients from Inpatient Services Policy (Discharge Transfer Policy)
7. Recommendation
The Board of Directors is asked to note the update from the Quality Committee held on 10
August 2107.
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Committee Name
Board of Directors
Agenda Item
Paper G Date 31 August 2017
Title of Paper
Safe Staffing 6 Month Review and Declaration – 1 January 2017 to 30 June 2017
Action Required
Decision Assurance Information
Prepared by
Wendy Fisher, Associate Nurse Director
Presented by
Dr Deborah Wildgoose, Director of Nursing and Quality
Delivery against
Strategic Goal(s)
1 2 3 5
Strategic Risk(s)
1.1 1.2 1.3 5.3
CQC Domain
S E W
Financial/Budget
There are no Financial Implications within this paper, however as the recommendations are developed within each Care Group there will be a requirement to consider the financial impact.
Equality & Diversity
All activities are considered in accordance with the Trust’s Equality and Diversity Policies and Processes.
Previously
Presented to
Quality Committee - 10 August 2017 EMT – 23 August 2017
Background /
Key Points /
Outcome
Following the Government’s response to the Francis Inquiry into Mid-
Staffordshire NHS Foundation Trust, ‘Hard Truths’ (DH 2013) NHS
England, published in November 2013: How to Ensure The Right
People, With The Right Skills, Are In The Right Place At The Right
Time - A Guide to Nursing, Midwifery and Care Staffing Capacity
and Capability (NHSE 2013). In this guide, endorsed by the National Quality Board (NQB), NHS England set out the expectations of commissioners and providers to optimise nursing, midwifery and care staffing capacity and capability so that they can deliver high quality care and the best possible outcomes for their patients, this was for each NHS Trust to set and publish its staffing levels monthly, at a ward by ward level along with other safety measures. A key component is to ensure the Board of Directors receive a 6 monthly review of staffing. A presentation (attached) on the Trust 6 Month Review and Declaration was given to the Trust Quality Committee on 10 August 2017 and Executive Management Team (EMT) on 23 August 2017 and has been updated following comments received.
The Declaration is comprised of two elements:
1. Look back review of safer staffing levels for 1 January 2017 - 30 June 2017
2. Review of baseline establishments for each ward For each element the following declaration can be made: 1. Look back review of safer staffing levels for 1 January 2017 - 30
June 2017 No patient safety/serious incidents occurred during the period 1 January 2017 - 30 June 2017 as a result of staffing issues.
2. Review of baseline establishments for each ward
Following a detailed establishment review an assurance opinion has been provided for all wards.
Immediate mitigation is in place for wards that have no assurance.
Recommendations have been made for action on wards where substantial assurance cannot be provided.
A detailed work plan is underway for each ward, actions reported through operational governance process, to the Executive Management Team and to the Quality Committee.
Following this meeting, the presentation will be posted on the Trust’s public website. The Board of Directors is asked to note:
The look back review of safe staffing
The detailed review of baseline establishments and levels of assurance, mitigation and plans in place to address the findings of the review
That the Declaration will be posted on the Trust public website.
Safe Staffing
6 Month Review and
Declaration
1 January 2017 - 30 June 2017
Board of Directors - 31 August 2017
Declaration Structure
National Context and Requirement
Declaration in two parts:
1. Look back and review of safer staffing levels for
1 January 2017 - 30 June 2017
2. Review of baseline establishments for each ward
National Context and
Requirement
In November 2013, NHS England published: How to Ensure The
Right People, With The Right Skills, Are In The Right Place At
The Right Time - A Guide to Nursing, Midwifery and Care
Staffing Capacity and Capability.’ (NHSE 2013) this set out the
expectations of commissioners and providers to optimise nursing,
midwifery and care staffing capacity and capability so that they can
deliver high quality care and the best possible outcomes for their
patients.
In July 2016 the National Quality Board published: ‘Supporting NHS
provider to deliver the right staff, with the right skills, in the
right place at the right time – Safe Sustainable and productive
staffing’. This publication builds on the 2013 guidance taking into
account both the need to balance quality and financial objectives.
• Process of safe staffing oversight: • Establishments set for each ward.
• Staffing levels managed on a day to day basis – each shift RAG
rated at ward level.
• Ward manager oversight of safe staffing levels on a day to day
basis, action taken at this level to prevent staffing levels being
unsafe and to eliminate RED shifts.
• Weekly reports to Modern Matron for oversight and necessary
action.
• Monthly reports to the Trust Clinical Staffing Review Group.
• Acuity and Dependency Escalation process in place for all wards.
1. Review of safer staffing levels
for 1 January 2017 - 30 June 2017
• Escalation process
• Matters of concern raised from the ward and service through the
Care Group to the Care Group Director.
• Monthly reports received and reviewed by the Clinical Staffing
Review Group.
• Areas reporting RED shifts and submitting IR1s triangulated and
appropriate actions undertaken.
• Monthly Reporting of staffing levels
• Monthly reports published on Trust public website.
• Reported monthly to Quality Committee.
• Update provided to Board of Directors through Quality
Committee Report.
Trust Wide Themes
• 31 shifts were rated as RED, out of a total 12,489 shifts for all
wards across the period - 0.24% of total shifts to cover all wards.
This is an overall increase of 8 RED shifts across the Trust from
previous 6 months.
• 47 IR1s submitted across the period in relation to staffing
concerns - 0.38% of the total shifts required. This represents an
increase of 25 IR1s from the previous 6 months.
• 2 identified hotspots – Skelbrooke and Goldcrest, these two
wards identified the majority of the RED rated shifts. Each RED
rated shift was reviewed in depth and contingency plans put in
place on each occasion.
• No patient safety/serious incidents occurred during the period
1 January 2017 - 30 June 2017 as a result of staffing issues.
2. Review of baseline
establishments for each ward
Methodology
• Reviews undertaken in May/June 2017.
• Review team – led by Director of Nursing, including - Clinical
Lead, Nursing and Quality, HR, Finance.
• Reviewed data – Workforce, Quality (Patient Safety), Finance.
Key Messages
• Variation in staffing levels for similar ward areas.
• Variation in psychological and AHP provision across the
wards.
• Drift in practice across the wards.
• Impact of Trust policies i.e. falls.
• Historical, flexible working arrangements.
• Changes to the acute mental health pathway and acuity.
Assurance level on
establishment review
Substantial Assurance: Controls are operating satisfactorily and objectives are being met - there are
no concerns about the minimum staffing levels that have been set.
Partial Assurance: Controls are operating however there are some weaknesses and objectives are
not always being met - There are some minor issues with regards to the safer staffing levels set.
No Assurance: Controls do not appear to be operating and objectives are not being met - there are
significant concerns about the safer staffing levels that require a service review.
The areas of no assurance have also been identified through monthly reports to the Quality Committee
and updates to Board of directors.
SUBSTANTIAL ASSURANCE PARTIAL ASSURANCE NO ASSURANCE
Emerald Lodge
Coral Lodge
Gold crest
Amber Lodge ISU
Amber Lodge R&R
Jubilee Close
Danescourt Residential Care
Bosworth
Cusworth
Osprey
Sandpiper
St John’s Hospice
Skelbrooke – days
Hawthorne
Hazel
Windermere
Coniston
Mulberry
Laurel
Ferns
Glade
Brambles
Magnolia
Kingfisher - days
New Beginnings
S136 Suites
Skelbrooke – nights
Kingfisher – nights
Identified Risks and Mitigation
Paper detailing areas of partial and no assurance presented to OMM.
Care Groups Directors leading action against findings and
recommendations.
Risks and Mitigation
New Beginnings
Additional staff are employed above the establishment to ensure safe staffing
levels are met.
Acute Mental Health Pathway (S136 suites: Skelbrooke/Kingfisher)
Since establishments were set there has been significant changes to the
demands on the acute care pathway.
The Section 136 suites are staffed from within the PICU/ward establishment
and additional staff are used to off set Section 136 activity.
Additional staff are being recruited and rostered to address the immediate
issues.
Declaration
1. Look back review of safer staffing levels for 1 January 2017 -
30 June 2017
No patient safety/serious incidents occurred during the period
1 January 2017 - 30 June 2017 as a result of staffing issues.
2. Review of baseline establishments for each ward
• Following a detailed establishment review an assurance opinion
has been provided for all wards.
• Immediate mitigation is in place for wards that have no assurance.
• Recommendations have been made for action on wards where
substantial assurance cannot be provided.
• A detailed work plan is underway for each ward, actions reported
through operational governance process, to the executive
management team and to the Quality Committee.
0
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Committee Name
Board of Directors
Agenda Item
Paper H Date 31 August 2017
Title of Paper
Summary Report from the Mental Health Legislation Committee
Action Required
Decision Assurance Information
Prepared by
Debbie Smith, Chief Operating Officer
Presented by
Jim Marr, Non Executive Director
Delivery against
Strategic Goal(s) 1,5 Strategic Risk(s) 1.1, 1.2, 1.4, 1.5, 5.1, 5.2, 5.3
CQC Domain S, E, C, R, W
Financial/Budget
Financial considerations are considered as part of individual actions.
Equality & Diversity
All activities of the Mental Health Legislation Committee are considered in accordance with the Trust’s Equality and Diversity policies and processes.
Previously
Presented to
Board of Directors
Background /
Key Points /
Outcome
The meeting of the Mental Health Legislation Committee (MHLC) was held on 2 August 2017. A summary of discussion and key highlights, assurances, risks, and gaps are detailed in the attached paper. The risk areas identified are:
Slow progress on seclusion suite building and process improvements.
Compliance with MHA requirements for medicine management.
Police and Crime Bill changes to s136. The Board of Directors is asked to note the update from the Mental Health Legislation Committee on 2 August 2017.
1
Summary Report from
Mental Health Legislation
Committee
2 August 2017
Debbie Smith
Chief Operating Officer
August 2017
0
1. Introduction The Mental Health Legislation Committee (MHLC) meets quarterly as a Sub Committee of the Board of Directors to receive assurance that the Mental Health Act (MHA) and Mental Capacity Act (MCA) are being delivered in accordance with the legislation relating to these Acts; this paper is a summary report that captures key messages from the MHLC, framed around:
Highlights
Assurance
Issues / Risks
Future
2. Highlights Highlight discussions took place relating to the following:
New 2 year contract signed to continue to provide administration to the section 12 Doctors Registration ending 31 March 2019.
LiA session on MCA Compliance attended by 44 staff. Learning to be used to develop use of MCA across the Trust.
3. Assurances
£1M liability assurance on S12 Doctors contract verbally assured.
Dashboards continue to develop in line with other dashboard developments within the Trust.
4. Gaps
The need to standardise the format of the action log for the MHLC, actions need to be more specific in terms of action definition / recording and detail of assurances sought recorded in the minutes.
Secretarial support needs to be provided to the meeting to allow the Mental Health Manager to participate more fully.
The development of a risk register specific to MHA issues
Mulberry Ward continues to present cause for concern in terms of non-compliance with aspects of the MHA Section 17 (S17) leave requirements
The need to understand the Section 136 (S136) changes due to the impact of the revised Police and Crime Bill and how has this affected admissions and the use of S136 suites.
The revised S136 Policy for the Trust is due and development is underway.
Implications of not having a S17 plan on discharge. 100% were completed but no evidence provided as to when all were completed and at what point during the six month review period.
5. Risks
Progress is slow on seclusion suite building and process improvements. Plan update and finishing date requested.
Continued concern around compliance with MHA requirements for medicine management, whilst new patient electronic record will address many of the issues, assurances have been requested from the Chief Pharmacist.
Police and Crime Bill changes to S136, increased rates in the use of S136 suite.
1
6. Opportunities
A following opportunity was highlighted during the meeting:
Survey of Consultants and AMHPs regarding Community Treatment Orders (CTOs) and their application as well as the disparity of use between Rotherham, Doncaster and North Lincolnshire will be presented next meeting.
7. Clinical Policies and Standard Operating Procedures Approved by Sub-Committees The following Policies and Standard Operating Procedures were submitted for approval at the previous Mental Health Legislation Sub-Committee:
Section 136 Protocol
Police Assistance and Conveyance Policy
Section 19 Transfer Procedure
Community Treatment Order Policy
8. Recommendation The Board of Directors is asked:
To note the update and the on-going developments from the 2 August 2017 Mental Health Legislation Committee.
1
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Committee Name
Board of Directors
Agenda Item
I Date 31 August 2017
Title of Paper
Report from the Finance Performance and Informatics Committee (FPIC)
Prepared by
Steve Hackett – Director of Finance and Performance
Presented by
Tim Shaw - Non-Executive Director, Chair of FPIC
Delivery against
Strategic Goal(s) 3
4
5
Strategic Risk(s) 3.1-3.2
4.1-4.2-
4.3-5.3
CQC Domain S
E
W
Financial/Budget
Overall budgets
Equality & Diversity
All activities are considered in accordance with the Trust’s Equality and Diversity policies and processes.
Previously Presented to
Not applicable
Action Required
Decision Assurance X Information X
Background / Key Points / Outcome
The assurances provided via the Committee in Section 1 of this report in relation to:
The achievement of financial targets as at Month 4 of the Financial Year 2017/18.
The achievement of the Single Oversight Framework performance requirements.
The key risks discussed at the Committee as highlighted in Section 2 of this report as follows:
The actions in relation to the performance hotspots for CAMHS and IAPT.
The update on the PMO.
Achievement of the Month 4 - 2017/18 Agency Cap.
The updates on other issues:
Data Quality Assurance
Capital Programme and Delivery
2
Report from the Finance Performance and Informatics Committee (FPIC) held on the 24th August 2017
1. Assurances 1.1 The Financial position as at Month 4 for the Financial Year 2017/18
The summary below describes the Month 4 financial position as discussed at the Committee. The key messages are as follows:
31 July 2017
No.
Performance
Indicator
Full Year
Annual Plan
Year to Date
Plan
Year to Date
Actual Forecast Narrative Trend
1NHS Improvement
Risk Rating1 1 1 1
The NHS Improvement financial risk rating is 1 for the year to date. All
metrics are 1.
2Control Total
Surplus£2.068m £0.951m £1.007m £2.068m
The year to date actual financial performance is a surplus of £1.007m.
The forecast is currently in line with plan .
3a Agency Cap £5.565m £1.855m £1.484m £5.565m
Agency expenditure in month is £0.389m, this is an increase on the
previous month. The agency cap for 2017/18 of £5.565m is forecast to
be achieved. All Agency appointments continue to be reviewed. The
Medical Agency cap was reduced by £0.391m for 2017/18.
3bMedical Agency
cap£2.271m £0.757m £0.836m £2.271m
Medical Agency is 10% above the ceiling and is being monitored on a
monthly basis
4 Cash £24.884m £25.539m £28.842m £25.470mThe year to date cash position is is higher than planned, mainly due to
the slippage in the payment of the Rotherham Lease buyout.
5 Capital £5.265m £0.900m £1.326m £5.265mCapital expenditure is ahead of plan for the year to date as schemes
are being delivered prior to the plan assumed timescales.
6 Delivery of QIPP £3.727m £1.747m £1.239m £2.857m
To date £1.239m or 33.3% of QIPP Plans have been delivered
recurrently and £2.368m remains outstanding. Plans are in place to
deliver £1.618m via the Trusts QIPP work streams and this is being
closely monitored by the Trusts PMO Team, however there is still a
recurrent gap of £0.870m where no plans are currently identified. The
plan detailed here is as per the trajectory sent to NHS I however
compared to budgetary phasing, it is phased in in equal twelfths to
ensure any non rec slippage of delivery of savings is shown within
Care Group positions.
7 Better Payments 95% 95% 97.80% 95%
The in month better payments for NHS payments is 99.8% and for Non-
NHS payments it is 99.0%. Total combined position for both NHS and
other for the month of July is 99.1%. The cumulative position to date
(Apr-Jul) is 97.8%.
Red Variance from Plan greater than 15% Plan
Amber Variance from Plan ranging from 5% to 15% Actual
Green In line, or Greater than Plan Forecast
Executive Summary / Key Performance Indicators
0.000
0.050
0.100
0.150
0.200
0.250
0.300
Val
ue
(£m
)
Trust Monthly I &E Profile
Original Planned Surplus / (Deficit) Actual Position before impairment Forecast
0.000
0.500
1.000
1.500
2.000
2.500
Val
ue
(£m
)
Trust Cumulative I & E Profile
Original Planned Surplus / (Deficit) Actual Position before impairment Forecast
20
25
30
1 3 5 7 9 11
0.0
2.0
4.0
6.0
1 3 5 7 9 11
92%93%94%95%96%97%98%99%
100%
1 3 5 7 9 11
0.0
1.0
2.0
3.0
1 3 5 7 9 11
0.0
10.0
1 3 5 7 9 11
0.0
5.0
1 3 5 7 9 11
0
1,000
2,000
3,000
4,000
1 3 5 7 9 11
0
0.5
1
1.5
1 3 5 7 9 11
3
1.2 NHS Improvement Single Oversight Framework (SOF) performance targets The Committee received a report detailing the current position in relation to the Single Oversight Framework performance targets as at the end of July. The report gave assurance that the Trust was achieving all the current requirements.
a) Compliance Trust declared compliance with all measures where there is a target in place for Quarter 1, 2017/18. Performance against the CPA 7 Day Follow Metric has deteriorated compared to previous performance which is largely due to issues with data capture in North Lincolnshire following the departure of social care staff. The Care Group are in the process of addressing this. The report highlighted a dip in performance in August on Doncaster IAPT, the number of people who have completed treatment and are moving to recovery, this issue is being actively managed but a risk has been raised that the 50% target may not be achieved in month.
b) Revised Single Oversight Framework NHS Improvement have now undertaken a review of the SOF and published a consultation on the proposed changes which the Trust has the opportunity to provide feedback to. Deadline is 18th September 2017.
2. Risks The Committee discussed the following risks: 2.1 Performance Hotspots The key performance issues are:
a) Rotherham CAMHS Following successfully negotiating with commissioners that the 3 week referral to assessment and 8 week referral to treatment targets are stretch targets, only the 6 week referral to assessment and 18 week referral to treatment targets are now contractual KPIs. The Trust is already achieving the 18 week referral to treatment KPI.
b) Doncaster IAPT Recovery Rates
Performance recovered and compliance reported for June and July 2017, however, August 2017 to date is 43.19%. Daily reporting to Chief Operating Officer, Care Group Director and Service Manager commenced on 21 August 2017. Action plan in place.
2.2 Performance against the Agency Cap
The Figure for July 2017 is 21% below the target;
There is an additional Medical Target of £391k, which will provide an additional challenge.
The Trust has spent £1.469m on agency expenditure to July 2017, which is 3.7% of the pay bill.
Below is a breakdown of the £1.469m:-
4
Run rate
Staff type Mth 11 Mth 12 Mth 1 Mth 2 Mth 3 Mth 4 Mth 5 Mth 6 Mth 7 Mth 8 Mth 9 Mth 10
Administration & Clerical 31,812 31,120 13,800 -21,688 -3,021 -6,068
Ancillary Staff Pay 0 0 0 0 0 0
General / Senior Managers 0 0 0 0 0 0
Medical Staff Pay 205,079 169,504 218,557 186,684 227,214 203,610
Nurses Pay 55,004 30,897 60,602 20,386 15,137 47,464
Nurses Pay (Non Qualified) 54,580 74,717 40,066 45,558 51,949 57,550
Other Agency Staff 0 0 14 550 0 0
Professional & Scientific Pay 22,893 16,757 44,148 25,439 14,024 36,433
Professional & Technical - Ptb 0 0 0 0 0 0
Profs Allied To Medicine Pay 15,930 25,289 11,843 7,518 18,714 14,714
Seconded Staff 0 0 0 0 0 0
Social Workers Pay -11,031 -89,334 10,961 5,590 6,986 10,349
CAMHS practitioners 31,076 122,282 38,578 15,003 25,379 24,922
Chairman & Non Exec Members 0 0 0 0 0
Total 405,342 381,232 438,569 285,040 356,382 388,974 0 0 0 0 0 0
Key
Continued reduction over last 3 months
Increases and reductions over 3 months
Continued increase over the last 3 months
Actual spend per month (inc. accruals)
Run rate
The Committee noted upcoming potential challenges to the Agency Cap position with forthcoming Medical Staff departures. 2.3 Project Management Office Report (PMO) The Committee received an update report on the PMO process following recent considerations at the Executive Programme Board and Executive Management Team.
a) 2017/18 QIPP As at the 31 July, the overall QIPP requirement for 2017/18 is £3.727m with the total actioned in the budget being £1.199m. (Just over £450k more than the previous month). Of the outstanding £2.528m QIPP, there are plans in place for £1,659m, leaving a recurrent gap of £870k. There is an extreme risk on the Trust Risk Register associated with the delivery of 2017/18 QIPP. Two new projects have been added to 2017/18, voice recognition and E-roster clinical bank, team resources have been rescheduled to accommodate these schemes.
b) 2018/19 QIPP Further discussions are planned for September 2017 Executive Programme Board regarding approach to 2018/19 QIPP.
3. Other information 3.1 Data Quality Assurance
A follow up report was presented that provided a wider stock take of the internal and external data quality work undertaken on the operational performance metrics as included in NHS Improvement’s Single Oversight Framework (SOF). Internal assurance has been received when an item has featured on the Information Quality Work Programme or when an alternative focussed programme of data quality work has been undertaken within other corporate functions. External assurance in this instance has been received when an organisation outside RDaSH has been invited or instructed to undertake a review. Any learning outcomes have been summarised.
5
3.2 Capital Programme and Delivery
The committee received a paper detailing the procedures for the on-going management of capital schemes, this details the roles and responsibilities, monitoring and reporting as well as how financial, contractual and health and safety risks are managed.
3.3 Governance
Board assurance framework, risk register and internal audit recommendations were discussed. The committee commented on in year risks that need to be managed within a defined deadline coupled with longer term risks that will mature and change over a number of financial years. Further discussions will take place on the process to reflect these points within the associated documents.
4 Recommendation The Board of Directors are asked:
4.1 To note the updates and assurances provided in section 1 of the report, including the Month 4 Single Oversight Framework declaration.
4.2 To note the risks and mitigations detailed in section 2 of the report.
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Committee Name
Board of Directors
Agenda Item
J Date 31 August 2017
Title of Paper
Report from the Charitable Funds Committee
Action Required
Decision X Assurance X Information
Prepared by
David Holmes, Deputy Director of Finance
Presented by
Jim Marr, Non-Executive Director / Chair of Charitable funds Committee
Delivery against
Strategic Goal(s) 3 Strategic Risk(s) CQC Domain
Financial/Budget
The individual implications of decisions are included in the detailed narrative below.
As at 30 June 2017 the Trust currently holds £2.861m in Charitable Funds.
Equality & Diversity All activities of the Charitable Funds Committee are considered in
accordance with the Trust’s Equality and Diversity policies and processes.
Previously
Presented to
This report summarises the work of the Charitable Funds Committee meeting held on 16 August 2017.
Background /
Key Points /
Outcome
The meeting of the Charitable Funds Committee was held on 16 August 2017. A summary of discussion and key highlights, assurances, risks and gaps are detailed in the attached paper.
The Board of Directors is asked:
1. To note the update from the Charitable Funds Committee on 16
August 2017.
2. To approve the Annual Report and Accounts for the Rotherham
Doncaster and South Humber NHS Foundation Trust Charitable
Fund for 2016/17.
3. To approve the signing of the Letter of Representation.
4. To note that once all documents are signed and final copies
exchanged with the auditors, that the Annual Report and
Accounts will be submitted to the Charity Commission and once
design and format work is complete, will be made available on
the Trust’s website. As from the next meeting the Chair of the Charitable Funds Committee will be Justin Shannahan, NED.
RDASH – Charitable Funds Committee Report to the Board of Directors
1. Introduction This paper is a summary report that captures key messages from the Charitable Funds Committee framed around:
Highlights
Assurance
Issues / Risks
Future
2. Highlights The Committee further considered the appointment of a full time Fundraising Manager from charitable funds. This post will have fundraising targets set for services, focusing on the services that have low balances. Further consideration is to be given for further investment in fundraising and the returns that could be achieved. Key legacies received were as follows: Quarter 1 - £6,070 for the Hospice
- £12,000 for Older peoples Services Applications were submitted and agreed for:-
St Johns Hospice Upgrade and Re-Design of rear garden £160,000 Memorial Dragonfly Statue £5,600
The Committee received the up to date financial position of the funds and received the investment report. The total funds held are £2.861m.
3. Assurances 1. The committee received information from Investec (CFC investment managers) that detailed
returns of 10.56% from 30 June 2016 to 30 June 2017 compared to a return benchmark of 13.78% (the basic indices FTSEWMA Conservative). The return was considered by the Committee to be reflective of the current risk appetite for investment.
2. The Committee received the Annual Report and Accounts for the Charitable Fund for 2016/17.
The Committee also received the independent Auditors report from PWC (External Auditors), the ISA 260 (report to those charged with governance) and a draft management representation letter for signature.
The Auditors report detailed an unqualified opinion and in their opinion, Rotherham Doncaster and South Humber NHS Foundation Trust Charitable Fund’s financial statements (the financial statements”):
give a true and fair view of the state of the charity’s affairs as at 31st March 2017 and of its
incoming resources and application of resources and cash flows, for the year then ended;
have been properly prepared in accordance with United Kingdom Generally Accepted Accounting Practice; and
have been prepared in accordance with the requirements of section 144 of the Charities Act 2011 and Regulation 8 of The Charities (Accounts and Reports) Regulations 2008).
The Committee agreed to recommend that the Board of Directors approves the Annual Report
and Accounts and recommend that the Letter of Representation can be signed. Once the signed documents are exchanged with the auditors, they will be submitted to the Charity Commission and then designed and formatted and placed on the Trust’s website.
4. Issues / Risks
The significance of the Hospice (53%) and Older Peoples (31%) funds within the total funds represents a risk that the remaining general fund (16% of the total) is proportionately small and is therefore unable to fund bids of a general nature.
5. Future
The Committee is considering an options appraisal for the future structure of the charitable funds held by the Trust, and will consider this further at future meetings.
6. Recommendation
The Board of Directors is asked:
5. To note the update from the Charitable Funds Committee on 16 August 2017.
6. To approve the Annual Report and Accounts for the Rotherham Doncaster and
South Humber NHS Foundation Trust Charitable Fund for 2016/17.
7. To approve the signing of the Letter of Representation.
8. To note that once all documents are signed and final copies exchanged with the
auditors, that the Annual Report and Accounts will be submitted to the Charity
Commission and once design and format work is complete, will be made available
on the Trust’s website.
Workforce and Organisational Development Directorate
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Trustee’s Annual Report and Accounts for Rotherham Doncaster and South Humber NHS
Foundation Trust Charitable Fund for the year ending 31 March 2017
Registered Charity Number 1055641
Foreword
Welcome to our 2016-17 Annual Report and Accounts for the Rotherham Doncaster and
South Humber NHS Foundation Trust Charitable Fund. This document records the activities
and Financial Accounts for the financial year 1 April 2016 to 31 March 2017. This year the
total income of the funds once again exceeded one million pounds and as a result a full audit
was undertaken by our auditors PriceWaterhouseCoopers and their opinion can be found
later in the report.
The Trust is immensely grateful to the many generous and committed individuals, groups
and local companies who have helped to raise funds. Donations range in size from a few
‘pennies’ to over a hundred thousand pounds but all are underpinned by an overwhelming
desire to care for people in our community who need help. On behalf of our service users,
carers and staff we send our appreciation to everyone who has helped in any way to make
this another successful year.
These funds have supported a wide range of charitable and health related activities over the
past year and have been used to support and/or enhance the experiences of our service
users, their carers and our staff.
Funds have been provided internally to support a variety of requests across our geograph-
ical footprint. You can read about some of the projects we have been involved in later on in
this annual report. The committee continues to encourage the use of the funds by staff to
enhance patient care.
Donations which are not used immediately are invested in accordance with the Charity
Commission guidelines ensuring an appropriate financial return is achieved. The
performance of the investments are reviewed regularly and decisions made to protect the
value of the portfolio until such time as they are needed to be spent.
The committee has had the benefit of our Trust Governors contributing at each meeting, as
well as between meetings, to help us focus on the best use of the funds. These Governors
do not have a voting right on the committee but play an active part in its business, for which I
am immensely grateful.
As Chair of the Charitable Funds Committee I offer my sincere thanks to everyone who has
contributed so generously in time, energy and money to support the Fund.
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The Financial statements on ‘Accounts Page 1 to Accounts Page 18’ were approved by the
Board of Directors on (31 August 2017) and signed on its behalf by:
James Marr
Chairman of the Charitable Funds Committee and Non-Executive Director of Rotherham
Doncaster and South Humber NHS Foundation Trust.
Lawson Pater
Chairman of Rotherham Doncaster and South Humber NHS Foundation Trust.
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Corporate Trustee
The Corporate Trustee presents the Charitable Fund Annual Report, together with the
Financial Statements for the year ended 31 March 2017.
The Charity’s Annual Report and Accounts for the year ended 31 March 2017 have been
prepared by the Corporate Trustee in accordance with the Charities Act 2011 and the Chari-
ties (Accounts & Reports) Regulations 2008.
During the period, funds were held for the benefit of the following organisation:
• Rotherham Doncaster and South Humber NHS Foundation Trust
Charitable Funds are available to benefit services in Doncaster, Rotherham, North
Lincolnshire, North East Lincolnshire and Manchester.
The Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH) is the
Corporate Trustee of the Charity governed by law applicable to Trusts, principally the
Trustee Act 2000 and the Charities Act 2011. The members of RDaSH Board of Directors
who served during the period 1 April 2016 to 31 March 2017 were as follows:
• Lawson Pater
• James Marr
• Kathryn Smart
• Alison Pearson
• Michael Smith (to 30 Sept 2016)
• Tim Shaw
• Justin Shannahan (from 14 Nov 2016)
• Dawn Leese (from 14 Nov 2016)
• Petar Vjestica (to 4 Sept 2016)
• Kathryn Singh
• Paul Wilkin
• Dr Nav Ahluwalia
• Rosie Johnson
• Richard Banks (to 30 June 2016)
• Dr Deborah Wildgoose
• Debbie Smith (from 1 July 2016)
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Reference and administrative details
The main charity of Rotherham Doncaster and South Humber NHS Foundation Trust Chari-
table Fund was registered as Charity 1055641 with the Charity Commission on 9 April 1996.
Charitable funds received by the charity are accepted, held and administered as funds held
on trust for purposes relating to the National Health Service and Community Care Act 1990
and these funds are held on trust by the corporate body.
Legal and administration
Principal Office
Rotherham Doncaster and South Humber
NHS Foundation Trust
Woodfield House,
Tickhill Road, Balby
Doncaster DN4 8QN
Bankers
National Westminster
12 High Street
Doncaster DN1 1EJ
Independent Examiner
PricewaterhouseCoopers LLP
Central Square
29 Wellington Street, Leeds
LS1 4DL
Investment broker
Investec Wealth and Investment Ltd
Beech House
61 Napier Street
Sheffield S11 8HA
Solicitors
DAC Beachcrofts LLP
7 Park Square East
Leeds LS1 2LW
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Structure, Governance and Management
The NHS Foundation Trust Board of Directors devolved responsibility for the on-going
management of the funds to the Charitable Funds Committee, which administers the funds
on behalf of the Corporate Trustee.
When money is given to the Charity, if it is given with a specific desire by the donor to be
used in a certain way, or to be used in a specific area, it is a ‘restricted’ fund i.e. it can only
be spent for the declared purpose.
If the money is given without any specific requirements it is an ‘unrestricted’ fund i.e. it can
be used anywhere by the committee as long as it satisfies our rules as described by NHS
Guidelines. The charity’s unrestricted fund was established using the Charity
Commissions’ model declaration of a trust for an NHS charity.
The Corporate Trustee fulfils its legal duty by ensuring that funds are spent in accordance
with the objects for each fund. By designating funds, the Trustee respects the wishes of our
generous donors to benefit patient care and advance the good health and welfare of
patients, carers and staff.
The charitable funds available for spending are generally allocated in accordance with the
Foundation Trust’s operational management structures. Each allocation is managed by use
of a ‘designated fund’ within the ‘general unrestricted fund’.
There are two funds within the main charity which are restricted for the benefit of St John’s
Hospice in Doncaster. There is one more restricted fund within the main charity for the
benefit of Coniston Lodge following a substantial legacy given in the later part of the year.
By allocating these funds the Trustee respects the wishes of our generous donors to benefit
patient care and advance the good health and welfare of patients, carers and staff in a
specific way.
The Committee is required to:
Ensure that Charitable Fund resources are appropriately utilised to augment the
services and facilities available to the Trust’s patients, carers and staff.
Ensure that the activities of the charity are appropriate to the charity’s aim and
comply with the Charity Commission’s guidance on Public Benefit.
Work to ensure that the requirements of the Charity Commission and Charities
Acts are complied with.
Ensure that Annual Accounts and an Annual Report are appropriately prepared in
the format required.
Receive and give direction in the development of policies, procedures and
administrative arrangements relating to the Trust’s Charitable Funds.
Periodically review the investments held by the Trust’s Charitable Funds and to
ensure that such resources are being effectively managed.
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The Charitable Funds Committee meets formally four times a year and consists of two Non-
Executive Directors and two Executive Directors of the Foundation Trust. Those Directors
currently serving on the Charitable Funds Committee are shown opposite. The Head of
Financial Management and the Charitable Funds Manager who both attend the meetings
also support the Committee. Investment brokers and other relevant advisors are invited to
attend as required.
Non-executive members of the Trust Board are appointed or re-appointed by the Governors
of the Trust and executive members of the Board are subject to recruitment by the NHS
Foundation Trust Board. Members of both the Trust Board and the Charitable Funds
Committee are not individual trustees under charity law but act as agents on behalf of the
Corporate Trustee.
Under a scheme of delegated authority approved by the Corporate Trustee, the Committee
must approve any expenditure over £5,000. Applications below that limit but above £1000
must have the approval of the Executive Director of Finance, Information and Estates and
applications below £1000 may be approved by the fund holder. Assistant Directors for each
division normally act as fund holders for their division and any application from members of
staff to spend these funds must be approved by them.
The Executive Director of Finance, Information and Estates acts as principal officer
overseeing the day to day financial management and accounting for the charitable funds
during the year and reports on the activities of the fund at the monthly meeting of the Trust
Board members.
The Accounting records and day-to-day administration of the funds are dealt with by the
Charitable Funds Manager, David Holmes and the Assistant Charitable Funds Manager,
Cheryl Bennett, in the Finance Department located at Tickhill Road Site, Balby, Doncaster
DN4 8QN.
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Rosie Johnson
Executive Director of Workforce and
Organisational Development
James Marr
Non- Executive Director and Chairman of the
Charitable Funds Committee
Tim Shaw
Non-Executive Director
Paul Wilkin
Executive Director of Finance/
Deputy Chief Executive
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Risk Management
The Charitable Funds Committee reviews the performance of the fund on a quarterly, year to
date and annual basis. Items reported to the Committee include the value of the invest-
ments compared with the previous quarter, the balance of cash reserves held throughout the
year, the amount of income and expenditure for the quarter and future spending plans. Any
potential risks arising from the report are highlighted in the meeting and discussed.
The Committee maintains a risk register which is reviewed as required, any concerns are
reported to Board.
After each meeting of the Charitable Funds Committee, the Chair presents a report to the
Board of Directors in order to update it on the most recent work of the Committee providing
assurances and escalating matters for further discussion as necessary.
Objectives and Activities
The Charitable Trust’s governing document, the Declaration of Trust, incorporates the object
or purpose of the Charity which is that:
“The Trustee shall hold the trust fund upon trust to apply the income and at its discretion, so
far as may be permissible, the capital, for any charitable purpose or purposes relating to the
National Health Service”
The Charitable Funds Committee takes account of the Charity Commission’s guidance on
public benefit in setting or reviewing the guidelines for fund advisers who are authorised to
spend charitable funds.
The committee has a set of objectives for the Charitable Funds Committee. The committee
works on specific activities to measure progress against these objectives so that we can
more clearly demonstrate the effectiveness of our work. These objectives were agreed by
the main Board and are shown below.
Ensure that the CFC is appropriately structured, managed and sustained to the required
legislation
To continue to encourage fund raising and donations to the Charitable Trust to benefit
service users and communities of the Trust, including the Hospice
To encourage a broad range of applications for support for initiatives from within and
outside the Trust to deliver benefits to service users, carers and RDaSH communities, in
the sphere of mental health and community services
To ensure the collection, management and distribution of all funds strictly in accordance
with legislation, best practice and Trust policies
To explore the widening of the involvement and patronage of the Charitable Trust across
RDaSH’s community and develop a campaign to recruit patrons and supporters.
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Grant Making Policy
Applications may be made for items which the NHS would not normally fund and these are
classified as charitable activities.
Applications from the designated funds for items which the NHS would normally fund but is
unable to do so due to funds not being available are classified as a grant payable to RDaSH.
They are approved according to the procedure identified above.
Applications to the General Fund are received from areas within the Trust which do not have
designated funds. These are considered and approved or declined, as appropriate, by the
committee.
Grants may also be approved by the committee for specialist charities and patient groups
which support the work undertaken by the Trust. In order to make an application these
groups must have the support of an RDaSH Senior Manager and be able to show that the
grant would benefit the Trust’s service users/patients and/or carers.
Reserves
The Trustee has established a Reserve Policy which stipulates a cautious approach to in-
vesting and seeking returns with the intention of avoiding major fluctuations in the amounts
of income available for distribution and for unforeseen contingencies.
The policy aims to maintain a minimum balance of funds available for further distribution,
equivalent to the actual expenditure in the previous financial year.
The exceptions to this policy are those funds associated with St John’s Hospice, where due
to higher levels of donations and expenditure a monetary reserve of £100,000 has been
agreed.
As the Trustee encourages funds to be expended for charitable purposes, it aims to maintain
a level of resources for the remaining funds equivalent to a minimum of twelve months
expenditure for the previous financial year.
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Money raised and projects supported
Detailed below are some of the projects supported by the Charitable Funds.
Doncaster Care Group
The Phoenix Garden project was awarded £350 of funds to provide a therapeutic garden to
inspire the senses and enhance the environment outside Skelbrooke ward by introducing
raised beds using recycled drainage pipes to grow vegetables and flowers; to create a
stunning 3D display of poppies and sunflowers from recycled plastic bottles providing impact
and colour when visitors enter the wards. The project also aims to develop an on-going
gardening project that will provide a weekly therapeutic activity.
The Podiatry Service were awarded £5,122 to purchase a higher specification of equipment
to help treat neurovascular corns which would result in the reduction of risk of injury to pa-
tients with insufficient blood flow, reducing the possibility of post treatment infection or limb
loss.
The Magnolia in-patient ward purchased a higher specification electric Oxford Presence
Hoist and Sling for £3716 to assist with providing individual assessed patient handling to
promote dignity and fulfil rehabilitation potential.
Funds of £1,000 raised by a raffle undertaken by Magnolia Ward were used to purchase ac-
tivities for therapeutic purposes for patients on the ward during the day and weekends.
Coniston
The Medical Directorate was awarded £30,000 to co-produce research in Dementia. By
working with patients, carers and staff on Coniston working focus groups would be created
to understand the key issues, seek and identify priority areas for people to give clarity on
what is most important to look at further. This would also aim to serve as a platform to co-
produce bids for further work to external bodies and work to improve our level and depth of
involvement and engagement with the core activity being on public and patient participation.
Chairs and furniture for the comfort of inpatients was purchased at a cost of £8,000 and 3
airflow mattresses for patient comfort were purchased for £13,000.
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The adaptation of the current snoezelen to multi-purpose room was granted £7,000 to
develop the room into a safe environment for agitated patients and for staff to care for them
in. The room was refurbished with sensory activities available on the ward.
Two bariatric beds to provide comfort and dignity to bariatric patients’ needs and minimise
the risk of people falling out of bed were purchased for £6,430 and a raiser lifting device to
help staff lift a patient from the floor was purchased for £2,795.
Forest Gate
£5,000 was awarded to lease and maintain a tropical fish tank column to make the area as
stimulating as possible in full consideration of client’s needs by reducing levels of anxiety,
agitation, aggression and other behavioural problems.
Rotherham Care Group
Woodlands were awarded £2,550 for a ceramics project to aid the improvement of motor
skills; alleviate tensions and frustrations; improve mental health & wellbeing and to improve
communication and prevent social isolation.
Rotherham Care Group have also been awarded funds of £6,186 for the continuation of the
service delivery by Kiveton Park Independent Advice Centre to provide benefits advice to
patients and carers within the inpatient community.
North Lincolnshire Care Group
£170 was provided for the Togetherness Choir Christmas buffet.
A Sensory Juke Box for Laurel Ward was purchased from a £500 donation to the ward.
St John’s Hospice
Throughout the year various fundraising activities have taken place raising approximately
£10,300 for St John’s Hospice. Some of the activities that have taken place include: a Yoga-
thon; Sponsored Pony Tail Removal; Children of Campsall Cake Sale; Close Brothers Dress
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Down Day; Coffee Mornings; Charity Football Match; Guess the Bear’s Name; Garden Par-
ty; Sparkles Charity Car Wash; Soul & Motown Night; St John’s Hospice Spring Fayre,
Christmas Fayre & Christmas Raffle.
Approximately £280,000 has been received in the form of legacies left to the Hospice within
2016/17.
Following the completion of the Hospice Refurbishment and upgrade and redesign to the
Hospice garden has now been identified. This has been agreed in principle subject to ten-
ders with an approximate cost of £160,000.
A ToTo patient turning device was purchased following the donation of funds for £2208.
This equipment gently changes the position of the patient without staff having to touch them,
is less invasive on family’s private time and is beneficial to staff from a moving and handling
perspective.
New, good quality, hardwearing crockery for the Hospice Café, Day Hospice and In-Patient
areas was purchased to ensure standardisation throughout the Hospice and enhance the
environment within which the patients are cared for.
A grant of £3318 was awarded to improve the patient experience at the chapel by providing
a new induction loop system for people wearing hearing aids; the installation of a ceiling
mounted projector to enable people to follow the proceedings; lockable wall mounted water
boiler to provide refreshments after services and to turn the garden at the back of the spir-
itual care centre into a memorial garden.
Donations were made throughout the year towards the cost of Complementary Therapy and
Arts and Craft sessions for patients.
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Giving
The trust treats patients across Doncaster, Rotherham, Manchester, North East Lincolnshire
and North Lincolnshire. This has a made a significant difference in many people’s lives and
been greatly aided by your generous donations.
The charity holds separate funds for each division within the trust which ensures all dona-
tions are gifted to the desired area of the benefactor.
How to give
Cheques/Postal Orders
If you would prefer to carry out transactions via the post, cheques should be made payable
to ‘RDaSH Charitable Fund’.
If you are using one of these methods of payment, please include a brief note to let us know
which area you would like to benefit from your donation.
If you include your name and address, including post code, we will be able to claim gift aid
on your donation.
Please send all cheques/correspondence to the following address:
Mr David Holmes
Charitable Funds Manager
Rotherham Doncaster & South Humber NHS Trust
Finance Department
Onyx Centre
Tickhill Road Site
Balby
Doncaster
DN4 8QN
Gift Aid
Gift Aid is a policy that enables tax-effective giving by individuals to charities in the United
Kingdom. If you are a tax payer the Charitable Fund can reclaim 25p from the Inland
Revenue for every £1 donated to our charity – at no extra cost to you.
14
To make a donation by Gift Aid, please indicate this on the donation form or send a letter
with your donation confirming this, including your name and address.
Legacies
A legacy can comprise a specified sum or you can leave all or part of the residue of your
estate. This means that the charity receives the remainder of your estate once any debts,
expenses, specific legacies and gifts have been cleared. Your solicitor or independent
financial adviser can discuss the various alternatives with you, together with the associated
tax benefits.
Payroll Giving
Payroll Giving is a way for employees to make regular payments to a charity directly from
their pay. People who receive their company/personal pension through Pay As You Earn
(PAYE) can participate too.
Payments that employees make though a Payroll Giving Scheme are deducted from their
pay before tax is deducted. This means that employees are given tax relief on their donation
immediately – and at their highest rate of tax.
Virgin Money Giving
A leading online platform for charity giving which is both secure and time efficient.
Donations can be accepted via our Virgin Money Giving website –
http://www.ukvirginmoneygiving.com/giving/
Accounts Page 1
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST CHARITABLE FUND
FUNDS HELD ON TRUST ANNUAL ACCOUNTS 2016-2017
The accounts of the Funds Held on Trust by Rotherham Doncaster and SouthHumber NHS Foundation Trust.
FOREWORD
These accounts for the year ended 31 March 2017 have been prepared by the Trustee in accordance with Part VI of the Charities Act 1993, the Charities Act 2011 and the Charities (Accounts & Reports) Regulations 2008.
STATUTORY BACKGROUND
The Rotherham Doncaster and South Humber NHS Foundation Trust Charitable Funds Held on Trust are registered with the Charity Commission and include funds in respect of Doncaster, Rotherham, North Lincolnshire North East Lincolnshire and Manchester services.
MAIN PURPOSE OF THE FUNDS HELD ON TRUST
The main purpose of the charity is to apply income for any charitable purpose relating to the National Health Service.
Accounts Page 2
NHS FOUNDATION TRUST CHARITABLE FUNDROTHERHAM DONCASTER AND SOUTH HUMBER
Statement of Trustee's responsibilities Under charity law, the trustees are responsible for preparing the trustees’ annual report and accounts for each financial year which show a true and fair view of the state of affairs of the charity and of the excess of expenditure over income for that period. In preparing these accounts, generally accepted accounting practice requires that the trustees: • Select suitable accounting policies and then apply them consistently • Make judgments and estimates that are reasonable and prudent • State whether the recommendations of the SORP have been followed, subject to any material
departures disclosed and explained in the accounts • State whether the accounts comply with the trust deed, subject to any material departures disclosed
and explained in the accounts • Prepare the accounts on the going concern basis unless it is inappropriate to presume that the
charity will continue its activities. The trustees are required to act in accordance with the trust deed and the rules of the charity, within the framework of trust law. The trustees are responsible for keeping proper accounting records, sufficient to disclose at any time, with reasonable accuracy, the financial position of the charity at that time, and to enable the trustees to ensure that, where any statements of accounts are prepared by the trustees under section 132(1) of the Charities Act 2011, those statements of accounts comply with the requirements of regulations under that provision. The trustees have general responsibility for taking such steps as are reasonably open to the trustees to safeguard the assets of the charity and to prevent and detect fraud and other irregularities. The Trustee confirms that it has met the responsibilities set out above and complied with the requirements for preparing the accounts. By Order of the Trustee Chairman of the Charitable Funds Committee.................................... Date. 31 August 2017 Chairman of the Trust....................................................................... Date..31 August 2017
Accounts Page 3
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST CHARITABLE FUND
Independent auditors’ report to the trustees of Rotherham Doncaster and South Humber NHS Foundation Trust Charitable Fund Report on the financial statements Our opinion In our opinion, Rotherham Doncaster and South Humber NHS Foundation Trust Charitable Fund’s financial statements (the financial statements”): • give a true and fair view of the state of the charity’s affairs as at 31st March 2017 and of its
incoming resources and application of resources and cash flows, for the year then ended;
• have been properly prepared in accordance with United Kingdom Generally Accepted Accounting Practice;
• and have been prepared in accordance with the requirements of section 144 of the Charities Act 2011 and Regulation 8 of The Charities (Accounts and Reports) Regulations 2008).
What we have audited The financial statements, included within the Annual Report and Accounts (the “Annual Report”), comprise: • the balance sheet as at 31st March 2017;
• the statement of financial activities for the year then ended;
• the cash flow statement for the year then ended; and
• the notes to the financial statements, which include a summary of significant accounting policies
and other explanatory information. The financial reporting framework that has been applied in the preparation of the financial statements is United Kingdom Accounting Standards comprising FRS 102 “The Financial Reporting Standard applicable in the UK and Republic of Ireland”, and applicable law (United Kingdom Generally Accepted Accounting Practice). In applying the financial reporting framework, the trustees have made a number of subjective judgements, for example in respect of significant accounting estimates. In making such estimates, they have made assumptions and considered future events. Other matters on which we are required to report by exception Sufficiency of accounting records and information and explanations received Under the Charities Act 2011 we are required to report to you if, in our opinion: • we have not received all the information and explanations we require for our audit; or
• sufficient accounting records have not been kept; or
• the financial statements are not in agreement with the accounting records and returns.
We have no exceptions to report arising from this responsibility. Other information in the Annual Report Under the Charities Act 2011 we are required to report to you if, in our opinion the information given in the Trustees’ Annual Report is inconsistent in any material respect with the financial statements. We have no exceptions to report arising from this responsibility. Responsibilities for the financial statements and the audit Our responsibilities and those of the trustees
Accounts Page 4
p As explained more fully in the Trustees’ Responsibilities Statement set out on page 2 of the Annual Report, the trustees are responsible for the preparation of the financial statements and for being satisfied that they give a true and fair view. Our responsibility is to audit and express an opinion on the financial statements in accordance with applicable law and International Standards on Auditing (UK and Ireland) (“ISAs (UK & Ireland)”). Those standards require us to comply with the Auditing Practices Board’s Ethical Standards for Auditors. This report, including the opinions, has been prepared for and only for the charity’s trustees as a body in accordance with section 144 of the Charities Act 2011 and regulations made under section 154 of that Act (Regulation 24of The Charities (Accounts and Reports) Regulations 2008)and for no other purpose. We do not, in giving these opinions, accept or assume responsibility for any other purpose or to any other person to whom this report is shown or into whose hands it may come save where expressly agreed by our prior consent in writing. What an audit of financial statements involves We conducted our audit in accordance with ISAs (UK & Ireland). An audit involves obtaining evidence about the amounts and disclosures in the financial statements sufficient to give reasonable assurance that the financial statements are free from material misstatement, whether caused by fraud or error. This includes an assessment of: • whether the accounting policies are appropriate to the charity’s circumstances and have been
consistently applied and adequately disclosed;
• the reasonableness of significant accounting estimates made by the trustees; and
• the overall presentation of the financial statements.
We primarily focus our work in these areas by assessing the trustees’ judgements against available evidence, forming our own judgements, and evaluating the disclosures in the financial statements. We test and examine information, using sampling and other auditing techniques, to the extent we consider necessary to provide a reasonable basis for us to draw conclusions. We obtain audit evidence through testing the effectiveness of controls, substantive procedures or a combination of both. In addition, we read all the financial and non-financial information in the Annual Report to identify material inconsistencies with the audited financial statements and to identify any information that is apparently materially incorrect based on, or materially inconsistent with, the knowledge acquired by us in the course of performing the audit. If we become aware of any apparent material misstatements or inconsistencies we consider the implications for our report. PricewaterhouseCoopers LLP Chartered Accountants and Statutory Auditors Leeds Date PricewaterhouseCoopers LLP is eligible to act, and has been appointed, as auditor under section 144(2) of the Charities Act 2011.
Accounts Page 5
Statement of Financial Activities for the year ended 31 March 2017
2016-17 2015-16Note Unrestricted Restricted Total Total
Funds Funds Funds Funds£000 £000 £000 £000
Income and endowments from:
Donations and legacies 3 414 0 414 1,452Charitable activities 0 0 0 0Other trading activities 4 13 0 13 14Investments 5 32 18 50 24
Total incoming resources 459 18 477 1,490Operating Activities
Expenditure on:
Raising funds 6 (33) (16) (49) (38)Charitable activities 7
- Patients' Welfare and Amenities (143) (39) (182) (271)- Staff Welfare and Amenities (179) (7) (186) (54)- New Building and Refurbishment (79) 0 (79) (44)- Grants to non-NHS bodies 8 (20) 0 (20) (12)
(421) (46) (467) (381)Total expenditure (454) (62) (516) (419)
Net gains/(losses) on investments 160 87 247 (28)Net income/(expenditure) 165 43 208 1,043
Transfers between funds 6 (6) 0 0
Net Movement in funds 171 37 208 1,043
Reconciliation of fundsFund balances brought forward at
1 April 2016 18 1,717 1,009 2,726 1,683Fund balances carried
forward at 31 March 2017 18 1,888 1,046 2,934 2,726
All results derive from continuing operations
All gains and losses recognised in the year are included in the Statement of Financial Activities
The notes at 'Accounts Page 8 to Accounts Page 18' form part of this account.
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST CHARITABLE FUND
Accounts Page 6
Balance Sheet as at 31 March 2017Note Unrestricted Restricted Total at 31 Total at 31
Funds Funds March 2017 March 2016£000 £000 £000 £000
Fixed assetsInvestments 14 1,655 918 2,573 2,065
Total fixed assets 1,655 918 2,573 2,065
Current assetsDebtors 15 9 5 14 6Cash and cash equivalents 16 271 148 419 805
Total current assets 280 153 433 811
Current liabilitiesCreditors falling due
within one year 17 (47) (25) (72) (150)
Net current assets 233 128 361 661
Net assets 1,888 1,046 2,934 2,726
Funds of the charity 18
Restricted income funds 0 1,046 1,046 1,009Unrestricted income funds 1,888 0 1,888 1,717
Total charity funds 1,888 1,046 2,934 2,726
The notes at 'Accounts Page 8 to Accounts Page 18' form part of this account.
Signed:
Name Jim Marr, NED and Chair of the Charitable Funds Committee
Date: 31 August 2017
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST CHARITABLE FUND
Accounts Page 7
Statement of Cash Flow for the year ended 31 March 2017
Note 2016/17 2015/16£'000 £'000
Cash flows from operating activities:Net cash (used in) provided by operating activities 19 (175) 1,136 Cash flows from investing activities:
Dividends, interest and rent from investments 5 50 24
Proceeds from sale of investments 14 77 177
Purchase of investments 14 (338) (1,663)
Net cash used in investing activities (211) (1,462)
Change in cash and cash equivalents in the reporting period (386) (326)
Cash and cash equivalents at the beginning of the reporting period 805 1,131
Cash and cash equivalents at the end of the reporting period 16 419 805
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST CHARITABLE FUND
Accounts Page 8
Notes to the Accounts
1 Accounting Policies
1.1 Basis of preparation
1.2 Funds structure
1.3 Incoming resources
1.4 Incoming resources from legacies
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST CHARITABLE FUND
The financial statements have been prepared under the historic cost convention, with the exception of investments which are included at market value. The accounts (financial statements) have been prepared in accordance with the Statement of Recommended Practice: Accounting and Reporting by Charities preparing their accounts in accordance with the Financial Reporting Standard applicable in the UK and Republic of Ireland (FRS 102) issued on 16 July 2014 and the Financial Reporting Standard applicable in the United Kingdom and Republic of Ireland (FRS 102) and the Charities Act 2011 and UK Generally Accepted Practice as it applies from 1 January 2015.
Unrestricted funds comprise those funds which the trustee is free to use for any purpose in furtherance of the charitable objects. Unrestricted funds include designated funds, where the donor has made known their non-binding wishes or where the trustee, at its discretion, has created a fund for a specific purpose. Restricted funds are those which must be used for a specific purpose as set out by the donor, or by the terms of a public appeal, or are subject to a restriction on the expenditure of capital.
Legacies are accounted for as incoming resources either upon receipt or where the receipt of the legacy is virtually certain. This will be once confirmation has been received from the representatives of the estate that payment of the legacy will be made or property transferred and once all conditions attached to the legacy have been fulfilled.
All incoming resources are recognised once the charity has entitlement to the resources, it is certain that the resources will be received and the monetary value of them can be measured with sufficient reliability.
Accounts Page 9
Notes to the Accounts
1.5 Resources expended
The Charitable Fund's accounts are prepared in accordance with the accruals concept,and expenditure is recognised when a liability is incurred.
i) Grants payableGrant payments are only made to related or third party NHS bodies and non-NHS third partiesin furtherance of the charitable objectives of the funds. A liability for such grants is recognisedwhen approval has been given by the trustee and the conditions for their payment have been met,or where a third party has a reasonable expectation that they will receive the grant.
ii) Governance costsGovernance costs comprise all costs incurred in the governance of the charity. These includeexternal examination fees, recharges of appropriate proportions of salaries and internal audit feesfrom the Rotherham Doncaster and South Humber NHS Foundation Trust, where applicable.
iii)
1.6 Irrecoverable VAT
Irrecoverable VAT is charged against the category of resources expended for which it was incurred.
1.7 Transfer of funds
Funds may be transferred for administrative purposes but they are kept for the purposefor which the donation was given.
1.8 Fixed asset investments
Fixed asset investments are stated at market value as at the balance sheet date.The Statement of Financial Activities includes the net gains and losses arising on revaluation and disposals throughout the year.
1.9 Short term investments
Short term investments consist of an instant access bank account and a 95 day notice account
Costs of generating fundsThe costs of generating funds are those costs attributable solely due to investment management and represent the brokerage charges and investment management fees incurred.
ROTHERHAM DONCASTER AND SOUTH HUMBERNHS FOUNDATION TRUST CHARITABLE FUND
The charity is restricted from making direct investments into companies involved in the manufacture of alcohol or tobacco.
Accounts Page 10
Notes to the Accounts
1.10 Realised gains and losses
All gains and losses are taken to the Statement of Financial Activities as they arise.Realised gains and losses on investments are calculated as the difference betweensales proceeds and opening market value (or purchase date if later). Unrealised gains and losses are calculated as the difference between the market value at the year end and the opening market value (or purchase date if later).
1.11 Change in the basis of accounting
There has been no change in the basis of accounting during the year.
1.12 Prior year adjustments
There have been no prior year adjustments.
1.13 Grant making policies
The fund managers have delegated authority from the trustee to decide how the funds may bespent. Grant payments are made from the Rotherham Doncaster and South HumberNHS Foundation Trust Charitable Fund to the Rotherham Doncaster and South HumberNHS Foundation Trust. Grants may be made to other NHS Trustsin order to transfer funds which could more readily be used for their intended purposeby the recipient Trust.
1.14 Allocation and apportionment of costs
ROTHERHAM DONCASTER AND SOUTH HUMBERNHS FOUNDATION TRUST CHARITABLE FUND
Costs are apportioned and allocated to the funds on the basis of the average fund balance during the year
Grants may also be made to external organisations within strict limitations and criteria. In particular it must be to an organisation which is an accredited, properly constituted body which supports RDaSH patients and/or service users or carers, and it must be able to demonstrate that the service it offers provides significant benefit to RDaSH patients, service users or carers.
Expenditure is classified as a grant payable to an NHS body using the principle that the expenditure incurred is of a kind that would normally be funded from revenue monies, but because of lack of revenue it is funded from charitable funds.
Applications from other organisations must have the support of senior RDaSH management and are approved or otherwise at the discretion of the Charitable Funds committee.
Accounts Page 11
2 Prior Year Comparatives2.1 Unrestricted funds - Statement of Financial Activity for year ended 31 March 2017
2016-17 2015-16£000 £000
Income and endowments from:Donations and legacies 414 558Charitable activities 0 0Other trading activities 13 14Investments 32 16
Total incoming resources 459 588
Expenditure on:Raising funds (33) (29)Charitable activities
- Patients' Welfare and Amenities (143) (211)- Staff Welfare and Amenities (179) (54)- New Building and Refurbishment (79) (14)- Grants to non-NHS bodies (20) (12)
(421) (291)Total expenditure (454) (320)
Net gains/(losses) on investments 160 (18)
Net income 165 250
Transfer between funds 6 0
Net Movement in funds 171 250
Reconciliation of fundsFund balances brought forward at
1 April 2016 1,717 1,467Fund balances carried
forward at 31 March 2017 1,888 1,717
Unrestricted funds - Balance Sheet as at 31 March 2017
2016-17 2015-16Fixed assets £000 £000
Investments 1,655 1,301 Total fixed assets 1,655 1,301
Current assetsDebtors 9 4 Cash and cash equivalents 271 508
Total current assets 280 512
Current liabilitiesCreditors falling due
within one year (47) (96)
Net current assets 233 416
Net assets 1,888 1,717
Total unrestricted funds 1,888 1,717
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST CHARITABLE FUND
Notes to the Accounts
Accounts Page 12
Prior Year Comparatives2.2 Restricted funds - Statement of Financial Activity for year ended 31 March 2017
2016-17 2015-16£000 £000
Income and endowments from:Donations and legacies 0 894Charitable activities 0 0Other trading activities 0 0Investments 18 8
Total incoming resources 18 902
Expenditure on:Raising funds (16) (9)Charitable activities
- Patients' Welfare and Amenities (39) (60)- Staff Welfare and Amenities (7) 0- New Building and Refurbishment 0 (30)- Grants to non-NHS bodies 0 0
(46) (90)Total expenditure (62) (99)
Net gains/(losses) on investments 87 (10)Net income 43 793
Transfer between funds (6)
Net Movement in funds 37 793
Reconciliation of fundsFund balances brought forward at
1 April 2016 1,009 216Fund balances carried
forward at 31 March 2017 1,046 1,009
Restricted funds - Balance Sheet as at 31 March 2017
2016-17 2015-16Fixed assets £000 £000
Investments 918 764 Total fixed assets 918 764
Current assetsDebtors 5 2 Cash and cash equivalents 148 297
Total current assets 153 299
Current liabilitiesCreditors falling due
within one year (25) (54)
Net current assets 128 245
Net assets 1,046 1,009
Total unrestricted funds 1,046 1,009
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST CHARITABLE FUND
Notes to the Accounts
Accounts Page 13
Donations Unrestricted Restricted Total Totaland legacies 3 Funds Funds 2017 2016
Funds Funds£000 £000 £000 £000
Donations from individuals 126 0 126 135Corporate donations 4 0 4 21Legacies 284 0 284 1,296Grants 0 0 0 0Total 414 0 414 1,452
Other trading Unrestricted Restricted Total Totalactivities 4 Funds Funds 2017 2016
Funds Funds£000 £000 £000 £000
Events organised by thefundraising team 13 0 13 14
Total 13 0 13 14
Investments 5 Unrestricted Restricted Total TotalFunds Funds 2017 2016
Funds Funds£000 £000 £000 £000
Fixed asset equity and similarinvestment 31 18 49 21Short term investments and deposits and cash on deposit 1 0 1 3
Total 32 18 50 24
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST CHARITABLE FUND
Notes to the Accounts
Accounts Page 14
Raising Unrestricted Restricted Total Totalfunds 6 Funds Funds 2017 2016
Funds Funds£000 £000 £000 £000
Fundraising events 4 0 4 10Investment management 19 10 29 14Support cost 10 6 16 14Total 33 16 49 38
Allocation between Raising Funds and Charitable Activities (See note 10)
Grant funded Support Total TotalAnalysis of activity costs 2017 2016charitable Funds Fundsexpenditure 7 £000 £000 £000 £000
Patients' welfare and amenities 0 182 182 271Staff welfare and amenities 0 186 186 54New building and refurbishment 0 79 79 44Other institutions (5) 20 0 20 12Total 20 447 467 381
Analysis ofGrants 8 No. of grants Total amount No. of grants Total amount
awarded paid awarded paid2017 2017 2016 2016
£000 £000
Rotherham Samaritans 0 0 5 7New Directions 0 0 1 2Wellbeing Group 7 1 0 0DonMentia 1 1 1 1Rotherham Abuse Counselling 1 3 1 2Aspire 1 13 0 0J E Wood - Choir 5 2 0 0Total 20 12
Total TotalMovements in Current Non-current 2017 2016funding liabilities liabilities £000 £000commitments 9
Opening Balance at 1 April 150 0 150 58Additional commitments made during the year (99) 0 (99) 191Amounts paid during the year 21 0 21 (99)Total 72 0 72 150
Allocation of Raising funds Charitable Total Totalsupport costs activities 2017 2016 Basis of Allocationand overheads 10 £000 £000 £000 £000
External Audit 0 7 7 7 Expenditure direct allocationOther professional fees 0 0 0 0Admin Support 0 9 9 7 Salaries of StaffGovernance 0 16 16 14Financial Administration 29 0 29 14 Expenditure direct allocationSalaries and related costs 4 0 4 10 Salaries of StaffTotal 33 16 49 38
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST CHARITABLE FUND
Notes to the Accounts
Accounts Page 15
Reserve Policy
11
Related party 12transactions
Tax exemptions
13
NHS FOUNDATION TRUST CHARITABLE FUND
The Trustee has established a Reserve Policy with the intention of avoiding major fluctuations in the amounts of income available for distribution and for unforeseen contingencies. The policy aims to maintain a minimum balance of funds available for future distribution, equivalent to the actual expenditure in the previous year. The exceptions to this policy are those funds associated with St John's hospice, where due to higher levels of donations and expenditure a a monetary reserve of £100,000 has been agreed. As the Trustee encourages funds to be expended for charitable purposes it aims to maintain a level of resources for the remaining funds equivalent to a minimum of twelve months expenditure for the previous financial year.
ROTHERHAM DONCASTER AND SOUTH HUMBER
The Charity is a registered charity, and as such is entitled to certain tax exemptions on income and profits from investments, and surpluses on any trading activities carried on in furtherance of the charity's primary objectives, if these profits and surpluses are applied solely for charitable purposes.
Notes to the Accounts
Related party transactions During the year none of the Trustees or members of the key management staff or parties related to them has undertaken any material transactions with the Doncaster and South Humber Healthcare NHS Charitable Trust.
During the year none of the Trustees or members of the key management staff or parties related to them has undertaken any material transactions with the Doncaster & South Humber Healthcare NHS Trust Charitable Trust. The charitable trust has made revenue payments to the Doncaster & South Humber Healthcare NHS Trust where the Trustees (whose names are listed below) are also members of the Trust Board.
The members of the Charitable Fund Committee are also members of the Rotherham Doncaster and South Humber NHS Foundation Trust, Trust Board. During the year none of the members of the NHS Trust Board or senior NHS Trust staff or parties related to them were beneficiaries of the charity. Transactions relating to administration charges paid to Rotherham Doncaster and South Humber NHS Foundation Trust for services provided throughout the year amounted to £12,505. At 31 March 2017 the total for creditors included an amount of £28,454 owed to Rotherham Doncaster and South Humber NHS Foundation Trust for invoices paid on behalf of the charity.
Accounts Page 16
Investments 14 2017 2016Investments: £000 £000Movement in investmentMarket value at 1 April 2,065 607Less: Disposals at carrying value (77) (177)Add: Acquisitions at cost 338 1,663Net gain/(loss) on revaluation 247 (28)Market value at 31 March 2,573 2,065
Historic cost at 31 March 2,245 1,968
Investments by type2017 2016£000 £000
Equities 959 773Fixed Interest 1,102 356Alternative Assets 177 107Property 211 83Cash held as part of the 124 746
investment portfolioTotal 2,573 2,065
Debtors 15 31 March 31 March2017 2016
Amounts falling due within one year: £000 £000
Accrued Income 14 6Total 14 6
Cash and Short Term Investments and Deposits 31 March 31 Marchcash 2017 2016equivalents 16 £000 £000
Cash at bank and in hand 9 495 Day Notice account 410 801Total 419 805
Creditors 31 March 31 Marchfalling due 2017 2016within one £000 £000year 17 Amounts falling due within one year:
Other creditors 31 102Accruals and deferred income 41 48
Total 72 150
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST CHARITABLE FUND
Notes to the Accounts
Accounts Page 17
Details of 18 Unrestricted Funds Balance Incoming Resources Grants Grants Gains and Other Balancematerial 31 March Resources Expended Receivable Payable Losses Transfers 31 Marchfunds- 2016 2017unrestricted £000 £000 £000 £000 £000 £000 £000 £000funds
Undesignated(General Fund) 59 1 (1) 0 (19) 4 0 44
Material Designated funds
A St John's Hospice 1,523 444 (398) 0 0 151 0 1,720B Doncaster Care Group 16 5 (21) 0 (1) 28 60 87C Rotherham Care Group 0 7 (9) 0 0 9 8 15D Others (3) 119 2 (5) 0 0 (32) (62) 22
Total 1,717 459 (434) 0 (20) 160 6 1,888
18 Name of fund Description of the nature and purpose of each fund
A St John's Hospice Care of the terminally ill and provision of palliative care servicesB Doncaster Care Group To support the treatment and care of patients within the Doncaster Care GroupC Rotherham Care Group To support the treatment and care of patients within the Rotherham Care Group
18 Restricted Funds
Balance Incoming Resources Grants Grants Gains and Other Balance31 March Resources Expended Receivable Payable Losses Transfers 31 March
2016 2017£000 £000 £000 £000 £000 £000 £000 £000
A St John's Hospice 21 0 0 0 0 2 0 23
B 6 0 0 0 0 0 (6) 0C Forest Gate 24 1 (2) 0 0 2 0 25D John Street 19 0 (3) 0 0 1 0 17E Coniston Lodge 939 17 (57) 0 0 82 0 981
Total 1,009 18 (62) 0 0 87 (6) 1,046
0Details of 18 Name of fund Description of the nature and purpose of each fundmaterial funds
St John's Hospice
ROTHERHAM DONCASTER AND SOUTH HUMBERNHS FOUNDATION TRUST CHARITABLE FUND
St John's Hospice Development Appeal
This fund represents a number of separate legacies which were bequeathed for St John's Hospice. Sufficient funds are available to allow the restriction to be complied with. The main purpose of St John's Hospice is for the care of terminally ill patients and the provision of palliative care services.
Coniston Lodge This fund represents a legacy which was bequeathed for Coniston Lodge. The main purpose is for the care and provision of services for patients with dementia.
Notes to the Accounts
Accounts Page 18
19 Reconciliation of net income to net cash flow from operating activities
2017 2016£000 £000
Net income/(expenditure) for 2016/17 (as per the Statementof Financial Activities) 208 1,043
Adjustments for:Depreciation charges 0 0(Gains)/losses on investments (229) 48Dividends, interest and rent from investments (50) (24)Profit on the sale of fixed assets (17) (21)Decrease in stocks 0 0Increase in debtors (8) (2)(Decrease)/increase in creditors (79) 92
Net cash (used in) provided by operating activities (175) 1,136
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST CHARITABLE FUND
Notes to the Accounts
Leading the way with care
Kathryn Singh – Chief Executive Lawson Pater – Chairman
Finance Department Onyx Centre
Tickhill Road Site Balby, Doncaster
DN4 8QN Tel: 01302 796356
Email: [email protected]
31 August 2017
PricewaterhouseCoopers LLP Central Square 29 Wellington Street Leeds LS1 4DL
Dear Sirs
This representation letter is provided in connection with your audit of the financial statements of Rotherham Doncaster and South Humber NHS Foundation Trust Charitable Fund (the “charity”) for the year ended 31st March 2017 for the purpose of expressing an opinion as to whether the financial statements give a true and fair view, have been properly prepared in accordance with United Kingdom Accounting Standards, comprising FRS 102 “The Financial Reporting Standard applicable in the UK and Republic of Ireland”, and applicable law (UK GAAP), and have been prepared in accordance with the Charities Act 2011 and Regulation 8 of The Charities (Accounts and Reports) Regulations 2008.
We confirm that the following representations are made on the basis of enquiries of management and staff of the charity with relevant knowledge and experience and, where appropriate, of inspection of supporting documentation sufficient to satisfy ourselves that we can properly make each of the following representations to you.
We confirm, for all trustees at the time the trustees’ report is approved, to the best of our knowledge and belief, and having made the appropriate enquiries, the following representations:
Financial Statements
We have fulfilled our responsibilities, as set out in the terms of the audit engagement letter dated 1st February 2017, for the preparation of the financial statements in accordance with UK GAAP and the Charities Act 2011 and The Charities (Accounts and Reports) Regulations 2008; in particular the financial statements give a true and fair view in accordance therewith.
All transactions have been recorded in the accounting records and are reflected in the financial statements.
All grants, donations and other income have been notified to you and where the receipt is subject to specific terms or conditions, we confirm that they have been recorded in restricted
Leading the way with care
Kathryn Singh – Chief Executive Lawson Pater – Chairman
funds. There have been no breaches of terms or conditions during the period in the application of such income.
We confirm that to the best of our knowledge all income receivable by the charity during the accounting period has been included in the financial statements. Where material, gifts in kind and intangible income have been included at a reasonable estimate of their value to the charity or at the amount actually realised.
Significant assumptions used by us in making accounting estimates, including those surrounding measurement at fair value, are reasonable.
All events subsequent to the date of the financial statements for which UK GAAP requires adjustment or disclosure have been adjusted or disclosed.
Information Provided
Each trustee has taken all the steps that he or she ought to have taken as a trustee in order to make himself or herself aware of any relevant audit information and to establish that you (the charity’s auditors) are aware of that information.
We have provided you with:
Access to all information of which we are aware that is relevant to the preparation of the financial statements such as records, documentation and other matters;
Additional information that you have requested from us for the purpose of the audit; and
Unrestricted access to persons within the charity from whom you determined it necessary to obtain audit evidence.
So far as each trustee is aware, there is no relevant audit information of which you are unaware.
Fraud and non-compliance with laws and regulations
We acknowledge our responsibility for the design, implementation and maintenance of internal control to prevent and detect fraud.
We have disclosed to you the results of our assessment of the risk that the financial statements may be materially misstated as a result of fraud.
We have disclosed to you all information in relation to fraud or suspected fraud that we are aware of and that affects the charity and involves: – Management; – Employees who have significant roles in internal control; or – Others where the fraud could have a material effect on the financial statements.
We have disclosed to you all information in relation to allegations of fraud, or suspected fraud, affecting the charity’s financial statements communicated by employees, former employees, analysts, regulators or others.
We have disclosed to you all known instances of non-compliance or suspected non-compliance with laws and regulations whose effects should be considered when preparing financial statements.
Related party transactions
We confirm that the ultimate controlling party of the charity is Rotherham Doncaster and South Humber NHS Foundation Trust.
We confirm that the attached appendix to this letter is a complete list of the charity’s related parties. All transfer of resources, services or obligations between the charity and these parties have been disclosed to you, regardless of whether a price is charged. We are unaware of any other related parties, or transactions between disclosed related parties.
Leading the way with care
Kathryn Singh – Chief Executive Lawson Pater – Chairman
Related party relationships and transactions have been appropriately accounted for and disclosed in accordance with the requirements of the Charities SORP for FRS 102, “Accounting and Reporting by Charities: Statement of Recommended Practice applicable to charities preparing their accounts in accordance with the Financial Reporting Standard applicable in the UK and Republic of Ireland (FRS 102)” and the Charities Act 2011 and the Charities (Accounts and Reports) Regulations 2008.
We confirm that we have identified to you all employees with emoluments over £60,000, as defined by “Accounting and Reporting by Charities: Statement of Recommended Practice”, and included their emoluments in the financial statement disclosures.
Employee Benefits
We confirm that we have made you aware of all employee benefit schemes in which employees of the charity participate.
Contractual arrangements/agreements
All contractual arrangements (including side-letters to agreements) entered into by the charity have been properly reflected in the accounting records or, where material (or potentially material) to the financial statements, have been disclosed to you.
Litigation and claims
We have disclosed to you all known actual or possible litigation and claims whose effects should be considered when preparing the financial statements and such matters have been appropriately accounted for and disclosed in accordance with UK GAAP.
Taxation
We have complied with the taxation requirements of all countries within which we operate and have brought to account all liabilities for taxation due to the relevant tax authorities whether in respect of any corporation or other direct tax or any indirect taxes. We are not aware of any non-compliance that would give rise to additional liabilities by way of penalty or interest and we have made full disclosure regarding any Revenue Authority queries or investigations that we are aware of or that are ongoing.
In managing the tax affairs of the charity, we have taken into account any special provisions such as transfer pricing, debt cap, tax avoidance disclosure and controlled foreign companies’ legislation as applied in different tax jurisdictions.
We confirm that to the best of our knowledge, throughout the year, the charity has acted within its charitable objectives and therefore there are no activities on which the charity should be accounting for direct taxes.
Other matters
Assets and liabilities
We have no plans or intentions that may materially alter the carrying value and where relevant the fair value measurements or classification of assets and liabilities reflected in the financial statements.
In our opinion, on realisation in the ordinary course of the business the current assets in the balance sheet are expected to produce no less than the net book amounts at which they are stated.
The charity has satisfactory title to all assets and there are no liens or encumbrances on the charity’s assets, except for those that are disclosed in the financial statements.
We confirm that we have carried out impairment reviews appropriately, including an assessment of when such reviews are required, where they are not mandatory. We confirm that we have used the appropriate assumptions with those reviews.
Leading the way with care
Kathryn Singh – Chief Executive Lawson Pater – Chairman
Transactions with directors/trustees/officers
No transactions involving trustees, officers and others requiring disclosure in the financial statements have been entered into.
As minuted by the Board of Directors at its meeting on 31 August 2017
........................................................................................
Jim Marr, NED and Chair of the Charitable Funds Committee
For and on behalf of Rotherham Doncaster and South Humber NHS Foundation Trust.
31 August 2017
Leading the way with care
Kathryn Singh – Chief Executive Lawson Pater – Chairman
Related parties and related party transactions appendix
Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH)
The members of the Charitable Funds committee are also members of RDaSH Trust Board. The members of the Charitable Funds Committee are not individual trustees under Charity Law, but act as agents on behalf of the Corporate Trustee (RDaSH).
The Members of the Charitable Funds Committee are:-
James Marr (Non-Executive)
Tim Shaw (Non-Executive)
Rosie Johnson (Director of HR and OD)
Paul Wilkin (Director of Finance – left 31.3.17)
Non-Voting Attendees
Helen Ward (Governor)
Ian Fairbank (Governor)
ROTHERHAM DONCASTER AND SOUTH HUMBER NHS FOUNDATION TRUST
Committee Name
Board of Directors
Agenda Item
K Date 31 August 2017
Title of Paper
Risk report
Action Required
Decision Assurance Information
Prepared by
Jane Charlesworth, Risk and Assurance Officer
Phil Gowland, Board Secretary/Director of Corporate Assurance
Presented by
Phil Gowland, Board Secretary/Director of Corporate Assurance
Delivery against Strategic Goal(s) 3 5
Strategic Risk(s) 3.1 3.2 5.2
CQC Domain W
Financial/Budget
The financial implications are noted within the risks – specifically within the risk that relates to the delivery of the financial plan
Equality & Diversity
None identified
Previously
Presented to
Executive Management Team – 17 & 24 August 2017 Finance, Performance and Informatics Committee – 24 August 2017
Background /
Key Points /
Outcome
The Board of Directors is responsible for the overseeing the effectiveness of the Risk Management Framework to manage the strategic and operational risks that may prevent the achievement of the strategic goals. This report provides an overview of the operational risks including the outline of the reporting and monitoring in place. The three extreme risks included in this paper were presented to and discussed by the Finance, Performance and Informatics Committee; one is longer standing risks and another is a new extreme risk.
The Board of Directors is asked to note Risk Register Update Report
Appendix A
Page 1 of 3
Risk Report
24 August 2017
Page 2 of 3
1. INTRODUCTION The Board of Directors is responsible for the implementation of the Risk Management Framework and for overseeing the effectiveness of processes for the identification, assessment, management and mitigation of risk.
To assist the Board of Directors in its duties the Committees are responsible for providing assurance in relation operational risks under the remit of their Terms of Reference. The Committees are scheduled to:
Review all extreme operational risks on a monthly basis
Review all operational risks on a quarterly basis
2. OPERATIONAL RISKS Extreme Operational Risks There are currently three extreme operational risks as at 24 August 2017 which are summarised below.
These were discussed in the month by the Executive Management Team and the Finance, Performance and Informatics Committee. The latest actions taken to mitigate the risks were discussed, but all were confirmed as remaining as ‘extreme’.
Risk Score Days as extreme
Responsible Committee
FP 2/17 (new risk)
If we fail to deliver the 2017/18 QIPP and develop a 2018/19 QIPP plan then there is a risk to the financial sustainability of the Trust.
I x 4 L x 4 RS= 16
8 FPIC
HI 10/14
If the capacity within the data warehouse and report writing teams is insufficient to deliver changes required to the reporting infrastructure, then there is a risk of not being able to produce information for either management or commissioners, complete the data warehouse build, and support the IM and Unity work streams.
I x 4 L x 4 RS = 16
33 FPIC
HI 2/16 If the implementation of the EPR system is sub-optimal then there may be a negative impact on record keeping, management information and clinical decision making.
I x 5 L x 3 RS = 15
197 FPIC
Risk FIN 8/16 regarding the delivery of the 2017/18 financial plan has been de-escalated by the Executive Management Team during August as this is expected be delivered non-recurrently. This risk will continue to be monitored via the Finance & Performance risk register on a monthly basis and via the Finance Sub Committee on a quarterly basis. Other Operational Risks There are currently 64 Operational (including the extreme rated risks). Each has a designated lead responsible for managing the risk and oversight – in terms of ensuring updates are undertaken - is provided by the relevant Committee and sub-committee.
Page 3 of 3
Moderation by EMT EMT is responsible for the implementation of risk management and is scheduled to:
Review all risks on a quarterly basis to provide a confirm and challenge function and moderate all risk
Moderation all risks score 15 or above onto and off the Extreme Operational Risk Register
Moderate the tolerated risk scored 8 or above where the likelihood is 3 or above.
The first set of meetings for the moderation of all risks took place in May 2017 and changes actioned. The second set of meetings is underway with the first two meetings having taken place on the 17 and 24 August 2017. These meeting covered:
Movement of risks and Percentage of review undertaken to date in 2017/18
Themes of the current risks
Review of the long-standing extreme risks; and also reviewed each risk included in the following registers:
Doncaster Care Group risks
Children’s Care Group risks
Rotherham Care Group risks
Operations risks
Corporate Assurance risks
Nursing & Quality risks
Finance & Performance risks The actions from this meeting are underway and will be completed by the end of September 2017. The next meeting is scheduled for the 29 August 2017 and will discuss the risks from:
North Lincolnshire Care Group
Health Informatics
Medical & Pharmacy