A MEETING OF THE BOARD OF DIRECTORS WILL TAKE PLACE …€¦ · WILL TAKE PLACE ON THURSDAY 6 August 2020 at 10.00am by Video-link . BARNSLEY HOSPITAL NHS FOUNDATION TRUST . Please

A MEETING OF THE BOARD OF DIRECTORS WILL TAKE PLACE ON THURSDAY 6 August 2020 at 10.00am by Video-link

BARNSLEY HOSPITAL NHS FOUNDATION TRUST Please note:- due to the Covid-19 outbreak this meeting will not be held in public.

No Item Sponsor Ref

1 Apologies and Welcome:-

Apologies:- Mr B Kirton, Ms R Moore

Mr T Lake Chairman

Verbal Assurance

2 To receive and review a patient’s story – Occupational Therapy.

Mrs J Murphy Director of

Nursing & Quality

Verbal Information (10:05 am)

3 To receive any Declarations of Interest. To confirm that due to Covid 19 the Board meeting is not held in public and will be held by secure video-link. This will be livestreamed and also a recording of the meeting placed on the Trust website.

Mr T Lake Chairman

Verbal Assurance

4 Confirmation of meeting quoracy. Verbal Assurance

5 To approve the minutes of the meeting of the Board of Directors held in public on 4 June 2020.

20/08/06/05 Approve

6 To approve the action log in relation to progress to date and review any outstanding actions.

20/08/06/06 Approve

ASSURANCE 7 To receive the COVID-19 response update. Dr R Jenkins

Chief Executive Verbal Assurance

8 To receive and approve the Chair’s Log for the Quality and Governance Committee (Q&G) held on 24 June & 29 July 2020 including:-

i Annual Infection Prevention and Control Board Assurance Framework.

ii Policy for Local Safety Standards for Invasive Procedures (LocSSIPs).

Mr P Hudson Chair of Quality &

Governance Committee

20/08/06/08

Assurance

9 To receive and approve the Chair’s Log for the People, Finance & Performance Committee (PFP) held 30 July 2020 including:-

i 25 June 2020 Chair’s log (amended)

Mrs K Firth Chair of People,

Finance & Performance Committee

20/08/09/09

20/08/06/09i

Assurance

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ii Death in Service Policy

20/08/06/09ii

10 To receive and approve the Chair’s Log for the Audit Committee held on 15 July 2020 including:- i Audit Committee Annual Report.

Mr N Mapstone Chair of Audit

Committee

20/08/06/10 20/08/06/10i

Assurance

11 To receive the Chair’s Log for Barnsley Facilities Services (BFS).

Mr F Patton Non-Executive

Director

20/08/06/11 Assurance

12 To receive and review the Chair’s Log on any escalation issues from the Executive Team (ET).

Dr R Jenkins Chief Executive

Verbal Assurance

13 To review the monthly Integrated Performance Report (IPR).

Mr S Ned Director of Workforce Mr A Potts

Deputy Director of Operations


14 To receive an update on:- i Board Assurance Framework (BAF) ii Corporate Risk Register (CRR).

Ms M Saunders Director of Corporate

Governance

20/08/06/14 20/08/06/14ii

Assurance

15 To receive the Health Education England Self-Assessment Return.

Dr S Enright Medical Director


16 To receive the Medical Director’s Quarterly Report.



STRATEGY 17 To receive and approve the Public Work Plan

August 2020 – March 2021. Ms M Saunders

Director of Corporate

Governance

20/08/06/17 Note

GOVERNANCE 18 To receive the Chair’s Log for the Barnsley

Integrated Care Partnership Group.

Mr T Lake Chairman

Verbal Note

OTHER ITEMS 19 To receive and review the monthly report from

the Chairman.

Mr T Lake Chairman

Verbal

Note

20 To receive and review the monthly report from the Chief Executive including:- i For information - update on the South

Yorkshire and Bassetlaw Integrated Care System (ICS)


20/08/06/20 Note

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21 Date of next meeting: Thursday 1 October 2020, 9.00 am - venue tbc subject to Covid-19 guidance.

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MINUTES OF A MEETING OF THE BOARD OF DIRECTORS

HELD ON THURSDAY 4 June 2020 BY VIDEO-CONFERENCE

Due to the current Covid-19 pandemic, the meeting was not held in public In the interest of maintaining transparency and openness during the Covid-19 lockdown

a recording of the meeting was placed on the Trust website for public access.

PRESENT:- Mr T Lake Chairman, Chair Dr R Jenkins Chief Executive Dr S Enright Medical Director Mr R Kirton Chief Delivery Officer & Deputy Chief Executive Mrs J Murphy Director of Nursing & Quality Mr C Thickett Director of Finance Mr S Ned Director of Workforce Mr T Davidson Director of ICT Ms E Parkes Director of Communications Mrs K Firth Non-Executive Director Ms R Moore Non-Executive Director Mrs S Ellis Non-Executive Director Mr F Patton Non-Executive Director Mr N Mapstone Non-Executive Director Mr P Hudson Non-Executive Director Mr K Clifford Associate Non-Executive Director Ms M Saunders Director of Corporate Governance Miss L J Watson Executive PA to CEO/Chairman (minute taker) IN ATTENDANCE:- Dr S Lobaz Consultant Anaesthetist (Item no 20/78) Katie Bacon Specialist Respiratory Physiotherapist (Item no 20/78) Maria Cooper Matron, Surgery (Item no 20/78) Leanne Battley Lead Nurse, Intensive Care Unit (Item 20/78) OBSERVERS:- Mr A Higgins Lead Governor 20/77 APOLOGIES & WELCOME

Mr Lake welcomed Executive and Non-Executive Colleagues, along with Mr Higgins, Lead Governor to the Board of Directors Meeting for June 2020. Due to Covid-19 the meeting was held via video-conferencing (Zoom) to comply with government guidelines on social distancing and lockdown. For openness and transparency, a recording of the public session will be available on the Trust’s website for a 2 week period. Questions were requested in advance of the meeting from the Non-Executives and submitted to the Executive Directors to enable responses being available today due to busy schedules in coping with the extra demands in dealing with the preparations and planning for Covid-19.

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20/78 PATIENT STORY Dr Lobaz and the Intensive Care Unit Team were in attendance, via zoom, to present James’ story. James was admitted to Hospital on 17 March 2020 with a viral like illness after being unable to manage his progressive symptoms at home. He was initially admitted onto a general ward and subsequently transferred to the Intensive Care Unit. Due to family members self-isolating the team arranged telephone calls and video link facetime before being placed on a ventilator. James was given a 50/50 survival rate and over a 2 week period fought between life and death during which time he underwent a tracheostomy in order to be weaned off the ventilator. Following removal, James remained unconscious for a number of days and after a few days of being cared for by the Critical Care staff, he was able to breath for himself and ready to be transferred back onto a general ward. A number of specialist teams were involved as part of the journey from admission to discharge which included physiotherapist and rehabilitation teams to provide support and facilitate psychological recovery. On discharge a “guard of honour” was performed by both the Critical Care Team and the Respiratory Team. On behalf of the Board, Mr Lake formally acknowledged all colleagues involved in the exceptional care which had been provided to James and his family under such difficult circumstances. Mr Lake also informed the team the Trust has been allocated funding specifically for Covid-19 and if any additional help from a psychological perspective is required, to liaise with Mrs Murphy and Ms Parkes, noting the Trust would be supportive of the requests. The story was received and noted by the Board.

20/79 QUORACY OF THE MEETING The Chair confirmed the meeting was quorate.

20/80 TO RECEIVE ANY DECLARATIONS OF INTEREST The standing declarations of interest were noted from Mrs Ellis and Mr Patton as Directors of Barnsley Facilities Services (BFS), Dr R Jenkins as Chief Executive Officer and Mr S Ned as Director of Workforce in their joint roles between Barnsley NHS Foundation Trust and The Rotherham NHS Foundation Trust.

20/81 MINUTES OF THE LAST MEETING The minutes of the meeting held on Thursday 7 May 2020 were reviewed and subject to minor amendments, accepted as an accurate record of events.

20/82 ACTION LOG All outstanding actions from the previous meetings were reviewed with updates noted accordingly.

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20/83

COVID-19 RESPONSE UPDATE Dr Jenkins provided a verbal update on the Trust’s response to Covid-19. Firstly, on behalf of the Board, acknowledgement was made that sadly people will continue to become ill and unfortunately, the Trust will continue to record Covid related deaths, members were asked to keep this in mind when reviewing statistics, as these numbers relate to loved ones. Secondly, to acknowledge the amazing contributions made by all staff in dealing with the latest phase of Covid-19, by taking onboard new ways of working whilst still providing the highest quality of care for patients. Over the last four weeks the Trust has reported no change in the number of admissions related despite the expectation that activity would slowly start to decrease over this period of time. This is being carefully monitored on a daily basis particularly in light of the Government’s relaxation on social distancing and lockdown measures. Currently there are 28 covid positive in-patients, three of whom are on ITU and to date, 122 patients have sadly died in hospital. Non-covid activity is slowly increasing with a slight increase reported in Accident & Emergency activity, between 200 - 250 patients per day as opposed to 300+ pre-covid. Planned surgical activity is also increasing with the previously reported issue of access to sterile surgical gowns as a constraint now easing. Work is currently ongoing to increase the diagnostic and planned care activity within the coming weeks. The Executive Team have recently agreed to move to a formal recovery meeting to capture the response of the next planning phase with discussions on how to bring activity back on stream. This will be a weekly meeting supplementing the Silver Tactical Coordinating Group (TCG) and Gold Strategic Coordinating Group (SCG) which are held three mornings per week. There are similar structures in place within the Integrated Care System (ICS) and Barnsley Place. The ICS has moved to a weekly Health and Care Management Team (H&CMT) where discussions are held around the regional response. In terms of recovery a recent timeout session has been held to systematically work through capturing the learning with plans to move onto the next phase of recovery. A Board Strategic Focus Session is scheduled for 2 July 2020 which will predominately focus on the Covid-19 recovery. Nationally there has been some issues with consistent availability of the preferred FFP3 face masks; whilst there are no shortages of masks for the Trust however the varieties are changing which unfortunately causes issues with FIT testing. In response to a question circulated prior to board by Mrs Firth asking how the Trust is capturing the patient experience of these changes, Dr Jenkins informed there are a range of plans in place to contact service users and their families of the Hospital. This will be conducted via telephone/video conferencing to capture their experiences during this pandemic, to gain an understanding from a patient and relative perspective.

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Mr Ned stated from Thursday 28 May 2020 the Trust commenced antibody testing for staff following an ask that organisations within the NHS provided this service. Within South Yorkshire and Bassetlaw (SY&B) the requirement was to undertake 1,000 tests across the area over the weekend. Colleagues in pathology/phlebotomy services went above and beyond in terms of implementing the service which was up and running within a matter days. Over the weekend 5,043 tests were performed across SY&B, of which 689 results tested positive for antibodies, reporting a 13.7% return. Despite the results of the antibody tests staff are reminded to remain vigilant around hand hygiene as well as maintaining social distancing. The NHS Test and Trace facility is now up and running which is causing a few challenges for the Trust. The results are being returned directly to staff as this is part of the National NHS Test and Trace facility. The text contains a link to the national test and trace service where the individual will be contacted by a contact tracer, one challenge for the Trust is to ensure staff remain socially distanced at work. Mrs Firth raised a query as activity/bed occupancy levels are increasing, how is this being managed and supported as staff will have to deal with an increase in attendees to the hospital. Dr Jenkins informed the Trust need to work out the correct solution in line with activity increasing and as yet, there is no definitive answer. Mrs Murphy outlined plans are in place to work with the Patient Experience Team as well as the Nursing Team to make this a fundamental part of the nursing role. The intention is to implement a new process to ensure the Trust is able to offer the correct qualitative support levels to both patients and relatives. From an operational perspective, Mr Kirton added the Trust has managed the escalation extremely well. As per Sir Simon Stevens letter, shared at the Board meeting on 7 May 2020, the Trust is working towards the narrative of recommendations and actions ensuring these are considered. A programmed summary is being implemented covering all key areas of the recommendations in particular social distancing and risk assessments which are currently being undertaken in all areas throughout the Trust. Work is on-going through the Silver Tactical Group and the Recovery Group to communicate key messages to staff, patients and visitors to the Trust. The verbal report was received and noted by Board.

20/84 CHAIRS LOG - QUALITY & GOVERNANCE COMMITTEE (Q&G) The Chair’s Log from the committee meeting held on 27 May 2020 was received and noted by the Board. Ms Moore, Chair of the Committee, presented the report highlighting the following key points:- • The Quality Exception Report was received providing assurance that the

Trust continues to deliver a high level of patient quality during Covid-19. • The Board Assurance Framework (BAF) and Corporate Risk Register

(CRR) for Quarter 4 were reviewed. • The Covid dashboard was reviewed by the committee with the

recommendation to include the latest hospital deaths with cumulative tools. • One case of hospital acquired MRSA Bacteraemia Infection was recorded

during April 2020. The case had been subject to a root cause analysis (RCA) and assurance was provided there was no evidence of a lapse in

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care. • As part of the national reporting requirements, the committee received the

Quarterly Learning from Experience Report and Annual Complaints Report. • The nursing, midwifery and medical staffing reports were received providing

assurance of the Trust’s response in dealing Covid-19.

20/85 CHAIRS LOG - PEOPLE, FINANCE & PERFORMANCE COMMITTEE (PF&P) The Chair’s Log from the committee meeting held on 28 May 2020 was received and noted by the Board. Mrs Firth, Chair of the Committee, presented the report highlighting the following key points:- • Sickness reporting within the workforce insight report this month has been

separated. Covid-19 sickness is reported at 1% and the remaining sickness at 4.5%, overall sickness has increased from 4.7% to 5.4% across both long term and short-term sickness.

• The committee received assurance that there will be a renewed focus on the sickness management and support with a revised sickness absence management policy which will be presented at the People and Engagement Group in June 2020.

• Mandatory training reported at 85.8%, reporting a decrease of 3% from last month. The traditional methods of delivery have been limited due to social distancing and staff capacity.

• Performance against the four-hour target showed a strong performance on patient access showing an increase in April to 95.3%. It was reported however the diagnostic performance deteriorated in April due to Covid-19 with the 6 week target not being achieved, reported at 64%. The committee received assurance plans are in place to improve this with the GI Endoscopy and non-urgent imaging activity to resume within the appropriate safety restrictions.

• The committee received assurance that a robust plan is in place for Medway System C, with a go live date of 11 July 2020. Training has commenced and a dress rehearsal is planned for 13 June 2020.

• Assurance was received of national measures being in place to support the Trust financially during April – June 2020, with the ability to claim via the NHS England (NHSE) top up process. The Trust has a consolidated break even position for the month after accruing an additional £0.077m top up from NHSE. Assurance was also provided that a strategy is in place to manage the cash position, end of month reported at £32.6m. Month One capital expenditure is £0.423m, of which £0.4908m is related to Covid-19 schemes.

• Due to Covid-19 the ED/Children’s Assessment Unit had been paused allowing for a reduction in planned costs enabling further investment for works in the roof structure, following the recommendations following he Grenfell Fire Report.

In response to questions/concerns circulated prior to Board:- 1 The report suggests various cost variations up and down. Can we have a

summary of the overall projected cost position – i.e. is it more or less than the externally provided funding? If we don’t know the position now, when can the Board expect to see it? (Mr P Hudson)

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Mrs Firth informed the costs of the ED/Children’s Assessment Unit will be monitored through the People, Finance and Performance Committee. There are still a few outstanding areas for contractors to provide further information in relation to dates and revised budgets.

20/86 CHAIRS LOG – AUDIT COMMITTEE The Chair’s Log from the committee meeting held on 13 May 2020 was received and noted by the Board. Mr Mapstone, Chair of the Committee, presented the report highlighting the following key points:- • The Annual Report was approved, subject to minor amendments. • The Annual Governance Statement (AGS) was approved, subject to further

information on the use of clinical audit as a source of assurance. • The Draft Accounts and Financial Statements were approved, subject to the

inclusion of an explanation of the differences between the Trust accounts and Group accounts.

• The Draft Barnsley Facilities Services (BFS) Accounts were approved and are now being considered by the BFS Board.

• Notification has been received from NHS Improvement (NHSi) that the Quality Accounts deadline has been extended to 15 December 2020. This will be discussed through the Quality and Governance Committee in June 2020 and then be presented to the Audit Committee in July 2020. A copy of which will also be circulated to the Council of Governors asking for an overview and comments, these will be provided via Mr Higgins, Lead Governor.

A number of questions were submitted which Mr Mapstone provided clarification to the Board prior to the meeting today, a brief overview was provided:- 1 The committee is to receive for approval a revised risk management

strategy at the July 2020 meeting. The auditor recognises that these are relatively fixable matters and hence was able to give a significant head of internal audit assurance opinion. (Raised by Mrs Ellis)

2 Limited assurance opinion relating to the Data Protection Tool Kit, which is

an indicative opinion only. Mr Davidson has requested for the auditors to undertake further testing. (Raised by Ms Moore)

3 The limited assurance opinion on Accounts Payable relates to the process

for the authorisation of changes to the Trust's supplier master file. A standard operating procedure has now been introduced which addresses this issue (Raised by Ms Moore)

4 The audit committee approved the draft accounts for external audit. The

audited accounts will be considered by the audit committee on 10 June and it is for the Board and BFS Board to sign off the final accounts. (Raised by Mrs Firth)

20/87 CHAIRS LOG - BARNSLEY FACILITIES SERVICES (BFS) The Chair’s Log from the committee meeting held in May 2020 was received and noted by the Board.

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Mr Patton, Chair of the Committee presented the report highlighting the following key points:- • BFS achieved all key performance indicators apart from some within

estates. • Support has been provided within the Trust through the reverse SLAs,

including meetings held with IT, Communications, Marketing & Design out Outpatient Pharmacy.

• Staff sickness at the end of April 2020 is reported at 2.85%, noting a reduction of 0.64% from March.

• Ongoing health and wellbeing support continues to be provided to staff due to the impact of Covid-19.

Mr Patton acknowledged an amendment was required to the chairs log relating to the annual report and accounts, this will be amended to reflect the change.

FP

20/88 CHAIRS LOG - EXECUTIVE TEAM (ET) Dr Jenkins provided a verbal update to the Board from the Executive Team. • A proposal paper has recently been approved to change the current system

for the complaints assessment and timeframe allocation. This will improve complainant satisfaction and experience, allow for a more focussed analysis and reporting of complaint responses and ensure appropriate timeframes are allocated based on the complexity of the complaints.

• Staff appraisals have been reinstated and will be conducted between June – August 2020. It is important for the Trust to maintain the high standards of managing the process during the Covid-19 pandemic.

• Medway System C is on track with a go live date of 11 July 2020, with the main focus being training requirements for staff. Mr Davidson explained the main challenge at the moment is providing training whilst adhering to the government social distancing guidelines. The team have done a fantastic job using technology available to bring the training to the individual as much as possible and being flexible in delivering the training, meeting the needs of clinical staff. To increase the capacity of training a number of actions have been put in place which include chasing up individual staff members as well as escalation to line management. Excellent feedback has been received from staff who have already taken part in the training of the new system

Mr Lake informed the proposed objectives for the Chairman have been set by the Nominations Committee and are to be presented at the Council of Governors meeting on 17 June 2020. Subject to approval these will be shared amongst the Executive and Non-Executive Directors as part of the appraisal and objective setting process. The Board noted and received the verbal update.

20/89 INTEGRATED PERFORMANCE REPORT (IPR) - Month 1 Mr Kirton informed Board members the Integrated Performance Report for Month One had been included for information purposes. For assurance, the report has been presented at the respective committees during the month of May 2020. The Trust’s performance remains in a strong position achieving 95.3% against

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the Emergency Department 4-hour standard for April 2020, the May target narrowly missed achieving 94.25% but was still a really strong performance considering the challenges faced. Performance was strong for the referral to treat (RTT) achieving 93.2% of pathways completed within 18 weeks as compared with the standard of 92%. A reduction in activity in March was recorded as a result of Covid-19 and as a consequence RTT performance was reported as 88.7%, noting March was the first month compliance was not met. The loss of activity resulted in six breaches of the 52-week standard for April. In terms of cancer, two week waits, 31/62 day referral to treat were all attained for March. In response to questions/concerns circulated prior to Board:- 1 In terms of pressure ulcers there seems to have been an increase, perhaps

linked to numbers in Intensive Care Unit (ICU) because of Covid-19. In total it appears 13 were due to lapses in care and one resulted in severe harm, so can we have more information and assurance on these incidents? (Mr Patton)

Mrs Murphy confirmed there has been an increase in the number of pressure ulcers within the Intensive Care Unit as a result of using proning techniques when treating patients with Covid. A learning process has been undertaken with a number of interventions made to relieve the pressure areas of patients and the team are currently looking to undertake research to gain a further understanding.

2 Can further detail be provided on the incident resulting in severe harm? (Mr

Patton)

Mrs Murphy provided an overview of a number of incidences resulting in harm, one of which is a maternity case currently being investigated as a Serious Incident (SI) by the Trust and also being investigated by South Yorkshire Police. There were also a few severe harm cases which are currently being investigated through the correct process. There was an avoidable fall reported, currently being reviewed under an SI, a risk assessment will also be completed as the patient was confused as well as Covid positive.

3 Could we flag any targets that have changed year on year and as discussed

at People, Finance &Performance Committee, are we signing off the Trust set targets here today? (Mr Patton)

Mr Kirton will circulate further information to members of the Board outside the meeting.

4 Under the narrative about complaints reference refers to concerns raised (rather than complaints) – are the concerns and enquiries general or Covid related? (Mrs Firth)

Mrs Murphy confirmed the narrative relates to general concerns, to note, very few covid related concerns were received during March 2020.

The report was noted and received by Board.

BK

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20/90 ANNUAL INFECTION PREVENTION AND CONTROL REPORT 2019/2020 Mrs Murphy presented the Annual Infection Prevention and Control Report for 2019/20 providing an overview of the work undertaken by the Infection Prevention and Control Group (ICPG). The purpose of the group is to monitor progress against the Trust’s strategy, arrangements and governance that are in place and to meet and deliver the requirements of the Health and Social Care Act 2008. In relation to questions/concerns raised prior to Board:- 1 What are we doing about enteral feeding and high impact interventions? (Mr

Patton)

Mrs Murphy informed this will be included within the Nutritional Nurse’s role and the improvement work when the candidate is in post. Due to a lack of interest in the role, the post is to be re-advertised with a view of having a development role.

2 What level of antibiotic prescriptions did we achieve, how far off the target

were we? (Mr Patton)

This is currently being looked into in more detail and information will be circulated once completed.

3 Pack page 71 point 9.4 why has this been zero for a number of years, were

we not monitoring this previously? How do we stand from a benchmark perspective? (Mr Patton)

Mrs Murphy confirmed this is a new benchmark and therefore was not previously measured.

4 What is happening with knees seems very high, what actions are we taking?

(Mr Patton)

Dr Enright confirmed as a result of three readmissions in Quarter 3 between October – December 2019 this reported an infection rate of 1.5 against the national average of 1.2. All three cases have had full RCA and no themes have been identified. This figure will be monitored closely over the coming months.

5 Is this report recommended by the Quality and Governance Committee

(Q&G) for approval? (Mrs Ellis)

Yes, Q&G recommend for approval. 6 Section 16 FFP3 testing referred to later in risk paper- are we still borrowing

equipment for this? (Mrs Ellis)

Mr Murphy confirmed the Trust is up to date with FFP3 testing. 7 Has the staffing of team been stable through the year? (Mrs Ellis)

Mrs Murphy confirmed staffing has been stable.

JM

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8 The Trust failed to achieve its reduction objective for the second consecutive year- for which target? (Mrs Firth)

Mrs Murphy informed this refers to C-diff targets. This will be amended as appropriate.

9 Could we have further information with regards to Saving Lives High Impact Interventions? (Mrs Moore)

This will be included within the IPC update to be presented at the Quality and Governance Committee on 24 June 2020.


JM JM

20/91 QUARTERLY REVIEW OF THE CORPORATE RISK REGISTER (CRR) Ms Saunders provided an overview of the current risks detailed within the Corporate Risk Register (CRR) following a full review at the respective committees in May 2020 noting the risks continue to be very well controlled. There was slight duplication within the report, risk 2323 is the correct risk, risk 2401 has been closed and does not relate to safe guarding. In response to questions/concerns prior to Board:- 1 Risk 2205 what is latest ICS position? (Mr Patton)

Mr Kirton informed the Trust is delivering effectively against the breast symptomatic targets. The breast screening (non-symptomatic routine surveillance) is currently under review with the ICS and are looking to implement a regional model which is more sustainable.

Following discussion, it was agreed to re-present the CRR to Board in August 2020 including updating the narrative of the extreme risks. The report was noted and received by Board.

MS

20/92 QUARTERLY REVIEW OF THE BOARD ASSURANCE FRAMEWORK (BAF) Ms Saunders provided an overview of the quarterly Board Assurance Framework (BAF) following a full review at the respective committees in May 2020. There has been a slight extension to the reporting of BAF due to the demands of Covid-19 with the intention to re-adjust and review timescales throughout the year to realign with the quality reporting. In response to a query raised by Mr Lake prior to Board regarding elective activity not being reflected in the comment, Mr Kirton informed the document was populated reflecting the quarter end position for January – March 2020 at which point the elective programme was reported accordingly. The concerns and risks will be included within the BAF for the next reporting period. For clarity, this report will be updated and presented at the August Board 2020. Dr Jenkins confirmed as part of the work plan for this year, the BAF is currently under review to scope out the requirements before working up a clear proposal, this is being undertaken by Dr Jenkins and Ms Saunders.

MS

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20/93 CHAIRS LOG - BARNSLEY INTEGRATED CARE PARTNERSHIP GROUP - (ICPG) Mr Lake provided a verbal update in relation to the Barnsley Integrated Care Partnership Group. The meeting was reinstated on Thursday 28 May 2020 which was a scoping meeting to identify what has been happening from all partners following the outbreak of Covid. Partners were asked to identify a framework which will be discussed with a small representative group from the Integrated Care Delivery Group (ICDPG) around reorganising priorities on a Barnsley Place basis. A small workshop with a number of partners to talk through the key priorities has been arranged on Friday 5 June 2020. The ICPG meetings are to be reinstated on a monthly basis and are to be held by video conferencing facilities. The update was noted and received by Board.

20/94 REPORT OF THE CHAIRMAN Mr Lake informed of no matters arising which required being brought to the attention of the Board. The Trust is continuing to work remotely in line with government guidelines on social distancing and lockdown and are able to effectively carry out the governance requirements in terms of Board, Governor and various meetings required through the use of technology. The Governors have asked to formally note their support and gratitude to the whole organisation in dealing with the Covid-19 pandemic. This was formally noted by Board. The verbal report was noted and received by Board.

20/95 REPORT OF THE CHIEF EXECUTIVE Dr Jenkins provided an overview of recent meetings and events that have recently been undertaken on behalf of the Trust, the main focus for the Trust this month being Covid-19 recovery and stabilisation. The Trust is looking into a number of ways of reinstating the Brilliant awards as well as hold a virtual Heart Awards event, recognising the importance of rewarding and recognising the contribution of staff during this difficult period. Ms Parkes added there are number of options available to run these events virtually which will be presented to the Executive Team. The South Yorkshire and Bassetlaw Integrated Care System (SY&B ICS) update was included for information. The report was noted and received by Board.

20/96 DATE AND TIME OF NEXT MEETING Prior to the meeting, a statement was made on the website inviting questions from members of the public to be submitted electronically, on checking this morning, no questions had been submitted. Mr Higgins, as Lead Governor, had been invited to observe the meeting today and was asked if he had any questions relating to the agenda items to be raised. On behalf of the Council of Governors, Trust Members and Constituents Mr

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Higgins, as Lead Governor raised the following comments/questions:- The heart awards celebrations would have taken place this week and hearing the Trust is working on arranging the heart awards to be held virtually is a fantastic idea which is fully supported by the Governors. The patient story presented at Board today showed the hard work of staff in caring for and rehabilitating patients, a suggestion was made for this story to be shared with Governors at a Council of Governors meeting in due course. At the beginning of Covid-19, outpatient letters were sent to patients asking not to attend hospital, can assurance be provided that the Trust is re-engaging with the patients? Mr Kirton informed that patients, as part of the access policy, are sent three did not attend (DNA) letters before being discharged back to the care of the GP. Despite the fact not everyone can attend Hospital, the Trust is still seeing around 50 – 60% of patients by either video calling/consultation and are working in a clear way with the GPs around the urgency of who needs to be seen. Waiting lists are regularly reviewed with specialties keeping in contact with patients in a way most suitable to the needs of the individuals Is there a risk going forward, once the Trust comes through the pandemic of a financial risk to the Trust? Mr Thickett confirmed that for the first four months, the Trust operated within a system and environment where all expenditure incurred in delivering services had a rebate mechanism in place and the Trust is funded for what is spent. It isn’t clear at the moment what will happen from August 2020 onwards however, the Trust is led to believe there will be some form of continuation of the block arrangements and funding mechanisms, but as yet this has not been fully clarified. Mr Ned provided an update for Board members of the recent risks associated with Black and Minority Ethnic (BAME) Colleagues which has caused a degree of anxiety regarding the disproportionate impact of Covid-19. Communication was sent in May 2020 asking for BAME colleagues to approach their manager to have a risk assessment undertaken. Following a low uptake of the risk assessments, individual letters have now been written to staff, who have identified themselves from a BAME background, asking the individual to directly approach their manager for a revised risk assessment to be completed. This has been produced with support from the Occupational Health Physician. Dr Enright added that over 50% of the medical body within the Hospital are from a BAME background. Following engagement with the British Medical Association (BMA) they are satisfied with the approach of the Trust’s support to the BAME community. The next meeting of the Trust Board is scheduled for Thursday 6 August 2020, 10.00 am which will be arranged via video conferencing, zoom.

TL

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REPORT TO THE BOARD OF DIRECTORS REF: BoD: 20/08/06/06

SUBJECT: BOARD ACTION LOG – PUBLIC

DATE: 6 AUGUST 2020 Private & Confidential

PURPOSE:

Tick as applicable Tick as

applicable For decision/approval Assurance

For review Governance For information Strategy

PREPARED BY: Margaret Saunders, Director of Corporate Governance SPONSORED BY: Trevor Lake, Chairman PRESENTED BY: Trevor Lake, Chairman STRATEGIC CONTEXT

To ensure that actions emerging from Board meetings are progressed and reported to Board in a timely manner.

EXECUTIVE SUMMARY

Current action log arising from Public Board meetings as attached.

RECOMMENDATION The Board of Directors is asked to: a) note and approve reported progress and any verbal updates and b) review any outstanding actions

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Key to RAG status Red Action overdue or no update provided Amber Update Provided but action not complete Green Update provided and action complete

Subject: Board Action Log Ref: BoD: 20/08/06/06 ACTIONS ON AGENDA: Table 1 Minute

ref Meeting

date Item Action Owner Due date Done Date Progress report RAG status

20/87 04.06.20 Chairs log – Barnsley

Facilities Services (BFS)

Amendment to be made to the annual report and accounts detailed within the chairs log.

FP 04.06.20 Mr Patton to make the relevant changes. Amber

20/89 04.06.20 Integrated

Performance Report (IPR) Month 1

As discussed at Performance, Finance and People committee, information to be circulated relating changes in targets year on year

BK 04.06.20 Information to be circulated in August 2020. Amber

20/90 04.06.20 Annual Infection

Prevention & Control Report 2019/20

Information to be circulated on the level of Antibiotic prescriptions achieved once work is complete.

JM 04.06.20 30.07.20

Audit complete and discussed at IP&C group, will be discussed at

the CBU Governance Meetings by the Matrons.

Green

Amended to be made to the data within the report to refer to C-diff targets which the Trust failed to achieve the reduction objective for the second consecutive year

JM 04.06.20 30.07.20 Due to Covid no target agreed for 2020/21 therefore Trust assume

target of 19 cases. Green

Saving Lives High Impact Interventions – to be included within the IPC update which is to be presented to the Quality & Governance Committee on 24 June 2020.

JM 04.06.20 To be presented at Quality &

Governance Committee on 26 August 2020.

Amber

20/91 04.06.20 Quarterly Review of the Corporate Risk

Register (CRR)

Report to be updated, including the narrative of the extreme risks, and represented at the Board meeting on 6 August 2020

MS 04.06.20 06.08.20

August 2020 Public Board agenda

item

Amber

20/92 04.06.20 Quarterly Review of

the Board Assurance Framework (BAF)

Report to be updated and represented at the Board meeting on 6 August 2020.

MS 04.06.20 06.08.20

August 2020 Public Board agenda item

Amber

Pack Page 17


20/96 04.06.20 AOB

The patient story “James” to be presented at a forthcoming Council of Governors meeting in due course.

TL 04.06.20 Date to be arranged. Amber

20/71 07.05.20 Integrated Performance Report

Staff appraisals year to date and year end forecast figures to be reviewed.

BK 04.06.20 Review to be undertaken August 2020. Amber

ACTIONS COMPLETED & CLOSED SINCE LAST MEETING: Table 2 – N/A Minute

ref Meeting


20/65 07.05.20 Covid-19 Response update

Clinical trials overview briefing to be circulated to Board members. SE 04.06.20 29.05.20 Complete – information circulated Green

20/72

07.05.20

Chairs Log – Barnsley Integrated Care

Partnership

Meeting to be re-instated for Thursday 28 May 2020 TL 04.06.20 04.06.20 Complete – meeting was held on

Thursday 28.05.20 Green

20/75 07.05.20 Monthly report from the Chief Executive

Detailed information to be circulated to Board members detailing the key points on the value engineering aspects of the current paediatric/CAU build project.

RJ 04.06.20 04.06.20 Complete – Discussed in PF&P

and will be monitored through the committee.

Green

20/52 02.04.20

Chairs Log – People, Finance and Performance Committee –

Organisational Strategy (OD)

Ms Moore had raised a number of concerns relating to the OD Strategy prior to approval and would liaise with Mr Ned via email or telephone to discuss.

SN/RM 07.05.20 30.04.20 Ms Moore has provided comments on the OD strategy to Mr Ned. Green

20/36 05.03.20 Bi-annual approval of the use of the Trust’s

Seal Register to be signed by Mr Lake. TL May 2020 23.07.20

To be completed once Government self- isolation restrictions relaxed. 23.07.20 – Complete register signed by Mr Lake.

Green

ROLLING TRACKER OF OUTSTANDING ACTIONS: Table 3 red = overdue Minute

ref Meeting


Pack Page 18


20/71 07.05.20 Integrated Performance Report

Information to be circulated regarding the 550 episodes of sickness relating to stress, anxiety & depression. The information also to be presented at PFP in May 2020. Mr Ned confirmed the reported sickness figures for next month will be separated into the three categories

SN

SN

04.06.20 04.06.20

Further information in relation to the 550 episodes of sickness

absence related to stress, anxiety and depression circulated to Board

members on 29th May, 2020.

Sickness figures separated in the Workforce insights report and

Covid dashboard – to be incorporated into IPR from June

2020

Amber

20/68 07.05.20 Chairs Log – Barnsley

Facilities Services (BFS)

BFS Strategic Business Plan 2020 – 2025 to be presented at a Board Strategic Focus Meeting. Dates to be circulated once finalised.

TL 04.06.20

Item has been added to the forward plan for a future Board

Strategic Focus Meeting. Dates to be circulated once finalised.

Amber

20/50 02.04.20 Covid-19 Emergency Preparedness Update

Fortnightly updates to be provided Governors due to meetings temporarily suspended

TL 07.05.20 09.04.20

Complete and ongoing 04.06.20 – Fortnightly updates are provided to Governors, the date to suspend the updates to be agreed by Mr Lake and Mr Higgins. The

Council of Governors and sub-group will be reinstated, albeit in a

different via ie, via video conferencing (zoom).

Amber

20/52 (cont)

The Organisational Development Strategy (OD) to be re-presented to P,F&P following the necessary amendments at an appropriate time and if necessary, re-present to Trust Board at a later date.

SN 07.05.20 30.04.20

The revised OD strategy will be presented to the People, Finance and Performance meeting following the meeting detailed above. 04.06.20 – Discussed and approved at the People, Finance & Performance Committee.

Amber

Pack Page 19


20/22 06.02.20 Questions from the public

Mr Higgins also sought views of the Board regarding Trust governance in relation to the work of the ICS. Mr Lake will respond to Mr Higgins, as Lead Governor, either via letter or at the next CoG meeting scheduled for 18 March 2020.

TL 05.03.20

28.02.20 - An update meeting with the lead governor and agreed to raise concerns with the ICS. 05.03.20 – Mr Lake has met with Mr Higgins, Lead Governor and will raise these issues at the ICS meeting on 6 April 2020. 02.04.20 – Mr Lake will note this item for discussion following Covid-19, when normal working has been reinstated. 04.06.20 – Mr Lake to raise governance with the ICS. This issue has been raised at the ICS Chairs Meeting on Monday 1 June 2020. The review governance was temporarily suspended due to Covid-19. Mr Lake will provide a further update following the next meeting scheduled for June 2020.

Amber

Pack Page 20

1

REPORT TO THE BOARD OF DIRECTORS REF:

BoD: 20/08/06/08 SUBJECT: QUALITY AND GOVERNANCE ASSURANCE REPORT DATE: July 2020

PURPOSE: Tick as

applicable Tick as applicable

For decision/approval Assurance For review Governance For information Strategy

PREPARED BY: Rosalyn Moore, Non Executive Director/Committee Chair SPONSORED BY: Rosalyn Moore, Non Executive Director/Committee Chair PRESENTED BY: Rosalyn Moore, Non Executive Director/Committee Chair STRATEGIC CONTEXT

The Quality & Governance Committee (Q&G) is one of the key committees of the Board responsible for Governance. Its purpose is to provide detailed scrutiny of quality and safety across the Trust in order to provide assurance and raise concerns (if appropriate) to the Board of Directors and to make recommendations, as appropriate, on quality and safety matters to the Board of Directors.

EXECUTIVE SUMMARY

This report provides information to assist the Board on obtaining assurance about the quality of care and rigour of governance. From the Q&G Committee Meeting on the 24th June 2020, the following papers were received and reviewed:

• COVID 19 Quality Exception Report – Recovery Plan, Risk Register, FTSU Guardian Update

• Quality Account 2019/20 – Quality Indicators 2020/21 • Q&G Annual Report & Terms of Reference • COVID 19 – Information Dashboard • May 2020 IPR • Integrated Care System (ICS) Cancer Update • Patient Safety and Harm Annual Report • PS&H Litigation Q3 & Q4 Reports • Policy for Approval – Local Safety Standards for Invasive Procedures (LocSSIPs) • Clinical Effectiveness Annual Report • Clinical Audit Annual Report • Mortality Report including Crude Mortality SHMI and HSMR figures, Learning from Deaths

Report • Patient Experience, Engagement & Insight Group Annual Report • Infection Prevention & Control Board Assurance Framework • Nursing, Midwifery and Medical Staffing Reports

There was further discussion concerning the submission date of submission for this year’s Quality Account. The Committee also considered changes to the forward plan and proposals for handling the annual review of the Q&G Committee and Sub Committees.

Pack Page 21

2

For the purpose of assurance, the items noted in the log below highlights items for the attention of the Board.

RECOMMENDATION(S) The Board is asked to receive and review the attached Log.

Pack Page 22

3

Subject: QUALITY AND GOVERNANCE ASSURANCE REPORT Ref: BoD: 20/08/06/08 CHAIR’S LOG: Chair’s Key Issues and Assurance Model Committee / Group: Quality and Governance Committee (Q&G) Date: 25th June 2020 Chair: Rosalyn Moore

Ref Agenda Item Issue and Lead Officer Receiving Body, i.e. Board or

Committee

Recommendation / Assurance/ mandate to

receiving body

1 COVID-19 Risk Register

The Committee reviewed the COVID-19 Risk Register providing assurance that the risks arising from the current situation are identified and mitigated including those relating to recovery. The Committee asked that risks relating to a second wave of COVID and winter pressures were included.

Board of Directors For assurance

2 IPR – Never Event

The Committee received an update on a previously reported Never Event (a wrong site procedure in Ophthalmology). Although the procedure was stopped, assurance was provided that there was no harm to the patient and that support had been provided. The case was being monitored through the Patient Safety Panel with oversight provided by the Deputy Medical Director (JB) who had audited and observed practice. The audit showed 100% compliance with the WHO Surgical Checklist.


3

Clinical Effectiveness Group (CEG) Chairs Log: Delay to E-Prescribing.

CEG escalated a report from the Medicines Management Committee concerning a delay to Phase 1 testing of the E-Prescribing System in order to investigate the GPC, NHS Digital and NHSX concerns about the legality of electronic signatures in the “advanced electronic prescription” function. Discussions are ongoing between IT, Pharmacy and the regulatory bodies.

Board of Directors For information

4 Integrated Care System (ICS) Cancer Services

The Committee received assurance that as a result of a consistent approach to clinical triage-led decision making, identification of priority patients and prioritisation of shared lists across the SYB Cancer Alliance, robust systems are in place to maintain the provision of cancer services for high risk patients in Barnsley.


Pack Page 23

4


Committee


receiving body

5 Patient Safety & Harm (PSH) Chairs Log: Safeguarding

The Committee received an update from the Director of Nursing on the 360 Internal Mental Health Act Audit that had resulted in a limited assurance opinion. A Task and Finish Group is overseeing the action plan and progress will be reported to the Audit Committee. The Director of Nursing reported that in order to progress the MH Strategy and improve Safeguarding, a Business Case had been supported to increase the Trusts safeguarding capacity.

Board of Directors

For information and assurance.

6 Patient Safety & Harm (PSH) Chairs Log: Paterson Enquiry

The Committee received assurance that practice in the Trust is in line with the seven applicable recommendations from the Paterson Enquiry to prevent medically unjustified surgical interventions.

Board of Directors For Assurance

7 COVID 19 Infection Prevention and Control Board Assurance Framework ( IPC BAF)

The Committee received the Trusts self-assessment against the NHSI/E IPC BAF checking compliance with PHE and other COVID-related infection prevention and control guidance. The framework had identified some gaps in assurance, all of which have been previously recognised and have mitigating action in place. This included clinical compliance with IPC training; environmental challenges to Isolation and the 2m social distancing rule; problems with proactive decontamination; fit testing due to frequent changing of the suppliers of FFP3 Masks. The framework will be updated and monitored by the Infection Prevention and Control Group and reported via the Chairs log to the Quality and Governance Committee. The Committee asked that the Corporate and Covid Risks are aligned with IPCBAF by the Director of Corporate Governance.

Board of Directors

For assurance

Pack Page 24

5


Committee


receiving body

8 Q&G Annual Report.

The following annual reports presented at the meeting were approved by the Committee noting that the IPC Annual Report has already been approved by the Board: -

• Patient Safety & Harm Annual Report • Clinical Effectiveness Annual Report • Patient Experience, Engagement & Insight Group Annual

Report • Health and Safety Group Annual Report

A draft version of the Quality & Governance Annual Report was received and will be finalised in the coming weeks in readiness for presentation at the next Board.


9 Clinical Audit Annual Report

The Committee received the annual report on Clinical Audit providing assurance that there was appropriate facilitation, provision and monitoring of the clinical audit programmes at the Trust. The Committee commended the efforts of the team in-year, the quality of the report and their increasing role in Quality Improvement.


10 Report on Open Pathways

The Committee received an update on the 26,500 Open Pathways that had been revealed during the transition from Lorenzo to Medway. As of June 2020, 12,132 of the above Open Pathways had been validated with just over 14,000 further records to be validated. One serious patient harm had been identified so far concerning a delay in the diagnosis of bladder cancer which resulted in the patient being denied the option of curative treatment. The Committee received assurance that the patient harmed was being adequately supported by the Trust and that the exercise was on track to be completed by the end of July 2020 and that action was being taken to address the underlying causes of poor data quality.


Pack Page 25

1


SUBJECT: QUALITY AND GOVERNANCE ASSURANCE REPORT DATE: 6 August 2020

PURPOSE: Tick as

applicable Tick as applicable

For decision/approval Assurance For review Governance For information Strategy

PREPARED BY: Philip Hudson, Non Executive Director/Committee Chair SPONSORED BY: Rosalyn Moore, Non Executive Director/Committee Chair PRESENTED BY: Rosalyn Moore, Non Executive Director/Committee Chair STRATEGIC CONTEXT

The Quality & Governance Committee (Q&G) is one of the key committees of the Board responsible for Governance. Its purpose is to provide detailed scrutiny of quality and safety across the Trust in order to provide assurance and raise concerns (if appropriate) to the Board of Directors and to make recommendations, as appropriate, on quality and safety matters to the Board of Directors.

EXECUTIVE SUMMARY This report provides information to assist the Board on obtaining assurance about the quality of care and rigour of governance. The Q&G Committee Meeting on the 29 July 2020 received reports from the Patient Safety and Harm Group, the Clinical Effectiveness Group, the Patient Experience, Engagement and Insight Group and the Infection Prevention and Control Group and also reviewed the following papers and updates:

• COVID 19 update and risk register • Board Assurance Framework (BAF) • Corporate Risk Register (CRR) • Q&G Terms of Reference • June 2020 IPR • Q1 Pressure Ulcer Report • Q1 Falls Report • Q1 Litigation Quarterly Report • Mortality Report • NICE Annual Report • Business Security Annual Report • Q1 Learning from Experience (LFE) Report • Infection Prevention BAF Update • Outbreak Closing Report – Ward 21 & 22 • Outbreak Plan Policy • Care and Management of Patients with COVID 19 Policy • IP&c Annual Effectiveness Report • FTSU – Ward 22 Infection Cluster Investigation Report • Nursing & Midwifery Staffing Update

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2

• Medical Staffing Update • Action Plan following an internal audit report on Mental Health Act compliance

For the purpose of assurance, the items noted in the log below highlights items for the attention of the Board. RECOMMENDATION(S) The Board is asked to receive and review the attached Log.

Pack Page 27

3

Subject: QUALITY AND GOVERNANCE ASSURANCE REPORT Ref: BoD: 20/08/06/08 CHAIR’S LOG: Chair’s Key Issues and Assurance Model Committee / Group: Quality and Governance Committee (Q&G) Date: 29th July 2020 Chair: Philip Hudson


Committee


receiving body

1

Action log - Report on open pathways.

The Committee reported last month on an update on the 26,500 Open Pathways that had been revealed during the transition from Lorenzo to Medway. The validation of records remains ongoing. No harm to any patient has been identified further to that noted last month. The Committee will continue to review this exercise.


2

Action log – Vascular Service Pathway

In order to address issues in the service, a CBU 2 team is developing a paper to identify the necessary service requirements. Meetings will be held with with Sheffield and Doncaster Hospitals, following which is it expected that the Trust will be able to enter into contractual arrangements with Sheffield and / or Doncaster to ensure effective provision of the service to Barnsley patients. The Committee will receive an update in 3 months.


3

Covid 19

An update was received which included details of the current status, steps being taken to move towards normal levels of pre-Covid service, and assurance in relation to flexibility to manage any increase in infection rates which may coincide with the winter period. The Covid 19 Risk Register was also reviewed.


4 Terms of Reference

The Committee’s Terms of Reference were reviewed and are recommended to the Board for adoption, subject to some small amendments.


5 IPR

It was noted that whilst the overall number of falls was broadly flat, a higher number of falls with fractures had been noted. A deep dive has been commissioned to look for trends and this will be

Board of Directors


Pack Page 28

4


Committee


receiving body

reported to the Committee.

6 Performance Reports – Chair’s log

It was noted that the externally funded post of Independent Domestic Violence Advisor had been decommissioned, which gives rise to concern at a time when domestic violence incidents are expected to be increasing. The Trust will be lobbying the CCG about the position.

Board of Directors For Assurance

7

Mortality Report

It was noted that whilst the crude mortality measure includes Covid related deaths, the SHMI and HSMR will not. Assurance regarding the separate arrangements for scrutiny of Covid related deaths was given. The annual rebasing of SHMI and HSMR is still outstanding with no indication of timescale. When it happens it expected to lead to an increase in the measures.

Board of Directors

For assurance

8 NICE Annual Report

The report provided assurance on the Trust’s measures to ensure compliance with NICE guidance and quality standards issued or updated in 2019/20. Of 97 items relevant to the Trust, 92 were either compliant or partially compliant, with work ongoing to achieve compliance. The remaining 5 were in the process of being assessed for compliance.


9 Business Security Annual Report The Committee received the report covering the Trust’s security management and planning, emergency preparedness and business continuity measures.


10 Infection Prevention and Control Group

The Committee received a number of reports covering the very extensive IP&C measures and governance processes in place at the Trust. This included the IP&C Board Assurance Framework. A gap was reported in the ability to maintain 2m bed space in all

Board of Directors

For assurance

Pack Page 29

5


Committee


receiving body

clinical areas. Mitigation has been agreed and reported to NHSe and no concerns have been fed back. The IP&C BAF is included within agenda item 08. A number of supporting documents are embedded within the BAFwhihc have been through the governace assurance framework and can be made available if required.

11

Mental Health Act Audit

An internal audit report had provided limited assurance as to the Trust’s compliance with the documentary requirements of the Mental Health Act. In response a task and finish group had been established and developed a detailed action plan. The Committee reviewed the action plan.

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1 | IPC board assurance framework

Infection Prevention and Control Board Assurance Framework Date: July 2020

1. Systems are in place to manage and monitor the prevention and control of infection. These systems use risk

assessments and consider the susceptibility of service users and any risks posed by their environment and other service users

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Systems and processes are in place to ensure: • Infection risk is assessed at

the front door and this is documented in patient notes

All patients attending ED are streamed to Hot/Cold ED. This pathway is maintained if the patient is admitted. Each patient is asked a series of questions to ascertain and mitigate risk. (please see embedded document). Documented in patient records. All patients with possible or confirmed COVID-19 infection are nursed in cubicles throughout their stay in ED. Direct GP admissions are reviewed using information from the GP and placed on the appropriate pathway.

Covid 19 Navigation

document.pdf

Trust follows PHE guidance, Reducing the

None

Possible under-

N/A

Ward teams escalate

Pack Page 31


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

• Compliance with the national

guidance around discharge or transfer of COVID-19 positive patients

• Patients and staff are

risk of transmission of COVID-19 in the hospital setting and IPC guidance. Patients only moved unless clinical indication or to isolate effectively – available on Trust COVID-19 HUB. On-call teams and site matrons aware via on-call meetings. Datix used to report any inappropriate patient moves. Patient transfer documentation used for internal and external transfers – documented if the patient is known to have or is suspected to have an infection. Patients returning to care homes are screened for COVID-19 prior to discharge. Discharge and patient flow team and Rightcare Barnsley part of review process. Datix reporting system in place to highlight non-compliance. Patient discharge information leaflet for patients who are positive for COVID-19

PPE available on all wards and departments.

reporting in Datix.

None

None

through normal escalation process. N/A

N/A

Pack Page 32

https://www.gov.uk/government/publications/coronavirus-covid-19-hospital-discharge-service-requirements


protected with PPE, as per the PHE national guidance

• National IPC guidance is

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

Out of hours store of PPE available if required – access via site matrons. Daily stock check of PPE undertaken by BFS PPE Action Group convened. Shortages in PPE escalated via recognised channels. Risk assessments in place for BAME staff and when deviating from national guidance. PPE audit used by matrons/lead nurses to monitor the compliance with PPE. PPE enquiry line in operation. Theatre pathway re PPE.

Theatre pathway for PPE.pdf

IPCN checks guidance for updates. Any significant updates escalated to CBU’s via Silver Command. Matrons, ADN’s and CD’s assist IPCN’s in disseminating significant changes. Current guidance available on Trust COVID-HUB. Site matrons and on-call management team assist in communication.

Not all staff may be aware of changes.

None

IPCN’s visible on wards and available for advice. Significant updates communicated also via Trust wide email. Matrons, ADNs and on-call management team support ward and clinical areas.

N/A

Pack Page 33

https://www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=103031

https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control


• Changes to guidance are brought to the attention of boards and any risks and mitigating actions are highlighted

• Risks are reflected in risk

registers and the Board Assurance Framework where appropriate

• Robust IPC risk assessment

processes and practices are in place for non COVID-19 infections and pathogens

Process of escalation from Silver to Gold Command and then to Trust Board. IPCG submits exception report/chairs log to Q&G. Exceptions reported by Q&G to Trust Board.

Risks held on the Trust risk register and local CBU registers. Process for reviewing risk registers in place.

IPC policies and procedures in place. Policies all current. IPCN’s providing service as normal Microbiologists undertake ward rounds and daily ITU review.

None

Mandatory training compliance low.

N/A

CBU’s contacted and requested to support IPC training. Staff who are non- compliant contacted by L&D department. Lead nurses contacted with details on how to access e-learning. Classroom sessions undertaken in May. Training plan in place.

Training Plan.xlsx

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

Pack Page 34

https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control


Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Systems and processes are in place to ensure: • Designated teams with

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

• Designated cleaning teams

Staff specifically working in COVID ‘hot areas’ trained in relation to appropriate use of PPE, donning and doffing etc.

Wards caring for patients with COVID-19 visited by IPCN/Microbiologist daily. Where ever possible staff are not moved between identified ‘hot’ and ‘cold’ areas as per PHE guidance. IPC isolation policy, care of the infectious patient and hand hygiene policies in place. Specific COVID-19 training slides available on COVID-19 HUB. Skills for Health module available via COVID-19 HUB.

5.1_Isolation Policy 2020.doc

PHE Taking_off_PPE_for_n

PHE_COVID-19_Doffing_gown_version.pdf

PHE_COVID-19_Doffing_quick_guide_gown

PHE_COVID-19_Donning_gown_version.p

PHE Putting_on_PPE_for_

PHE_COVID-19_Donning_gown_version.p

PHE_Donning_coveralls_guidance_instruc

PHE_Doffing_coveralls_guidance_instructio

Domestic movement between ‘Hot’ and

Shortfalls in staffing may lead to staff being moved to work on other areas.

Not possible for

Where movement is planned upskilling of teams has taken place. Matrons and IPCN’s available for advice and support.

Movement between hot

Pack Page 35


with appropriate training in required techniques and use of PPE, are assigned to COVID-19 isolation or cohort areas.

• Decontamination and terminal

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

• Increased frequency of

cleaning, at least twice daily in areas that have higher environmental contamination rates as set out in the PHE and other national guidance

‘Cold’ areas minimised. Domestic teams trained in donning and doffing of PPE and appropriate use of PPE. Domestic staff mask fit tested for FFP3 masks.

Face to face training in isolation room cleaning completed by domestic staff. Annual refresher training completed.

Training records available from Domestic Services manager.

Tristel used as standard cleaning product. RAG room cleaning regime in place. Information via communications sent Trust wide in relation to cleaning. IPCN’s and Matrons available for advice

6_Barnsley_RAG_poster281119 updated 2 Environment coordinators aware of frequent touch points. Enhanced cleaning (at least 2 cleans per day) in place in high risk areas e.g. ‘hot’ ED, including resus; ‘hot’ ITU, respiratory care unit and designated COVID -19 wards. Cleaning schedules updated and placed in all areas. Additional cleans on an ad-hoc basis of bays and cubicles where patients positive

domestic teams to be based solely in one place.

None

None

and cold areas minimised as much as possible. Domestic teams aware of the appropriate use of PPE. Hand hygiene facilities available. Cleaning equipment not transferred between areas. N/A N/A

Pack Page 36

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/881489/COVID-19_Infection_prevention_and_control_guidance_complete.pdf



• Attention to the cleaning of

toilets/bathrooms, as COVID-19 has frequently been found to contaminate surfaces in these areas.

• Cleaning is carried out with

neutral detergent, a chlorine-based disinfectant, in the form of a solution at a minimum strength of 1,000ppm available chlorine, as per

for COVID-19 are nursed. Requests recorded at BFS Domestic Offices. Schedule in place regarding operating theatres.

17_Cleaning schedule.doc

Proactive programme of cleaning toilets and bathrooms introduced in 2019. All toilets cleaned with products suitable against COVID-19 (Tristel). Frequent checks of public toilets undertaken by domestic staff. Check sheets in toilet area. Checks of toilets in ward areas also undertaken by nursing staff.

18_Copy of sanitary check sheet.xls

All areas cleaned using Tristel. Confirmed as been effective against enveloped virus. Adequate supply of Sochlor in the event of supply issues with Tristel. Communication with Tristel rep, domestic

Proactive programme not to plan due to lack of equipment. None

Proposal made for additional UV machine.

N/A

Pack Page 37


national guidance. If an alternative disinfectant is used, the local infection prevention and control team (IPCT) should be consulted on this to ensure that this is effective against enveloped viruses.

• Manufacturers’ guidance and recommended product ‘contact time’ must be followed for all cleaning/ disinfectant solutions/products

• As per national guidance:

o ‘Frequently touched’ surfaces, e.g. door/toilet handles, patient call bells, over-bed tables and bed rails, should be decontaminated at least twice daily and when known to be contaminated with secretions, excretions or body fluids

o Electronic equipment, e.g. mobile phones, desk phones, tablets, desktops and keyboards should be cleaned at least twice

services and procurement if supply issues anticipated. Tristel and SoChlor available for ward/clinical teams to clean equipment. Disinfectant wipes available for cleaning of non-high risk equipment, effective against enveloped viruses.

Domestic teams and ward staff trained in the use of Tristel. Records available for staff trained. Cascade training implemented. Posters for cleaning products in areas.

Additional cleaning of frequent touch points undertaken by domestic staff. Environment coordinators in post in most wards. Required additions to cleaning SOP’s emailed to all lead nurses. Workplace risk assessments in place – cleaning of office equipment identified. Wipes suitable for the cleaning of electronic equipment available through procurement.

None

Evidence from clinical teams that this is taking place. Evidence from clinical teams that this is taking place.

N/A

Observations of clinical practice undertaken by matrons and IPCT. Managers observing practice.

Pack Page 38


daily

o Rooms/areas where PPE is removed must be decontaminated, timed to coincide with periods immediately after PPE removal by groups of staff (at least twice daily)

• Linen from possible and

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

Ward 37 and ward 24 have cubicle’s with anteroom. If covid positive patient nursed in the cubicle, anteroom will be cleaned twice daily. Ward staff spot clean. Doffing area on ITU/Respiratory Care cleaned twice daily.

Doffing Checks.doc

Linen is laundered as per the HTM 01 04, Decontamination of linen from health and social care, all items are put into a water soluble bag before being placed into the relevant coloured plastic linen bag. Monthly meetings held with the laundry provider, yearly audit competed at the premised where calibration certificates, Health & Safety documents and training records are reviewed Face to face training has been completed; all areas have been issued with laundry posters to ensure compliance. PHE guidance available on COVID-19 HUB. Patients clothing quarantined for 3 days before use. Receipt and collection of patient belongs by appointment.

Evidence of completion

None

Check and sign sheets implemented.

N/A

Pack Page 39



• Single use items are used

where possible and according to Single Use Policy

• Reusable equipment is

appropriately decontaminated in line with local and PHE and other national policy

• Review and ensure good

ventilation in admission and waiting areas to minimise opportunistic airborne transmission

Policies in place. IPC mandatory training highlights use of single use items. IPCN’s liaise with procurement and CBU’s when purchasing new equipment.

Products on site are suitable for deactivating COVID-19. Decontamination policy in place. Equipment and environment audits undertaken. Environment coordinators on most wards Matrons, lead nurses and IPCN’s monitor cleanliness of equipment. All high risk re-useable medical equipment is decontaminated on-site centrally.

2_Decontamination.doc

10_INFECTION CONTROL AUDIT TOO

10_INFECTION CONTROL AUDIT TOO

Waiting areas naturally ventilated. Doorways opened to improve airflow and reduce contact. Social distancing in place.

None None

None

N/A None

N/A

Pack Page 40



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

Key lines of enquiry

Evidence Gaps in Assurance Mitigating Actions

Systems and process are in place to ensure: • arrangements around

antimicrobial stewardship are maintained

• Mandatory reporting

requirements are adhered to and boards continue to maintain oversight

Although AMS ward rounds were limited to reduce footfall on the wards and improve social distancing, review of patients on antibiotics is completed over the phone by Microbiologists and on Careflow by the AMS pharmacist. On Careflow a dedicated AMS portal is used by ward pharmacists to report patients in need of a review. Mandatory reporting continues as usual.

Reports to IPCG, Trust Board oversight via Q&G.

Re-establish ward rounds and AMS group meetings to help improve AMS stewardship.

None

Work underway to re-establish AMS ward rounds whenever safe to do so.

N/A

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

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Systems and processes are in place to ensure: • Implementation of national

guidance on visiting patients in a care setting

Information cascaded via communications, re-enforced by CBU. Information available on COVID-19 HUB.

Staff may not be aware of process.

IPCT provide a facility to ‘ask the team a question’ via IPC HUB.

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https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/C0030_Visitor-Guidance_8-April-2020.pdf

https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/C0030_Visitor-Guidance_8-April-2020.pdf


• Areas in which suspected or

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

• Information and guidance on

COVID-19 is available on all Trust websites with easy read versions

IPCN and senior nursing team available for advice. Site matrons and on call management team provide support to staff. Group convened to plan a safe process to re-introduce visiting.

Visiting SOP - Physical Visiting (2).do

SOP - Virtual Visiting.doc

ITU – ‘Hot’ and ‘Cold’ area identified. Patients having respiratory precautions identified with barrier precautions sign. ED – clear signage and restricted access in ‘hot’ and ‘cold’ areas. Respiratory Precautions barrier nursing signage used.

4_Respiratory barrier precaution - g https://www.barnsleyhospital.nhs.uk/covid-19-coronavirus/ https://www.barnsleyhospital.nhs.uk/news/easy-read-guide-to-explain-covid-19-and-other-resources/

None

None

Patient Experience message and video calls service. Procurement of electronic devices to help patients keep in touch with visitors.

N/A

N/A

Pack Page 42

https://www.barnsleyhospital.nhs.uk/covid-19-coronavirus/

https://www.barnsleyhospital.nhs.uk/covid-19-coronavirus/

https://www.barnsleyhospital.nhs.uk/news/easy-read-guide-to-explain-covid-19-and-other-resources/




• Infection status is

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

http://intranet.bdgh-tr.trent.nhs.uk/teams/covid-19/ Infectious state of patient documented on external and internal transfer documentation. Result readily available via IPC in-patient dashboard. Result available on ICE – access available to GP’s and other local Trusts. Datix reporting in place to alert to process failures.

None

N/A

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

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Systems and processes are in place to ensure: • Front door areas have

appropriate triaging arrangements in place to cohort patients with possible or confirmed COVID-19 symptoms and to segregate them from non COVID-19

ED has designated space for streaming and then triage in the appropriate areas i.e Hot/Cold.

Covid-19 Navigation v2.pdf

None

N/A

Pack Page 43

http://intranet.bdgh-tr.trent.nhs.uk/teams/covid-19/

http://intranet.bdgh-tr.trent.nhs.uk/teams/covid-19/


cases to minimise the risk of cross-infection

• Mask usage is emphasized for suspected individuals

• Ideally segregation should be

with separate spaces, but there is potential to use screens, e.g. to protect reception staff

• For patients with new-onset

symptoms, it is important to achieve isolation and instigation of contract tracing as soon as possible

Surgical masks provided for patients when appropriate taking into consideration the patient’s condition.

2 metres between bed spaces reiterated. Curtains can be drawn between patients. Perspex screens erected on reception desks

Isolation policy in use. Procedure and algorithm for the management of patients with new onset of symptoms. Contact tracing undertaken by IPCN. Datix reporting if unable to immediately isolate patient. Possibility of co-horting patients assessed. IPCT undertake alert organism surveillance. Able to detect where possible HCAI has occurred. Incident/outbreak meetings held if 2 more cases of possible HACI in one area, minutes available from IPCT. Escalation to ET of possible HCAI.

Ward 22 Infection Cluster Investigation

16_Patient pathway for patients in COVID

15_COVID-19 Management of suspe

None

None

None

N/A

N/A

N/A

Pack Page 44


• Patients with suspected

COVID-19 are tested promptly

• Patients that test negative but

display or go on to develop symptoms of COVID-19 are segregated and promptly re-tested

All non-elective patients swabbed on admission – either in ED or AMU. Datix reporting in place to alert to process failures. Screening process for elective admissions Patients with new onset of symptoms screened. IPCN and microbiologist available for advise re screening.

Process and documentation in place. Site matrons aware of need to isolate. Patients receive regular medical and nursing staff review. IPCN and Microbiologists available for advice. Screening process for elective admissions. Patients with new onset of symptoms screened. Consent process and letter sent to elective patients. Datix completed for all hospital onset cases. Rapid improvement reviews when hospital onset cases identified.

None

Availability of isolation facilities.

N/A

Datix reporting system. IPCN’s and microbiologists available for advice (24 hours). Surgical masks available for patient use. Site team have access to IPCT dashboard to aid placement of patients. Patient microbiological alerts on Lorenzo to assist in review and selection of isolation requirements.

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• Patients that attend for routine

appointments who display symptoms of COVID-19 are managed appropriately

Rapid improvement tool Acute COVID -19

Action card developed to guide correct practice in outpatient settings

(2) Updated outpatient action card

Limited evidence of action being required due to the switch to virtual outpatient consultation and very small numbers attending for face to face.

Ward boards link to IPCT dashboard to easily identify patients with alert organisms.

Patients attending outpatients required to wear a face covering.

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

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Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Systems and processes are in place to ensure: • All staff (clinical and non-

clinical) have appropriate training, in line with latest PHE and other guidance, to ensure their personal safety and working environment is safe

• All staff providing patient care

are trained in the selection and use of PPE appropriate for the clinical situation and on how to safely don and doff it

IPC training mandated annually for staff having patient contact and every 3 years for staff who don’t have clinical contact. IPC mandatory update and induction updated to include COVID-19. PHE guidance available via COVID HUB. Links to PHE video on donning and doffing on COVID HUB.

Posters on wards – donning and doffing, hand hygiene. Education links can be accessed via the COVID HUB – Skills for Health, COVID-19 slide show

FFP3 mask fit testing undertaken. Priority given to those staff regularly undertaking AGP. Posters available on clinical areas advising of appropriate PPE and donning and doffing. Advice to staff by IPCN’s, Matrons and ADN’s. Additional on-site shower facilities provided.

Compliance with mandatory training is below Trust target. Limited number of classroom sessions available. Limited support for development of e-learning packages.

Temporary delays in mask fit testing due to unavailability of solution and order placed for alternative fit test not fulfilled. Changes in the supply of masks results in staff not being mask fit tested to the current mask in use.

IPCT and CBU’s promoting e-learning. IPCN’s and senior nursing staff challenge poor compliance with IPC precautions and advise on correct procedures.

Assistance gained from South Yorkshire Fire and Rescue and other companies to assist with mask fit testing. BFS contracted company to provide mask fit testing.

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https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/877658/Quick_guide_to_donning_doffing_standard_PPE_health_and_social_care_poster__.pdf


• A record of staff training is

maintained

• Appropriate arrangements are

in place that any reuse of PPE in line with the CAS alert is properly monitored and managed

Record of mask fit testing activity maintained. Able to confirm what types of mask staff are fit tested to. ITU maintained records on training given on donning and doffing. Training records held centrally via ESR

Responsibility of Trainers.pdf

Qualitive Fit Test Report Sheet.pdf

12_Qualitative Mask Fit test record 2020.x

Train the trainer process enhanced.

Infection Control SOP for Mask Fit Test

Lesson plan for fit mask testing t-code 1

Lesson plan for train the trainer fit mask te

Any CAS alerts related to COVID-19 are immediately shared with Silver Command in addition to the relevant teams and departments as per CAS policy. Current Trust advice, not to reuse unless recommended by manufacturer. Risk assessment in place for acute PPE shortages

Some returned records are incomplete

None

IPCT improving system of Train the Trainers with updates.

N/A

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https://www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=103031


• Any incidents relating to the

re-use of PPE are monitored and appropriate action taken

• Adherence to PHE national

guidance on the use of PPE is regularly audited

PPE shortages.doc

Risk assessment in place for acceptance of visors not supplied via normal supply route.

Visor.doc

Re-processing of visor bands manufactured on site via BFS Decontamination Services. Process validated prior to introducing the visor Gowns suitable for laundering purchased and manufactured by the Trust. Policy and risk assessment for laundering in place Not current practice to re-use equipment unless deemed safe to do so by manufacturer. Datix reporting system in place.

PPE audit available and to be undertaken as a minimum weekly. CBU’s to monitor actions. Results fed back to the PPE Action Group and then by exception to the IPCG

None

Audit programme not yet fully embedded

N/A

Observation of practice, feedback to individuals at the time.

Pack Page 49

https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/covid-19-personal-protective-equipment-ppe



• Staff regularly undertake hand

hygiene and observe standard infection control precaution

• Hand dryers in toilets are

associated with greater risk of droplet spread than paper towels. Hands should be dried with soft, absorbent, disposable paper towels from a dispenser which is located close to the sink but beyond the risk of splash contamination, as per national guidance

• Guidance on hand hygiene,

including drying, should be clearly displayed in all public toilet areas as well as staff

PPE.doc

Programme of hand hygiene audits undertaken in clinical areas weekly. Monitored by the CBU’s. Compliance escalated to IPCG through exception report. Non-compliance addressed by CBU’s and IPCT. Audit undertaken by volunteers – patient’s observations of hand hygiene amongst staff prior to COVID-19. Observation of practice undertaken by IPCN’s. Portable hand wash basins placed on entrance to high risk areas. Alcohol hand rub available to staff. No hand dyers in the Trust

Hand hygiene audits not consistently 100% None

Not all toilets have specific signage on hand drying.

Non- compliance addressed by medical staff. Hand hygiene champions deliver ward based practical sessions on hand hygiene. N/A

Signage to be sourced, ordered and appropriately placed.

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areas • Staff understand the

requirements for uniform laundering where this is not provided for on site

• All staff understands the

symptoms of COVID-19 and take appropriate action in line with PHE and other national guidance if they or a member of their household display any of the symptoms.

Soap and alcohol gel dispensers have 6 step hand hygiene technique printed onto the dispenser. Hand hygiene prompts in main public toilets Alcohol hand rub dispensers have 6 step technique demonstrated

Uniform policy in place-specifies laundry requirements. Trust wide email from communications team on laundering. Clinical and non-uniformed staff provided with scrubs to wear and launder. Advice on COVID HUB COVID reporting line for staff. Advice given regarding swabbing and isolation requirements. All advice then re-iterated and explained by the staff swabbing team when contacting the staff member to arrange the appointment and again at the swabbing appointment.

None None

N/A N/A

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https://www.nhs.uk/conditions/coronavirus-covid-19/check-if-you-have-coronavirus-symptoms/

https://www.nhs.uk/conditions/coronavirus-covid-19/check-if-you-have-coronavirus-symptoms/


7. Provide or secure adequate isolation facilities

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Systems and processes are in place to ensure: • Patients with suspected or

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

• Areas used to cohort patients

with suspected or confirmed COVID-19 are compliant with the environmental requirements set out in the current PHE national guidance

• Patients with resistant/alert

organisms are managed according to local IPC

Patients identified on admission whether high risk of COVID. Patients at high risk isolated or cohorted with barrier precautions. Operating theatre cases – revised list to ensure adequate time between cases to allow for cleaning and minimise cross infection. Patients not placed in positive pressure cubicles. Barrier precaution signage in use.

Cleaning frequencies increased in high risk areas. RAG decontamination poster in use All cleaning products suitable to deactivate COVID -10 Barrier Precautions signage in place

IPC alert system through Lorenzo. IPCT alerted to patients with alert organisms.

Isolation facilities not always available. Cohorted areas not always situated in desired area on the ward.

Unable to guarantee 2 metre space between patients. Not always able to designate separate ends of the ward for cohorted bays.

None

Escalation process for unavailability of side rooms. Availability of surgical masks for patients where appropriate. Enhanced cleaning regimes for areas where covid positive patients. Datix reporting to have an overview of the situation.

Use of privacy curtains between bed spaces where safe to do so. Doors closed to bays to ensure segregation from the rest of the ward.

N/A

Pack Page 52



guidance, including ensuring appropriate patient placement

IPCT dashboard and case management system. IPC policies in place. Escalation procedure if unable to isolate within isolation policy Site Matron team work with IPCN’s to appropriately place patients IPCN’s review all patients with an alert organism. Datix reporting system in place IPC dashboard available for viewing by ward and site team. Ward boards linked to IPCT dashboard enabling easy identification of alert organisms.

8. Secure adequate access to laboratory support as appropriate

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions There are systems and processes in place to ensure: • Testing is undertaken by

competent and trained individuals

• Patient and staff COVID-19

testing is undertaken promptly and in line with PHE and other national guidance

Procedure in place for taking swabs for COVID-19.

3_Collection of viral nose and throat swab

Patients tested on admission. Staff assessed for testing when contact COVID reporting line Patients requiring discharge to a care home are swabbed 48 hours before discharge.

None

None

N/A N/A

Pack Page 53

https://www.gov.uk/guidance/coronavirus-covid-19-getting-tested


• Screening for other potential

infections takes place

Drive through facility available for staff testing.

IPC policies in place. Microbiologists and IPCN’s available for advice. Laboratory facilities available to undertake screening for other infections.

None

N/A

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

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Systems and processes are in place to ensure that: • Staff are supported in

adhering to all IPC policies, including those for other alert organisms.

IPC mandatory training annually for clinical staff. Audits of compliance to policies undertaken – feedback given to ward staff. IPCT available for advice and support. Answer phone to pick up out of hours queries. 24 hour microbiologist cover provided. Site matron and on-call management team available outside normal working hours. ‘Ask the team a question’ facility on the IPC HUB page. IPC HUB with advice. ‘Bug of the Month’ produced by IPCN’s.

None

N/A

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• Any changes to the PHE

national guidance on PPE are quickly identified and effectively communicated to staff

• All clinical waste related to

confirmed or suspected COVID-19 cases is handled, stored and managed in accordance with current national guidance

IPCN’s visit wards daily.

7_(1) Bug Of The Month Wuhan novel c

Changes communicated via Silver command to CBU’s and BFS. Changes alerted to communications team. Suspension of other Trust communications to ensure messages are clear regarding COVID-19. IPCN’s visit wards on a daily basis. Site matrons and on-call management team assist in communication.

Waste is disposed of in line with the HTM 07 01, :safe management of healthcare waste, for waste from known or suspected Covid-19 the new guidance from NHSE are followed as listed • Outer packaging must be removed before

going into the wards • Confidential Waste in COVID- 19

contaminated areas must be stored for 72 hours before being removed/ shredded.

• No more use of yellow bags. Areas must

None

None

N/A

N/A

Pack Page 55




• PPE stock is appropriately

stored and accessible to staff who require it

move on to using Yellow rigid containers for the duration of COVID 19.

• No double bagging of Orange bags • No Domestic waste can go to Landfill • There is a statement regarding

implementing contingency arrangements as there could be a national shortage of Yellow clinical waste carts/ Wheelie bins.

The waste register is held with the Facilities Support Manager where consignment notes are held, the quarterly returns are held both electronically and in the register.

All PPE is received into BFS Procurement stores and kept securely in receipts area. All wards and areas get daily stock allocations and daily monitoring is in place across all PPE items. Report on allocation / usage / ward is provided daily to Silver command for review and dissemination

Weekly PPE Daily Usage Master.xlsx

None

N/A

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

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions

Pack Page 56


Appropriate systems and processes are in place to ensure: • Staff in ‘at-risk’ groups are

identified and managed appropriately including ensuring their physical and psychological wellbeing is supported

• Staff required to wear FFP

reusable respirators undergo training that is compliant with PHE national guidance and a record of this training is maintained

Risk assessments are completed and acted on accordingly, those shielding and or working from home receive welfare calls and agree programme of calls and or signposting to agencies who can offer appropriate support. Risk assessments stored locally and centrally.

Covid-19 Risk Assessments - Manag

BAME letter 20 5 20 final.doc

Covid-19 risk reduction framework

Email wording 26.6.20.docx

LETTER - Supporting our BAME staff and th

All staff informed that must be mask fit tested to safely wear FFP mask. Mask fit testing available to all staff. Undertaken by trained personnel. Record maintained of all trainers Train the trainer system in place Record maintained by IPCT.

Where individuals and or manages have not recorded so not on list to follow up.

Staff wearing FFP3 masks who have not been fit tested. Staff may fail the fit test, alternative PPE not always available.

To send out communication reminding manager and individuals of all guidance and support available and where to send documents to ensure support/welfare of individual.

No evidence to suggest staff undertaking AGP’s haven’t been mask fit tested. Staff failing fit testing who would potentially undertake AGP’s do not perform these procedures. Employee responsibilities in Health and Safety legislation.

Pack Page 57

https://www.hse.gov.uk/news/face-mask-ppe-rpe-coronavirus.htm


• Consistency in staff allocation is maintained, with reductions in the movement of staff between different areas and the cross-over of care pathways between planned and elective care pathways and urgent and emergency care pathways, as per national guidance

• All staff adhere to national

guidance on social distancing (2 metres) wherever possible, particularly if not wearing a facemask and in non-clinical areas

• Consideration is given to

staggering staff breaks to limit the density of healthcare workers in specific areas

Senior member of nursing team holds staffing bleep. Staffing allocation reviewed daily by the CBU matron. As outpatient work stopped, specialist nurses allocated to clinical areas that will support their clinical skill set.

Request via communications on social distancing. Posters displayed. Floor markings denoting 2 metre distance All staff wearing surgical masks in public spaces and when 2 metres social distancing cannot be maintained. Furniture removed or marked as not in use to assist with social distancing

Staff breaks staggered wherever possible. Posters displayed. Staff requested to use dining room if staff rest areas on clinical areas do not facilitate social distancing.

Unable to guarantee that staff not moved between areas.

Evidence that staff not consistently following social distancing. Further work required.

Not always possible to reduce the number of healthcare workers in one area.

Any movement of staff is risk assessed. Support provided by CBU to staff who are requested to move areas. Lead Nurses have regular NHSP workers to try and minimise staff working across clinical areas as much as possible. PPE and IPC processes in place.

Increased communications. Further mitigation required.

Staff aware of need to socially distance.

Pack Page 58


• Staff absence and well-being

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

• Staff that test positive have

adequate information and support to aid their recovery and return to work.

All those shielding and working from home are contacted and assessed, appropriate sign posting is offered, and agree a support package, which includes providing details of how to access swabbing. We also ensure they are aware of how to access Trust communications which is constantly updating with advice.

Staff informed of their positive result, microbiologist available to answer any questions 7 days per week. Staff are called back on receipt of a negative swab, if remain off duty at 7 and 14 days, to provide advice, information and any support to aid recovery and return to work.

Where individuals and or manages have not recorded so not on list to follow up. Those accessing swabs elsewhere may not receive timely advice from Occupational Health as the team are not informed till much later in the process. Staff may not be able to attend the drive through testing service.

To send out communication reminding manager and individuals of all guidance and support available and where to send documents to ensure support/welfare of individual. Information from the Trust has also been placed in the local newspaper. To support staff as soon as become aware of result. Proposal for drop off and collection approved by ET.

Pack Page 59

REPORT TO THE BOARD OF DIRECTORS REF: BoD: 20/08/06/08ii

SUBJECT: POLICY FOR LOCAL SAFETY STANDARDS FOR INVASIVE PROCEDURES (LocSSIPs)

DATE: 6 AUGUST 2020

PURPOSE:




PREPARED BY: Tracey Radnall, Head of Patient Safety & Quality Improvement SPONSORED BY: Dr Simon Enright, Medical Director PRESENTED BY: Dr Simon Enright, Medical Director STRATEGIC CONTEXT The introduction of the WHO Safer Surgery Checklist provides safer care for patients undergoing operations. Following on from its use experience has suggested the benefits of a checklist approach can be extended beyond surgery towards all invasive procedures performed in hospitals. Checklists in themselves cannot be fully effective in preventing adverse incidents without including teamwork and human factors. National Safety Standards for Invasive Procedures (NatSSIPs) were created from national analysis of Never Events, Serious Incidents and Near Misses. Never Event guidance is published by the NHS and updated each year to provide a list of Never Events and corresponding national safety requirements. Never Events are a particular type of serious incident which are wholly preventable because of guidance or safety recommendations that are available at a national level and should have been implemented by all providers. Never Events and the associated preventative guidance, as published by NHS improvement, are intended to provide a framework for the production of Local Safety Standards for Invasive Procedures (LocSSIPs). LocSSIPS are created by multi-professional clinical teams, and are implemented against a background of education in human factors and team working. LocSSIPS do NOT replace the WHO Safer Surgery Checklist. Rather, they build on it and extend it to patients undergoing other interventions. They standardise key elements of procedural care, ensuring that care is harmonised, reinforcing the importance of education in patient safety.

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EXECUTIVE SUMMARY

This policy aims to ensure that invasive procedures are conducted consistently, in a standardised manner to mitigate against inevitable risks and reduce avoidable harm to patients. It supports teams to ensure that critical safety steps are followed to minimise risk and errors and prompts good team communication and correct completion of all intended steps associated with any interventional procedure. RECOMMENDATION

Consultation with relevant groups has taken place and the policy has been approved by the Clinical Effectiveness Group (17 June 2020) and the Patient Safety and Harm Group (18 June 2020). The Board is now asked to approve the policy.

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Page 1 of 12

Policy for Local Safety Standards for Invasive Procedures

(LocSSIPs)

Author/Owner Head of Patient Safety & Quality Improvement

Equality Impact Assessment

Yes

Date:

Version 1

Status Draft/Approved

Publication date Date, month, year

Review date 6 August 2022

Approval recommended by

Patient Safety & Harm Group

Clinical Effectiveness Group

Date: 18 June 2020

Date: 17 June 2020

Approved by Quality & Governance Committee / Trust Board

Date: 24 June 2020

Distribution Barnsley Hospital NHS Foundation Trust – intranet

Please note that the intranet version of this document is the only version that is maintained.

Any printed copies must therefore be viewed as “uncontrolled” and as such, may not necessarily contain the latest updates and amendments

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Page 2 of 12

Contents

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

2. Objective .......................................................................................................................... 3

3. Scope ............................................................................................................................... 4

4. Documentation of Invasive Procedures ........................................................................... 4

5. Sequential LocSSIPs ....................................................................................................... 5

6. Team Briefing .................................................................................................................. 6

7. Workforce ........................................................................................................................ 6

8. Roles and responsibilities ................................................................................................ 7

9. Associated documents and reference ............................................................................. 7

10. Training and resources ................................................................................................ 8

11. Monitoring and audit ..................................................................................................... 8

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Page 3 of 12

1. Introduction The introduction of the WHO Safer Surgery Checklist provides safer care for patients undergoing operations. Following on from its use experience has suggested the benefits of a checklist approach can be extended beyond surgery towards all invasive procedures performed in hospitals. Checklists in themselves cannot be fully effective in preventing adverse incidents without including teamwork and human factors. National Safety Standards for Invasive Procedures (NatSSIPs) were created from national analysis of Never Events, Serious Incidents and Near Misses. Never Event guidance is published by the NHS and updated each year to provide a list of Never Events and corresponding national safety requirements. Never Events are a particular type of serious incident which are wholly preventable because of guidance or safety recommendations that are available at a national level and should have been implemented by all providers. Never Events and the associated preventative guidance, as published by NHS improvement, are intended to provide a framework for the production of Local Safety Standards for Invasive Procedures (LocSSIPs). LocSSIPS are created by multi-professional clinical teams, and are implemented against a background of education in human factors and team working. LocSSIPS do NOT replace the WHO Safer Surgery Checklist. Rather, they build on it and extend it to patients undergoing other interventions. They standardise key elements of procedural care, ensuring that care is harmonised, reinforcing the importance of education in patient safety. 2. Objective This policy aims to ensure that invasive procedures are conducted consistently, in a standardised manner to mitigate against inevitable risks and reduce avoidable harm to patients. It supports teams to ensure that critical safety steps are followed to minimise risk and errors and prompts good team communication and correct completion of all intended steps associated with any interventional procedure.

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Page 4 of 12

3. Scope This policy applies to all staff involved in the scheduling, planning, preparation, conduct and post-procedural care of any patient undergoing any invasive procedures. Separate local departmental policies cover the use of the WHO checklist, site marking guidance and safety standards within theatres, interventional radiology and endoscopy. A separate WHO checklist is available for Ophthalmology surgery and WHO also provide a Safe Childbirth Checklist.

An invasive procedure is defined as:

• A surgical and interventional procedure performed in operating theatres, outpatient treatment areas, labour ward delivery rooms and other procedural areas within an organisation

• Surgical repair of episiotomy or genital tract trauma associated with vaginal delivery. • Invasive cardiological and vascular procedures such as cardiac catheterisation,

angioplasty, stent insertion and insertion of central venous lines • Endoscopic procedures such as gastroscopy and colonoscopy • Interventional radiological procedures • Thoracic interventions such as bronchoscopy and the insertion of chest drains • Biopsies and other invasive tissue sampling

4. Documentation of Invasive Procedures NatSSiPs do NOT replace the WHO Safer Surgery Checklist. Invasive procedures that take place outside of the theatre and endoscopy environment must still be subject to safety standards and checks. The development of LocSSIPs in areas such as outpatients give clinical teams the opportunity to create standardised documentation for patients undergoing invasive procedures that promotes the sharing of patient information between individuals and teams at points of handover, and forms a record for future reference. It is recognised that the structure of the documentation can in itself contribute to safe working practices. Both electronic and paper documentation must be designed in such a way that key safety checks in the patient pathway are performed in sequence and are accurately documented. It is therefore important that the documentation reflects the processes of the department it is used in, rather than a one size fits all approach. Documentation for invasive procedures performed in all areas must ensure the recording of essential information throughout the patient pathway, to include pre- procedural assessment and planning, any use of anaesthesia including local or regional anaesthesia or sedation, the invasive procedure itself and post-procedural care. The documentation should promote the implementation and audit of and record compliance with or variation from, other LocSSIPs, to include handovers of care, safety briefing, sign in, time out, checks to ensure correct site surgery, the insertion of the correct prosthesis, prevention of the retention of foreign objects, the sign out at the end of the procedure and debriefing. Invasive procedure documentation should allow the identification of the members of the team present at each stage in the patient pathway.

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Page 5 of 12

Documentation must be complete, legible and contemporaneous, and must use locally agreed standardised terminology, avoiding the use of abbreviations or jargon. A record should be kept of the performance of the key safety checks in the patient pathway. Clinical teams can decide whether this is simply confirmation that the check has been performed by the procedure team, or whether a particular individual or individuals should be responsible for confirming, on the team’s behalf, that the check has been performed. When paper and electronic documentation are both in use, both systems should be aligned such that there is no unnecessary duplication of data entry or inconsistency. The organisation must identify which is the primary information source for later reference. The Medway programme and its suite of programmes, will be developed to gradually over the Trusts digital agenda, to digitise all paper documentation where possible to aid in the communication for all healthcare professionals and therefore increase patient safety.

Any locally developed LocSSIP checklists should be sent to the patient safety team for inclusion on the LocSSIP Sharepoint site.

5. Sequential LocSSIPs The LocSSIP should be sequential and is likely to include the following key areas:

• Staff involved in the procedure • Patient identification • Patient consent • Procedural verification (and site marking) • Safety briefing • Sign in • Time out • Prosthesis verification (where applicable) • Prevention of retained foreign objects (unless deliberate in which case record what

has been retained) • Sign out • Debriefing

Patient safety during the performance of invasive procedures is dependent upon adequate preparation, the accurate scheduling of procedures and the management of any procedure lists. LocSSIPs must include the unambiguous use of language in all communications relating to the scheduling and listing of procedures. Laterality must always be written in full, i.e. ‘left’ or ‘right’. The use of abbreviations should be avoided. Clinical teams must have LocSSIPs in place to ensure the accurate reconciliation of items used during all invasive procedures. The methods detailed in the LocSSIPs for counting and reconciliation should be consistent in all areas in which invasive procedures are performed within the organisation, and should use accepted and published methodologies when they are available. The information that accompanies the scheduling of a procedure should include when relevant, but is not limited to:

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• Patient name • BHNFT Hospital Number • NHS number with or without hospital number. • Date of birth. • Planned procedure. • Site and side of procedure if relevant.

6. Team Briefing Procedural team briefing is a key element of practice in the delivery of safe patient care during invasive or interventional procedures, and forms part of the Five Steps to Safer Surgery. Noise and interruptions should be minimised during the safety briefing. Team briefing must take place at the start of all procedure sessions where there is a scheduled list of procedures due to take place. A Team Briefing is essential in the delivery of safe patient care during invasive procedures and is a Stop Point for Safety. As a Stop Point for Safety, noise and interruptions should be minimised and all team members should give the Stop Point their undivided attention. Team Briefing should take place out of the hearing of patients, in an area where all team members can attend. The briefing should include anyone intended to be involved in any aspect of the procedure. The briefing should include any changes to the planned or printed procedural list known before the start of the session. Any changes, to list order, procedural details or patient details, must be recorded on a list that will remain in full view for the duration of the session. All such changes must be communicated to relevant individuals. If there is a change of personnel it is essential that the Team Briefing is repeated. 7. Workforce This standard supports the principle that the safe care of patients undergoing invasive procedures depends upon having the correct numbers of appropriately trained, skilled and experienced staff members who work together effectively in a team. Clinical teams must develop LocSSIPs that clearly identify the workforce necessary to deliver safe patient care in every invasive procedural area in the organisation. These should be developed and agreed within the CBU. The LocSSIPs must account for the full scope of local services, e.g. the needs of different clinical specialties and factors such as complexity, technology, elective and non- elective activity, and variability in demand and capacity. If professional responsibility and accountability is transferred between individuals or teams the use of structured handover forms as a prompt for all handover conversations should be considered. Handovers should be both verbal and written, and should be documented. On

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rare occasions, the immediate urgency of a procedure may mean that there is only time for a verbal handover. Under these circumstances, documentation can be retrospective. 8. Roles and responsibilities The Chief Executive is ultimately accountable for ensuring the implementation of and compliance with this policy via delegation to the following senior staff: The Medical Director and Executive Director of Nursing are responsible for ensuring the Trust complies with this policy, as they have joint responsibility for patient safety and for overseeing the strategic and operational aspects of safety across the organisation. They have Trust Board responsibility for all aspects of this policy The CBU Triumvirates will ensure there is a LocSSIPs lead in each ward or department and maintain an up to date record within the CBU of all invasive procedures requiring NatSSIPs and LocSSIPs. The triumvirates have responsibility to ensure that adequate resources are available within the work area to follow correct procedures and ensure that regular annual audit of agreed processes and procedures takes place to monitor the effectiveness of practice and that remedial action is implemented where required.

A CBU Matron representative will attend the PSHG to report once a year on compliance with this policy (agenda item).

The Ward/Department Managers and Speciality Clinical Leads are responsible for facilitating the implementation of this policy within their own area of responsibility; ensuring new staff have comprehensive training as part of their induction programme. The Clinical medical and nursing teams are responsible for adhering to the policy. This policy is applicable to all medical and clinical staff involved in the care of patients undergoing clinical procedures. Any deviation from the policy must be reported on Datix. ‘Wrong site surgery’ is classed as a ‘Never Event’ by the Department of Health and should be reported in line with Trust policy.

9. Associated documents and reference

This document overarches the LocSSIPs for each invasive procedure and should be used in conjunctions with them. • National Safety Standards for Invasive procedures (NatSSips) available at:

https://www.england.nhs.uk/wp-content/uploads/2015/09/natssips-safety-standards.pdf • Examples of Local Safety Standards for Invasive Procedures available at:

https://improvement.nhs.uk/resources/examples-local-safety-standards-invasive-procedures/

• Five Steps to Safer Surgery available at: https://improvement.nhs.uk/resources/learning-

from-patient-safety-incidents/

• Acknowledgment to IOW NHS Trust for sharing their NatSSIPs and LocSSIPs Policy

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https://www.england.nhs.uk/wp-content/uploads/2015/09/natssips-safety-standards.pdf



https://improvement.nhs.uk/resources/learning-from-patient-safety-incidents/

https://improvement.nhs.uk/resources/learning-from-patient-safety-incidents/

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• Templates (including a generic starter template) for LocSSIps at BHNFT are available

via the Patient Safety HUB site Link to Patient Safety HUB site - http://intranet.bdgh-tr.trent.nhs.uk/teams/corporate-services/patient-safety/

Link to Local Safety Standards Checklist (directly to Sharepoint) - https://teamsites.bdgh-tr.trent.nhs.uk/CBU4/Safety%20Standard%20Checklists/Forms/AllItems.aspx

10. Training and resources

Human Factors Training is available for clinical and non-clinical staff Clinical teams must identify sufficient time and ensure human resources are allocated to support full implementation and audit of all LocSSIPs. This will include regular multidisciplinary meetings and discussion at departmental and CBU governance meetings. To support use of the safety standards, procedural teams will need to undergo regular, multidisciplinary training that promotes teamwork and includes clinical human factors considerations. Compliance by the clinical teams with Human Factors training must be demonstrated. 11. Monitoring and audit/compliance

Minimum requirement

to be monitored

Process for monitoring e.g. audit

Responsible individual/

group/ committee

Frequency of

monitoring

Responsible individual/

group/ committee for

review of results

Responsible individual/ group/

committee for development of

action plan

Responsible individual/group/

committee for monitoring of action

plan and Implementation

LocSSIPs are being used

appropriately and being completed

fully

Annual audit of a sample of 10 LocSSIPs

Department lead

Initial year only then as requested by PSHG

CBU

Governance quarterly

Department Lead & CBU

Governance

CBU Governance PSHG Annually

LocSSIPS are in use for any

invasive procedures

A list of invasive

procedures (outside of

theatres) to be maintained

with confirmation

that LocSSIPs are in use (see

table below)

Department lead Yearly for departments

CBU

Governance quarterly

Department Lead & CBU

Governance

CBU Governance PSHG Annually

HRG Code or Procedure code

Procedure Description

Invasive Yes/No

If Yes, do you have a Local Safety Standard for the procedure?

Is the template listed on the Patients safety hub

WARD CBU Lead Name

All patient safety incidents and near misses should be documented and reported on DATIX. These should be analysed, investigated as appropriate, and learning should be fed back to staff for continuous improvement. This should be in accordance with the Trusts Serious Incident Framework and Never Event Framework.

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http://intranet.bdgh-tr.trent.nhs.uk/teams/corporate-services/patient-safety/

http://intranet.bdgh-tr.trent.nhs.uk/teams/corporate-services/patient-safety/

https://teamsites.bdgh-tr.trent.nhs.uk/CBU4/Safety%20Standard%20Checklists/Forms/AllItems.aspx

https://teamsites.bdgh-tr.trent.nhs.uk/CBU4/Safety%20Standard%20Checklists/Forms/AllItems.aspx

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12. Equality and Diversity

This section is mandatory for all Trust Approved Documents and must include the statement below: The Trust is committed to an environment that promotes equality and embraces diversity in its performance as an employer and service provider. It will adhere to legal and performance requirements and will mainstream equality, diversity and inclusion principles through its policies, procedures and processes. This policy should be implemented with due regard to this commitment. To ensure that the implementation of this policy does not have an adverse impact in response to the requirements of the Equality Act 2010 this policy has been screened for relevance during the policy development process and a full equality impact assessment is conducted where necessary prior to consultation. The Trust will take remedial action when necessary to address any unexpected or unwarranted disparities and monitor practice to ensure that this policy is fairly implemented. This policy can be made available in alternative formats on request including large print, Braille, moon, audio, and different languages. To arrange this please refer to the Trust translation and interpretation policy in the first instance. The Trust will endeavor to make reasonable adjustments to accommodate any employee/patient with particular equality, diversity and inclusion requirements in implementing this policy. This may include accessibility of meeting/appointment venues, providing translation, arranging an interpreter to attend appointments/meetings, extending policy timeframes to enable translation to be undertaken, or assistance with formulating any written statements.

12.1. Recording and Monitoring of Equality & Diversity This section is mandatory for all Trust Approved Documents and must include the statement below: The Trust understands the business case for equality, diversity and inclusion and will make sure that this is translated into practice. Accordingly, all policies will be monitored to ensure their effectiveness. Monitoring information will be collated, analysed and published on an annual basis as part of Equality Delivery System. The monitoring will cover the nine protected characteristics and will meet statutory employment duties under the Equality Act 2010. Where adverse impact is identified through the monitoring process the Trust will investigate and take corrective action to mitigate and prevent any negative impact.

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Appendix 1

Rapid Equality Impact Assessment Form

For Clinical Policies or Procedures only

See Guidance for advice on completing this assessment.

Please use the guidance provided and give particular consideration to the needs of people with protected characteristics age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, sex race, religion or belief and sexual orientation.

Department: Patient Safety & Quality Improvement

CBU/Area/ward/ Corporate

Title of Person(s) completing this form:

Head of Patient Safety & Quality Improvement

New or Existing Policy/Procedure

New Policy

Title of Policy/Procedure being assessed:

Policy for NatSSIPs and LocSSIPs

Implementation Date:

1. What is the main purpose (aim/objective) of this policy/procedure?

Who does the proposed policy/procedure affect

Staff Patients Carers Public

2 Will the proposal have any impact on discrimination, equality of opportunity or relations between groups? If so what?

Yes No

3. Will there be a positive benefit to the users or workforce as a result of the proposed work? If so what? Promotes multi-professional clinical team working and the use of human factors theory.

Yes No

4. Will the users or workforce be disadvantaged as a result of the proposed work? If so, how?

Yes No

If you are unsure of your answers or have answered yes to any of the above you should refer to the guidance for information on each of the protected groups and complete the Impact Assessment found on page 34 of the guidance. If the answer is yes to questions 2 or 4 then please complete the impact assessment form found on page 34 of the guidance.

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When is the next review? Please note review should be immediately on any amendments to your clinical policy or procedure 1 Year 2 year 3 Year

Appendix 2 Glossary of terms List all terms/acronyms used within the document and provide a summary of what they mean. WHO World Health Organisation

WHO Safer Surgery Checklist

A checklist developed by the World health organisation to reduce patient harm in the operating theatre

NatSSIPs National Safety Standards for Invasive Procedures

National Safety Standards for Invasive Procedures

Safety standards created from national analysis of Never Events, serious incidents and near misses to meet national safety requirement

Never Events A particular type of serious incident which are wholly preventable because of guidance or safety recommendations that are available at a national level and should have been implemented by all providers.

LocSSIPs Local Safety Standards for Invasive Procedures

Local Safety Standards for Invasive Procedures

LocSSIPs are created by multi-professional clinical teams, and standardise key elements of procedural care

Invasive procedure Defined in section 3 of the policy

Appendix 3 (must always be the last appendix) Maintain a record of the document history, reviews and key changes made (including versions and dates) Version Date Comments Author Review Process Prior to Ratification: Name of Group/Department/Committee Date Patient Safety & Harm Group Quality & Governance Committee

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SUBJECT: PEOPLE, FINANCE AND PERFORMANCE ASSURANCE REPORT

DATE: 6 AUGUST 2020

PURPOSE:

Tick as applicable

Tick as applicable

For decision/approval x Assurance For review Governance For information Strategy

PREPARED BY: Keely Firth, Non-Executive Director, Chair People, Finance & Performance Committee

SPONSORED BY: Keely Firth, Non-Executive Director, Chair People, Finance & Performance Committee

PRESENTED BY: Keely Firth, Non-Executive Director, Chair People, Finance & Performance Committee

STRATEGIC CONTEXT

The People, Finance & Performance Committee (P,F&P) is one of the key committees of the Board responsible for Governance. Its purpose is to provide detailed scrutiny of financial matters, operational performance and indicators relating to our people in order to provide assurance and raise concerns (if appropriate) and to make recommendations, as appropriate, on people, financial and performance matters to the Board of Directors.

EXECUTIVE SUMMARY KEY: £k = thousands £m = millions

This report provides information to assist the Board to obtain assurance regarding the people, finance and operational performance and appropriate rigour of governance. The following papers were received at the meeting on the 30 July 2020: • Action log • Covid-19 recovery plan and risk register • Workforce report, Death in Service Policy, Annual Disciplinaries, Grievances, Bullying and

Harassment Report • Covid-19 Individual Risk Assessments • Integrated performance report (IPR) • Monthly ICT report • Board Assurance Framework (BAF) quarterly update • Corporate Risk Register (CRR) quarterly update • Consolidated finance report & ICS finance report • 2020/21 Annual Financial Plan • Chairs’ logs from operational groups.

RECOMMENDATIONS

Board members are asked to receive and review the attached log.

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Subject: People, Finance and Performance Committee Assurance Report Ref: BoD: 20/08/06/09

CHAIR’S LOG: Chair’s Key Issues and Assurance Model Committee / Group Date Chair People, Finance and Performance Committee 30 July 2020 Keely Firth, Non Executive Director KEY: FTE: Full Time Equivalent; £k = thousands; £m = millions

Agenda Item Issue and Lead Officer Receiving Body

Recommendation / Assurance /

mandate

Covid-19 Recovery

Plan & Risk Register

The committee welcomed the latest recovery plans to reintroduce activity and people back into the organisation safely and following a number of discussions were assured on progress despite the limiting factors inherent with this highly challenging programme of work. Concerns regarding the impact of the increasing pressure on people were expressed and actions are underway for example recruiting more volunteers, using charitable funds with further communications planned to ensure our people know what is available to support them.

Board

For information, assurance and

to note concerns re the impact on

our people.

Workforce Insight Report

The committee considered in depth the report which provides analysis of the issues facing the Trust from a workforce perspective. The key points to be highlighted are as follows: - - Sickness Absence and Wellbeing: Sickness absence has decreased by 0.84% to 4.2% with confirmed

sickness for Covid-19 accounting for 0.4% and the remaining 3.8% due to other reasons. Revised policies are progressing through the governance committees to support people and reduce absence.

- Headcount & FTE: The headcount for the month is 4,278 (4,030 excluding bank). The contracted FTE is recorded as 3,493 which when compared to funded establishment of 3,494 gives a variance of 1 with positive developments in new training placements and new starters on the horizon.

- Staff Turnover: The turnover rate is at 9.94% and within the target range of between 7–10%. The areas of high turnover are comparable nationally with the exception of Allied Health Professionals which is an area of focus for the Trust. There were 20 leavers in the month with the top reason classified as “Voluntary Resignation Promotion”. There were 2 people who retired and returned to work in these numbers.

- Mandatory Training: Mandatory Training is at 85% (a small increase from last month). Restrictions have now been lifted and all 10 topics are being delivered primarily via e-learning.

- Appraisals: The appraisal window is now open to 31st August 2020 with remote and home working solutions being provided.

-

Board For information

and assurance.

Death in Service Policy

The policy has been developed to ensure that the management and administrative arrangements following a death in service are conducted swiftly and with due respect to families, friends and colleagues. The committee recommends this policy for approval by the Trust Board.

Board Approval

Disciplinary, Suspensions, Bullying and

Harassment and Grievances

The committee received details of the activity in these areas in a report for the year to 31st March 2020 and analysis of the data by CBU and characteristics. Outcomes and timescales were also provided and benchmarking information was well received. The committee noted that a forthcoming audit would provide independent opinion and offer best practice opportunities where appropriate.

Board For information

and assurance.

Covid-19 The committee received a report to be submitted to NHSE/I detailing the position to date for the number of risk Pack Page 75



mandate Individual Risk Assessments

Black and Minority Ethnic

(BAME) Background

assessments completed within the Trust. The position as at 30 July 2020 is as follows: - 87% of risk assessments have been completed for staff who are known to be from a BAME background. - 61% of risk assessments have been completed for staff who are known to fall within the categories, nationally

defined as ‘at risk’ from Covid-19. - 12% of risk assessments have been completed for all staff

Board

For information

and assurance.

Integrated Performance

Report

The committee reviewed the IPR focusing on performance around patient access, people and finance. As reported previously, Covid-19 continues to present a significant risk to the delivery of the targets in 2020/2021. The Trust is succeeding in its responsiveness to the changes but now faces a challenging recovery plan.

- Emergency access & Patient Flow: Performance against the four hour standard decreased in month to 91.4% from 94.3%. The Department continues to be configured into “hot” and “cold” departments with a resultant loss of efficiency. The Clinical Decision Unit (CDU) has ceased to function as its accommodation is required for Resuscitation which alone has caused a reduction in performance of around 1.5%. The increased admissions in June, combined with the impact of infection control segregation measures, resulted in lengthier waits for beds which contributed 2.2% of the deterioration in performance. A number of actions are being taken to address these issues including the establishment of a temporary CDU and reduced turnaround time for Covid19 test results.

- RTT: During May 73.92% of patients were treated within 18 weeks compared with 80.66% in April. The Trust’s performance was the 12th best nationally. Elective activity in May was largely restricted to urgent activity and all surgical specialties are now non-compliant. Despite continuing increases in the scope and scale of elective surgery, including additional after-hours sessions and use of the private sector, further deterioration in performance against the RTT standard is expected as the backlog of non-urgent treatment continues to grow as urgent surgery is prioritised.

- Cancer: The 2 week wait from referral standard was achieved in May although the 31-day standard for first definitive treatment was narrowly missed. It is expected that these two standards will be achieved regularly over the coming months as priority is given in the allocation of clinic and operating theatre to patients with cancer (and other urgent conditions). For May the Trust was the 5th best performing nationally with regard to the 2 week wait standard reflecting the priority given to maintaining as much urgent outpatient capacity as possible during the Covid19 crisis. The 62-day referral to treatment standard was not attained in May and is expected to continue to prove challenging over the next quarter as a result of backlogs in the diagnostic phase of pathways with endoscopy a notable bottleneck as a result of non-emergency endoscopy investigations being suspended for two months per national guidance. The 2-week symptomatic breast referral target was achieved but not the 38-day inter-provider transfer target.

- Diagnostic Waits: Performance against the 6-week diagnostic standard improved significantly in June with 36% of investigations performed within target compared with 27% in May. Urgent endoscopy and non-urgent imaging services were restored in June albeit with much reduced rates of output due to distancing requirements. Increased use of the private sector and provision of after-hours imaging and endoscopy sessions will help reduce the backlog. The total diagnostics waiting list size has stabilised after steep increases during April and May.

Board

For information, assurance and

to note the ongoing risk to

delivery of access targets.

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mandate

ICT Report

The committee wishes to acknowledge once again the team members who continue to work hard under pressure to facilitate the significant shift to our new Electronic Patient Record (EPR).

- System C Medway EPR project – The implementation has progressed smoothly since going live in the early hours of Sunday 12th July. Whilst causing inconvenience to many departments, the 24 hour floor walkers and System C have been committed to resolving issues in a timely way. There are residual issues on Care Plans, in Maternity and general catching up on installation and configuration of printers which is complex. Overall, staff appear complimentary and have adapted to it very quickly.

- Developments interrupted – there are a number of developments that have been put on hold to allow for Medway stabilisation which are not considered to be high risk.

Board For information and assurance

BAF CRR quarterly update

The committee received the latest updates which provided assurance that risks are visible, managed and monitored with mitigating action taken where possible. Board For information

and assurance

Trust/BFS Finance Report

The committee received assurance that national measures are in place to support Trusts during the April – July 2020 period with the ability to retrospectively claim via the NHSE top up process. Consequently the Trust has a consolidated breakeven position for the month after receiving a £0.08m top-up.

The revenue impact of COVID-19 (before offsets and block arrangements) is a reduction in NHS clinical income by £18.5m; non-NHS income has fallen by £1m and revenue costs increased by £3.3m.

The cash position at the end of the month is £38.6m and capital expenditure on Core Programme schemes at Month 2 is £0.7m which is £0.17m less than plan. A further £0.68m was spent on COVID-19 schemes.


Revised 2020/21

Annual Plan

The committee considered the revised Annual Plan which is still indicative and awaiting final guidance on the remuneration mechanisms from September onwards. Whilst the national arrangements appear to result in block payments thus minimising financial risk there are concerns that national measures will be prescribed regarding efficiency requirements. Members recommended that plans to achieve efficiency targets continued to be developed both within the Trust and across the locality.


Strategy Delivery Progress Report

The report was well received by the committee and commended Trust colleagues for the completion and good progress with the initiatives pre Covid-19 pandemic. It is recommended that the recovery plan dovetails into the strategic plan going forward.


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REPORT TO THE BOARD OF DIRECTORS REF: BoD: 20/08/06/09i

SUBJECT: PEOPLE, FINANCE AND PERFORMANCE ASSURANCE REPORT – (June corrected)

DATE: 6 AUGUST 2020

PURPOSE:

Tick as applicable

Tick as applicable

For decision/approval x Assurance For review Governance For information Strategy

PREPARED BY: Keely Firth, Non-Executive Director, Chair People, Finance & Performance Committee

SPONSORED BY: Keely Firth, Non-Executive Director, Chair People, Finance & Performance Committee

PRESENTED BY: Keely Firth, Non-Executive Director, Chair People, Finance & Performance Committee

STRATEGIC CONTEXT

The People, Finance & Performance Committee (P,F&P) is one of the key committees of the Board responsible for Governance. Its purpose is to provide detailed scrutiny of financial matters, operational performance and indicators relating to our people in order to provide assurance and raise concerns (if appropriate) and to make recommendations, as appropriate, on people, financial and performance matters to the Board of Directors.

EXECUTIVE SUMMARY KEY: £k = thousands £m = millions

This report provides information to assist the Board to obtain assurance regarding the people, finance and operational performance and appropriate rigour of governance. The following papers were received at the meeting on the 25 June 2020: • Action log • Open Pathways • Covid-19 recovery plan and risk register • Workforce report, People Strategy quarterly update and Apprenticeship annual report • Integrated performance report (IPR) and Integrated Care System performance • Monthly ICT report and annual Information Governance (IG) report • Annual effectiveness report of PF&P Committee and sub-committees and revised Terms of Reference • Trust Governance Update • Consolidated finance report & ICS finance report • ICS Activity, Capacity and Capital submission June 2020 • Chairs’ logs from operational groups.

RECOMMENDATIONS

Board members are asked to receive and review the attached log.

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Subject: People, Finance and Performance Committee Assurance Report Ref: BoD: 20/08/06/09i

CHAIR’S LOG: Chair’s Key Issues and Assurance Model Committee / Group Date Chair People, Finance and Performance Committee 25 June 2020 Keely Firth, Non Executive Director KEY: FTE: Full Time Equivalent; £k = thousands; £m = millions

Agenda Item Issue and Lead Officer

Receiving Body, i.e. Board or

Committee

Recommendation / Assurance / mandate to

receiving body Open

Pathways The committee received assurance that progress is being made regarding the validation of open pathway records and underlying quality of the data systems. The project is expected to conclude by end July 2020. Board For information

and assurance.

Covid-19 Recovery

Programme update and risk register

The committee welcomed early sight of detailed recovery plans to reintroduce activity and people back into the organisation safely and were assured on progress despite the external factors, space, people and financial risks inherent with this highly challenging programme of work. Views from members were collated and will be reviewed at a strategic session of the board in a week’s time. Members were assured that the risk register is regularly monitored and acknowledged that it is a dynamic and evolving situation and the details will be modified if required after the strategic Trust Board session.

Board For information and assurance.

Workforce Insight Report

The committee considered in depth the report which provides analysis of the issues facing the Trust from a workforce perspective. The key points to be highlighted are as follows: - - Sickness Absence and Wellbeing: Sickness absence has decreased from 5.43% to 5.04% across both

long term and short term sickness with confirmed sickness for Covid-19 accounting for 0.89% and the remaining 4.15% due to other reasons. There are examples of good practice which trust colleagues are in the process of exploring further with a view to implementing at pace.

- Headcount & FTE: The headcount for the month is 4,239 (4,015 excluding bank). The actual FTE is recorded as 3,460 which when compared to funded establishment of 3,476 gives a variance of 10.

- There were 107 new starters in May including 43 2nd year nursing students in response to Covid. The majority of the 3rd year students have accepted job offers at the trust commencing in September.

- Staff Turnover: The turnover rate is at 10.46% and above the target range of between 7–10%. - Concerns raised at the May committee led to the presentation of a more detailed analysis of the Allied

Health Professionals (AHPs) with therapists in particular an area of interest due to higher numbers of leavers. Further concerns have been raised as Covid-19 restrictions have required the service delivery to switch to the community. Changes to career pathways have been introduced which will take time to see benefits and flexible working arrangements are being explored where possible. The other areas with higher turnover rates continue to be (i) Prof and Tech at 13.5% and (ii) Nurses & Midwives at 12.9%. The committee was assured that some measures are already in place for example improved career paths and stay discussions with more focus and actions planned. There were 27 leavers in the month with the top reason classified as “Voluntary Resignation Promotion”.

- Mandatory Training: Mandatory Training is at 85% (a small decrease from last month).


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Committee


receiving body Restrictions have now been lifted and all 10 topics are being delivered primarily via e-learning.

- Appraisals: The appraisal window is now open to 31st August 2020 with remote and home working solutions being provided.

People Strategy Quarterly Update

The committee received a helpful paper regarding the progress on the strategy. Whilst acknowledging that there are a number of proactive arrangements in place to support the key elements of the strategy, members made suggestions to ensure plans are SMART, clearly align with CQC, IIP and NHS Leadership standards and embrace resources already widely available.


Apprenticeship Annual Report

The committee received assurance that our Apprenticeship programme is well managed and performs very strongly within the South Yorkshire region. Members expressed thanks to the teams involved and to the departments who support them and offered suggestions for further expansion of the Apprenticeships’ offer.


Integrated Performance

Report

The committee reviewed the IPR focusing on the key performance indicators around patient access, people and finance. As reported in May, the Trust continues to strive to deliver strong performance but Covid-19 presents significant delivery pressures. With nationally prescribed requirements and the warning of new outbreaks, the Trust is succeeding in its response to the changes but now faces a challenging recovery plan. - Emergency access & Patient Flow: Performance against the four-hour standard decreased in May to

94.3% from 95.3%. ED attendances continue to steadily rise but Covid-19 measures continue to disrupt the flow of patients through the department.

- RTT: Covid-19 affected the position in April with most specialties non-compliant with further deterioration expected as a result of continuing limitations on elective services. A recovery plan is being developed.

- Cancer: Covid-19 restrictions on cancer services resulted in the 2 week wait from referral and 62 day referral to treatment national standards not being attained in April. The 31 day first treatment standard and the 2 week symptomatic breast referral target were achieved. It is expected that the 2 week target will be achieved from May but the 62 day target will continue to prove challenging with the diagnostic phase of pathways particularly problematic

- Diagnostic Waits: Performance against the 6 week diagnostic standard declined further in May as a result of Covid-19 restrictions on services with 27% of investigations performed within target.

- Urgent endoscopy and non-urgent imaging services are being restored in June albeit with reduced rates of output due to distancing requirements. Planned diagnostics recommenced on the 15th June.

Board

For information, assurance and to

note the increased risk to delivery of access targets.

ICT Report and Annual Information Governance

Report

The committee wishes to acknowledge once again the team members who continue to work hard under pressure to facilitate the significant shift in our approach to operational delivery. - System C Medway EPR project – a dress rehearsal was competed successfully over the weekend of

the 13th June and whilst there were no major issues it is clear that engagement from staff for both training and at go-live will be key to the success of the migration. Whilst training is proving to be challenging in the current situation, members were assured that staff were being encouraged to book and complete the training which for many is a refresh of what was undertaken for the original go live date.


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Committee


receiving body - Measures introduced due to COVID-19 – all changes have been agreed and logged via the major

incident governance processes and the executive team for any changes impacting clinical staff. - Annual IG report – the committee received the annual report which set out the activities relating to IG

controls, incidents and monitoring. There were 1,181 Freedom of Information requests, 1,494 subject access requests and no serious IG incidents in year.

Committee Effectiveness

Review

The committee received a review of the effectiveness of the committee and sub committees and approved the terms of reference for the sub committees. The report will be provided to the August Trust Board and the committee recommends the approval of the revised terms of reference.

Board For information, assurance and Board approval

Trust Governance

Update

Assurance was provided regarding the revised Covid-19 governance arrangements for sub committees which are continuing to meet regularly with the exception of the CIP steering group. Members advised that this group will need to be reenergised to respond to potential funding restrictions post Covid-19.


Trust/BFS Finance Report

The committee received assurance that national measures are in place to support Trusts during the April – July 2020 period with the ability to retrospectively claim via the NHSE top up process. Consequently the Trust has a consolidated breakeven position for the month after accruing an additional £0.06m top-up. The revenue impact of COVID-19 (before offsets and block arrangements) is a reduction in NHS clinical income by £14m; non-NHS income has fallen by £0.6m and revenue costs increased by £2.4m. The cash position at the end of the month is £38.9m and capital expenditure on Core Programme schemes at Month 2 is £0.2m which is £0.14m less than plan. A further £0.64m was spent on COVID-19 schemes. Looking ahead it is probable that block arrangements will continue with nationally prescribed deliverables.


ICS Activity, Capacity and

Capital submission

The committee received a report regarding the Trust’s recent planning submission to inform future capacity plans including a comparison to high-level assumptions which had been made by the regional teams. The submission was split in 2 parts, part 1 being what could be delivered within the current envelope considering recovery constraints through social distancing, part 2 being what would it take to recover 100% of the 19/20 activity levels, again with the recovery constraints through social distancing. The Trust also submitted capital bids in support of the 2 recovery scenarios with option 1 to meet inpatient demand, totalling £6.6m and option 2 to permanently relocate ITU, totalling £6m. Members were supportive of the rationale used which appears to consider a more realistic projection of demand and capacity than the assumptions made by regional teams.


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F&P 27th JUNE 2019:

REPORT TO THE TRUST BOARD REF: BoD: 20/08/06/09ii

SUBJECT: DEATH IN SERVICE POLICY (NEW)


PURPOSE:


applicable For decision/approval X Assurance


PREPARED BY: Ian Hall, HR Business Partner SPONSORED BY: Steve Ned, Director of Workforce PRESENTED BY: Steve Ned, Director of Workforce STRATEGIC CONTEXT The Trust is committed to ensuring that the very highest standard of care is given to all those who may be affected following the death of a colleague. The policy outlines the steps the Trust will take in order to meet those standards and to ensure consistency in these matters. It also supports line managers with clear guidance.

EXECUTIVE SUMMARY

This Policy has been developed to ensure that the management and administrative arrangements following a death in service are conducted swiftly and with due respect to families, friends and colleagues. It is designed to balance sensitivity with the practical arrangements of administering pay and, if applicable, pension benefits during a difficult time for the next of kin.

RECOMMENDATION

That Trust Board ratify the new policy that has been recommended by the People, Finance & Performance Committee.

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1

Policy

Death in Service

Author/Owner Ian Hall – HR Business Partner

Equality Impact Assessment

Yes Date: July 2020

Version 1

Status Draft

Publication date August 2020

Review date August 2022

Approval recommended by

People, Finance & Performance Committee

Date: 30.07.20

Approved by Trust Board Date:

Distribution Barnsley Hospital NHS Foundation Trust – intranet

Please note that the intranet version of this document is the only version that is maintained.

Any printed copies must therefore be viewed as “uncontrolled” and as such, may not necessarily contain the latest updates and amendments

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2

Table of Contents Section heading Page

1.0 Introduction 2

2.0 Objective 2

3.0 Scope 2

4.0 Procedure Following a Death in Service 3

4.1 Completion of Leavers Form 4

4.2 Payment of Final Salary / Pension Arrangements 4

4.3 Bereavement Leave 4

4.4 Attendance of Trust Representatives at Funeral 4

4.5 Terminal Illness 5

4.6 Employee who Dies at Work 5

4.7 Salary Sacrifice Schemes 5

4.8 Sensitivity 5

5.0 Roles and responsibilities

5.1 Line Manager 5

5.2 Pensions and Financial Advice 6

5.3 Chief Executive 6

6.0 Associated documents and references 6

7.0 Training and resources 6

8.0 Monitoring and audit 6

9.0 Equality, diversity and inclusion 6

9.1 Recording and monitoring of equality, diversity and inclusion

7

Appendix 1 Equality impact assessment 8

Appendix 2 Document history/version control

8

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Section Headings

1.0 Introduction This Policy has been developed to ensure that the management and administrative arrangements following a death in service are conducted swiftly and with due respect to families, friends and colleagues. It is designed to balance sensitivity with the practical arrangements of administering pay and, if applicable, pension benefits during a difficult time for the next of kin. 2.0 Objective The Trust is committed to ensuring that the very highest standard of care is given to all those who may be affected following the death of a colleague. The following policy outlines the steps the Trust will take in order to meet those standards and to ensure consistency in these matters. It also supports line managers with clear guidance. Each case will be managed appropriately and will be dependent on the circumstances involved. Additionally, it is accepted that the death of a colleague has a major impact on the team. Managers should ensure appropriate support is put into place/offered to colleagues through this difficult and emotional time. 3.0 Scope This document applies to all NHS staff employed by the Trust affected by a death in service and will be applied consistently and equitably to all staff. 4.0 Procedure following a Death in Service When a death in service occurs, the deceased employee’s line manager must undertake the following actions:

• Inform the relevant Director (for clinical areas both the Associate Director of Nursing and Operations)

• Inform the Chief Executive’s office • Liaise with the Communications Team • Inform Payroll (via the PAYROLL email address at [email protected] detailing

employee name, date of death, and next of kin contact details) • Inform the relevant HR Business Partner • Inform Occupational Health • Inform E-rostering • Complete a leavers form (e-form) clearly identifying that the employee died in

service. Once informed via the Chief Executive’s Office, the Director of Workforce will contact the colleague’s next of kin to offer condolences on behalf of the Trust and agree what support the Trust can offer. However, careful consideration will be given to the appropriateness and circumstances surrounding the individual case. The relevant Associate Director / Line Manager is also welcome to write and make contact with the deceased employee’s next of kin. However, careful consideration will be given to the appropriateness and circumstances surrounding the individual case and the relationship between colleagues, manager and the Trust.

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mailto:[email protected]

4

The relevant Associate Director / Line Manager will liaise with the Trust’s Communications Team to agree how best to cascade notification of the death to relevant colleagues via email. This should always be undertaken in a sensitive manner. It is important to consider whether the next of kin is aware of the death at this point. Under normal circumstances the next of kin will notify the Trust, however if there has been a death whilst at work the Trust will be the first people to know. It is important in this situation that the family is formally notified before any colleagues. Advice should be taken from HR and the Communications Team. Where there is likely to be press interest in the death of an employee, the relevant Associate Director / Line Manager will liaise with the Communications Team to agree a strategy for dealing with media interest. It is accepted that a death of a colleague has a major impact on the team. Managers should therefore ensure appropriate support is put in place / offered to colleagues through this difficult and emotional time. Examples of support may include:-

• Support from the staff counselling and support service (EAP) • Spiritual and pastoral care • Support from the Occupational Health Service

Once payroll are notified of the death in service, the Payroll Manager will contact the next of kin to discuss pension and death in service benefits where appropriate. Payroll will also help the next of kin with these arrangements as they can be complicated and cumbersome. The Line Manager will contact the employee’s next of kin to sensitively arrange for any personal belongings that are currently at work to be returned. The manager will also ensure the return of Trust items e.g. trust ID badges, laptops etc. Managers needs to be mindful of certain cultural sensitivities, where appropriate, regarding practices after death e.g. speed of the funeral. Further guidance and advice can be sought from the Trust’ Equality, Diversity and Inclusion Lead. 4.1 Completion of a Leavers Form When a death in service occurs, the deceased employee’s line manager is responsible for completing an electronic leavers form as soon as practicable. To prevent an exit interview questionnaire being issued and to prevent unnecessary communication with the next of kin, the leaver form must state “Death in Service”. The leaver form should include any outstanding annual leave owed to the deceased employee. However where the employee has taken too much annual leave, any overpayment will not be pursued. 4.2 Payment of Final Salary / Pension Arrangements Payroll cannot start to process any payment of salary or benefits until they have been advised by the HR Business Partner and/or the Line Manager. Where the deceased employee was a member of the NHS pension scheme, Payroll will liaise with the executors, next of kin and the NHS Pensions Agency about the pension administration. 4.3 Bereavement Leave

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Details of Bereavement Leave can be found in the Trust’s Family Friendly Policy (Section 9, page 10) 4.4 Attendance of Trust Representatives at Funeral In the event of a death in service, the Trust would wish to show support at a senior level to the next of kin and the deceased employee’s colleagues. Where appropriate it may be seen suitable that a Trust Director or Senior Manager attend the deceased employee’s funeral to represent the Trust. Line Managers should discuss this with the family and will assess whether this representation is appropriate. 4.5 Terminal illness In the event of a member of staff developing a terminal illness, sensitive and supportive management should take place. The absence of the member of staff should always be recorded as sickness absence, to ensure that the sick pay continues to be paid. HR and Occupational Health must also be informed of the situation and kept updated in order to provide appropriate advice and support in relation to progressing ill health retirement. 4.6 Employee who Dies at Work If an employee dies as a result of natural causes or an accident at work, the Line Manager must immediately call the emergency 999 number and ask for an ambulance and/or the Police. They should also contact the Health and Safety Executive. Internally, the Line Manager must also inform the Trust’s Non-Clinical Risk Advisor (who sits within the Trust’s Health and Safety Team) as well as the on-call Silver Manager. The Line Manager should then complete a Datix, including as much information about the incident as possible. This should be completed as soon as possible after the accident. 4.7 Salary Sacrifice Schemes Where a member of staff has an agreement with payroll for payment of goods, i.e. Cycle to Work Scheme, lease car, electrical goods, and the deductions are taken directly from their salary; the agreement will cease if the member of staff dies. No further payments will be deducted from their salary. The outcome of what will happen to any goods obtained in this way will be dependent on the contract signed at the time of agreeing to take part in the scheme. 4.8 Sensitivity Sensitivity must be displayed at all times when dealing with the death of a member of staff. Relatives and colleagues must be treated with courtesy and respect. It is recognised that this is a difficult time for colleagues and referrals to the Occupational Health Service can be requested if and when required. 5.0 Roles and responsibilities 5.1 Line Manager

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The line manager is likely to be the first person to be advised when a member of staff dies, therefore, it is the manager’s responsibility to inform relevant parties in line with this policy. As well as the tasks identified in this policy, the line manager is also responsible for:

• Responding appropriately to the requests of the next of kin, bearing in mind the need to be sensitive to any religious or cultural beliefs or practices

• Where appropriate, arranging with IT for the member of staff’s email account to be assigned to them so that messages can be dealt with in an appropriate way.

• Ensuring that the deceased employee’s details are removed from circulation lists, rotas etc. Ensuring that the deceased employees IT and email accounts are disabled.

• Dealing sensitively with the return of personal belongings to the next of kin • Ensuring the return of Trust property e.g. keys, ID Badge, mobile phones etc. is dealt

with at an appropriate time. However, relatives or next of kin should not be pressured immediately after the death to return such items.

5.2 Pensions and Financial Advice If the member of staff is in the NHS Pension Scheme, payroll will liaise with the Pension Department to ensure that the member of staff is properly advised and aware of their options and related entitlements. 5.3 Chief Executive The Chief Executive will ensure that appropriate condolences are expressed at a senior level from the organisation to the next of kin and deceased member of staff’s team. Where the death in service occurs in the workplace the Chief Executive has overall responsibility for ensuring the appropriate incident procedures are implemented. 6.0 Associated documents and references Guidance document – Bereavement due to Covid-19 NHS Pensions Death in Service Benefits page - https://www.nhsbsa.nhs.uk/member-hub/family-and-your-pension Life assurance booklet - https://www.nhsbsa.nhs.uk/employer-hub/technical-guidance/family-benefits-and-life-assurance 7.0 Training and resources This Policy will be available on the Trust’s Approved Documents Page. HR are also available to answer any questions from managers.

8.0 Monitoring and audit Minimum requirement to be monitored Correct application of policy ensures

Process for monitoring e.g. audit Audit

Responsible individual/ group/ committee Director of Workforce

Frequency of monitoring Annual

Responsible individual/ group/ committee for review of results People and Engagement Group

Responsible individual/ group/ committee for development of action plan Director of Workforce

Responsible individual/group/ committee for monitoring of action plan and Implementation People and Engagement Group

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https://www.nhsbsa.nhs.uk/member-hub/family-and-your-pension

https://www.nhsbsa.nhs.uk/member-hub/family-and-your-pension

https://www.nhsbsa.nhs.uk/employer-hub/technical-guidance/family-benefits-and-life-assurance

https://www.nhsbsa.nhs.uk/employer-hub/technical-guidance/family-benefits-and-life-assurance

7

statutory and contractual compliance 9.0 Equality and Diversity The Trust is committed to an environment that promotes equality and embraces diversity in its performance as an employer and service provider. It will adhere to legal and performance requirements and will mainstream equality, diversity and inclusion principles through its policies, procedures and processes. This Policy should be implemented with due regard to this commitment. To ensure that the implementation of this Policy does not have an adverse impact in response to the requirements of the Equality Act 2010 this policy has been screened for relevance during the policy development process and a full equality impact assessment is conducted where necessary prior to consultation. The Trust will take remedial action when necessary to address any unexpected or unwarranted disparities and monitor practice to ensure that this policy is fairly implemented. This Policy can be made available in alternative formats on request including large print, Braille, moon, audio, and different languages. To arrange this please refer to the Trust translation and interpretation policy in the first instance. The Trust will make reasonable adjustments to accommodate any employee/patient with particular equality, diversity and inclusion requirements in implementing this policy. This may include accessibility of meeting/appointment venues, providing translation, arranging an interpreter to attend appointments/meetings, extending policy timeframes to enable translation to be undertaken, or assistance with formulating any written statements. 9.1 Recording and Monitoring of Equality & Diversity The Trust understands the business case for equality, diversity and inclusion and will make sure that this is translated into practice. Accordingly, all policies will be monitored to ensure their effectiveness. Monitoring information will be collated, analysed and published on an annual basis as part of Equality Delivery System. The monitoring will cover the nine protected characteristics and will meet statutory employment duties under the Equality Act 2010. Where adverse impact is identified through the monitoring process the Trust will investigate and take corrective action to mitigate and prevent any negative impact.

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Appendix 1

EQUALITY IMPACT ASSESSMENT TEMPLATE INITIAL ASSESSMENT STAGE 1 (part 1)

Department: Human Resources

Division: Business Partner Team

Title of Person(s) completing this form:

HR Business Partner

New or Existing Policy/Service

New

Title of Policy/Service/Strategy being assessed:

Death in Service Implementation Date:

July 2020

What is the main purpose (aims/objectives) of this policy/service?

This Policy has been developed to ensure that the management and administrative arrangements following a death in service are conducted swiftly and with due respect to families, friends and colleagues. It is designed to balance sensitivity with the practical arrangements of administering pay and, if applicable, pension benefits during a difficult time for the next of kin.

Will patients, carers, the public or staff be affected by this service? Please tick as appropriate.

Yes No If staff, how many individuals/which groups of staff are likely to be affected? Any staff could be affected

Patients X Carers X Public X Staff X

Have patients, carers, the public or staff been involved in the development of this service? Please tick as appropriate.

Patients X If yes, who did you engage with? Please state below: Trade Union Representatives at Policy Review Group. Managers and Directors at People & Engagement Group, and People, Finance & Performance Committee

Carers X Public X Staff X

What consultation method(s) did you use?

n/a

Equality Impact Assessment Stage 1 PART 2 Based on the data you have obtained during the consultation what does this data tell you about each of the above protected characteristics? Are there any trends/inequalities?

Consultation with staff side as part of the normal HR governance processes when introducing a new policy. As a new policy, it will go through the full Trust governance process which means it will be reviewed and discussed fully, including at the Trust’s Executive Team.

What other evidence have you considered? Such as a ‘Process Map’ of your service (assessment of patient’s journey through service) / analysis of complaints/ analysis of patient

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satisfaction surveys and feedback from focus groups/consultations/national & local statistics and audits etc.

Have considered the different processes of other departments such as Communications, Payroll etc. Have researched a number of other national NHS organisations to look at best practise and tried to incorporate these into the policy.

Equality Impact Assessment Stage 1 PART 3

ACCESS TO SERVICES

What are your standard methods of communication with service users?

Please tick as appropriate.

Communication Methods Yes No Face to Face Verbal Communication x Telephone x Printed Information (E.g. leaflets/posters) x Written Correspondence x E-mail x Other (Please specify)

If you provide written correspondence is a statement included at the bottom of the letter acknowledging that other formats can be made available on request?

Please tick as appropriate.

Yes No

Are your staff aware how to access Interpreter and translation services?

Interpreter & Translation Services Yes No Telephone Interpreters (Other Languages) x Face to Face Interpreters (Other Languages) x British Sign Language Interpreters x Information/Letters translated into audio/braille/larger print/other languages?

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EQUALITY IMPACT ASSESSMENT – STAGE 1 (PART 4)

Protected Characteristic

Positive Impact

Negative Impact

Neutral Impact

Reason/comments for positive or negative Impact

Why it could benefit or disadvantage any of the protected characteristics

Men

X

Women

X

Younger People (17 –

25) and Children

X

Older people (60+)

X

Race or Ethnicity

X

Learning Disabilities

X

Hearing impairment

X

Visual impairment

X

Physical Disability

X

Mental Health Need

X

Gay/Lesbian/Bi

sexual

X

Trans

X

Faith Groups (please specify)

X

Marriage & Civil

Partnership

X

Pregnancy & Maternity

x

Carer Status

X

Other Group X

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(please specify)

INITIAL ASSESSMENT (PART 5)

Have you identified any issues that you consider could have an adverse (negative) impact on people from the following protected groups?

YES NO x

IF ‘NO IMPACT’ IS IDENTIFIED Action: No further documentation is required. IF ‘HIGH YES IMPACT’ IS IDENTIFIED Action: Full Equality Impact Assessment Stage 2 Form must be completed. (c) Following completion of the Stage 1 Assessment, is Stage 2 (a Full Assessment) necessary? Assessment Completed By: Ian Hall Date Completed: 29th May 2020 Line Manager - Karl Hickman Date July 2020 Head of Department - Steve Ned Date July 2020 When is the next review? Please note review should be immediately on any amendments to your policy/procedure/strategy/service. 1 Year 2 year - X 3Year Appendix 2 Maintain a record of the document history, reviews and key changes made (including versions and dates) Version Date Comments Author 1 20.5.2020 new policy I Hall Review Process Prior to Ratification: Name of Group/Department/Committee Date Policy review Group 20.5.2020 People & Engagement Group 18.06.2020 People, Finance & Performance Committee 30.07.2020

YES NO x

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BoD August 2020


SUBJECT: AUDIT COMMITTEE CHAIR’S LOG

DATE: 6 AUGUST 2020

PURPOSE:




PREPARED BY: Nick Mapstone, Chair of the Audit Committee SPONSORED BY: Nick Mapstone, Chair of the Audit Committee PRESENTED BY: Nick Mapstone, Chair of the Audit Committee STRATEGIC CONTEXT

The Audit Committee provides assurance to the Board on the effectiveness of the controls established to mitigate risks to the delivery of the Trust’s objectives.

EXECUTIVE SUMMARY

The Committee:

• reviewed the Trust’s response to the Limited Assurance opinion received from internal audit following a review of compliance with the Mental Health Act;

• reviewed the draft risk management strategy;

• noted the Annual Audit Letter;

• agreed changes to the Internal Audit Plan 2020/21; and

• noted arrangements to appoint a new external auditor. RECOMMENDATION

The Board of Directors is to note the assurances provided by the Audit Committee.

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BoD August 2020

Subject: AUDIT COMMITTEE ASSURANCE REPORT Ref: BoD: 20/08/06/10 CHAIR’S LOG: Key Issues and Assurance Committee / Group Date Chair Audit Committee 15 July 2020 Nick Mapstone

Agenda Item Issue Receiving Body,

i.e. Board or Committee

Recommendation/ Assurance/ mandate to

receiving body

Board Assurance Framework and Corporate Risk Register The BAF and CRR were not available for the Committee to see; however, both will be available for members of the Committee to see at the assurance committees later in July.

Board To note

5

Mental Health Act Audit The Director of Nursing has prepared an action plan to respond to the Limited Assurance opinion received following an internal audit review. Delivery of the plan will be overseen by a new Mental Health Strategy and Implementation Group, reporting to the Quality and Governance Committee.

Board Q&GC Assurance

7

Draft risk management strategy, policy and procedures A paper had been approved by the Executive Team and submitted to the Audit Committee for scrutiny prior to it being considered by the Board. The Committee made the following observations that the Board may wish to consider:

Board Information

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BoD August 2020 Page 2 of 5




receiving body The Committee is of the view that:

• There is a need to link risk appetite with the Quality Impact Assessment process.

• The two tables on page 6 are inconsistent. • To target the correct audience, there may be merit in dividing the

current draft into:

(a) a risk management policy; (b) a risk appetite statement; and (c) a standard operating procedure with a risk register template.

• The BAF/CRR need to distinguish between risks and issues. • The Board should consider the merit of a single risk register

incorporating strategic risks (the Board Assurance Framework) and operational risks (the Corporate Risk Register) as recommended by NHS England.

• The BAF and CRR should be considered at every meeting of the assurance committees and the Board (not quarterly as stated in the paper.)

• Every report to the Board or assurance committees should be cross referenced to risks on the BAF/CRR.

• The Likelihood matrix on page 34 needs to be clearer and more consistent.

• The risk of fraud, corruption and bribery should be included in the policy.

• The paper should be shorter.

8.1 Annual Audit Letter

Board Assurance

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receiving body The Annual Audit Letter for the last financial year was received. It reflected the positive outcome of the audit.

8.2

Internal Audit Plan 2020/21 The delivery of the plan has been compromised by the impact of the pandemic. The Committee agreed to reduce the plan by 57 days by dropping or deferring the following reviews:

• Integrated Care System • Policy management • Performance management • Rostering • Transformation – new EPR

Board Recommendation

8.3

Counter Fraud The Committee received the CFS progress report. There is a need to improve the Trust’s arrangements for declaring and managing conflicts of interest. The DoF proposes that staff will not be allowed to requisition or authorise procurement of goods or services unless a completed declaration has been logged.

Board Assurance

8.4

Clinical audit and compliance with NICE/NCEPOD The Committee reviewed a comprehensive report that provided assurance from the clinical audit programme about the quality of services provided by the Trust. It was suggested that an example of clinical audit improving the

Board Information

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receiving body quality of services should be presented to the Board as a ‘patient story’.

10

Invitation of Tenders for External Audit Services The External Auditor’s contract ends on 31 August 2020. The DoF said that Procurement is currently reviewing the market and it is likely that only one firm on the current framework is likely to be interested in the contract. If t The Council of Governors will need to approve the appointment of new external auditors at its meeting on 16 September 2020. Members of the Audit Committee will need to meet before then to make a recommendation to the Governors.

Board

Assurance

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BoD Front Sheet - template

REPORT TO THE BOARD OF DIRECTORS REF: BoD: 20/08/06/10i

SUBJECT: AUDIT COMMITTEE ANNUAL REPORT


PURPOSE:




PREPARED BY: Nick Mapstone, Chair of Audit Committee SPONSORED BY: Nick Mapstone, Chair of Audit Committee PRESENTED BY: Nick Mapstone, Chair of Audit Committee STRATEGIC CONTEXT

The Trust’s governance arrangements require that each assurance committee prepares an annual report on its activities in the previous financial year and reflects on its effectiveness.

EXECUTIVE SUMMARY

The annual report describes the Committee’s work during 2019/20 and explains how it has discharged its duties as set out in the terms of reference. Regular attendees were invited to complete an anonymised survey based on a template recommended by the Healthcare Financial Management Association. The results of the review and the survey do not raise any material concerns, though the challenges for 2020/21 are noted. RECOMMENDATION The Board is invited to review the Audit Committee’s annual report. The Committee’s Terms of Reference are attached for annual review (Appendix 1). It is proposed that they be amended as indicated to reflect the Committee’s responsibility for data quality and oversight of the work of the Data Quality Group. The Committee has conducted an evaluation of its effectiveness. The results are attached for discussion (Appendix 2).

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Audit Committee Annual Report 1. Executive Summary

Throughout 2019/20, the Audit Committee has supported the Board of Directors by reviewing and reporting on the effectiveness of systems of internal control. It has maintained oversight of the totality of organisational risk and the public disclosure statements that flow from assurance processes. The Committee has maintained good working relationships with its external and internal auditors and counter-fraud service. 2. Introduction and Purpose of the Report The Audit Committee is established under Board delegation with approved terms of reference. The Committee independently reviews, monitors and reports to the Board of Directors on the attainment of effective control systems and financial reporting processes. The Membership and Terms of Reference are subject to annual review. This report sets out how the Committee has satisfied its terms of reference during the financial year. 3. Membership and Attendance The Audit Committee comprises three non-executive directors (NEDs) and the Associate NED. Two NEDs must be present for the Committee to be quorate. The Committee has been chaired since January 2018 by Nick Mapstone. Keely Firth and Philip Hudson were the other members of the Committee throughout 2019/20. Kevin Clifford, the associate non-executive director, joined the Committee in January 2020. The NEDs bring an excellent combination of skills to the Committee. Keely is an accountant, Philip is a lawyer and Kevin is a clinician. The four NEDs are also members of the Trust’s other two main assurance committees, thus providing full oversight of the Trust’s governance arrangements.

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Tony Dobell, a public governor, attends the Committee as an observer and thus is able to report to the governors of the management of organisational risk. The Committee met six times during 2019/20. There was 100 per cent attendance from members and auditors; and nearly 100 per cent attendance from regular officers. Other staff, for example the Director of ICT, attended when necessary to provide assurance about clinical, operational and financial risks. 4. Principal Review Areas 4.1 Governance, Risk Management and Internal Control During 2019/20 the Committee reviewed relevant disclosure statements, in particular the Annual Governance Statement (AGS), the Head of Internal Audit Opinion (HoIAO), the external audit opinion and other independent assurances. It considers that the AGS is consistent with the Committee’s view on the Trust’s system of internal control. Accordingly, the Committee recommended Board approval of the AGS for 2019/20. The Committee reviews the Trust’s corporate risk register and Board Assurance Framework at every meeting. This is to consider whether the internal controls and processes are resilient rather than reviewing individual risks. 4.2 External Audit The Trust appointed its current external auditors, Grant Thornton (GT) in 2016 for a three year period. The Committee recommended to the Council of Governors that the option should be taken to extend the contract for a further year. This was agreed. The Committee will oversee the invitation of tenders for the external audit service to run from September 2020. The Committee expects an increase in external audit fees in view of the increasingly stringent demands placed on auditors by the National Audit Office and the Financial Reporting Council. Progress reports are received from GT at Committee meetings, including the audit opinion on the Trust’s annual financial statements and quality account. The Committee has discussed the significant risks identified during the year. These include the risk that the valuation of land and buildings may be overstated in the light of an expected fall in property values; management override of controls and going concern considerations. (The latter is now less of a risk with the debt for equity swap following the Government’s decision to write off NHS debt.)

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The GT intelligence reports are informative and enable the Committee to horizon-scan for risks. During the year, private meetings with both the external and internal auditors can be provided as a standing offer. In the event, we met in private on one occasion. In informal discussion, both sets of auditors have expressed satisfaction with the level of cooperation received from the Trust and no matters of concern have been raised. 4.3 Internal Audit The Trust’s internal audit service has been provided by 360 Assurance and its predecessor organisations for the last eleven years. In May 2018, an independent review by CIPFA confirmed that 360 Assurance’s work complies with Public Sector Internal Audit Standards. The Committee has worked effectively with internal audit throughout the year to review, assess and develop internal control processes as necessary. An annual internal audit plan (238 days) was agreed, of which eight days were carried forward to 2019/20. The Committee reviews progress against the agreed internal audit work plan for 2019/20 via routine written progress reports from 360 Assurance at each meeting. Written progress reports outline the status of the planned audit work for the year and the outcome of individual reviews performed, along with associated recommendations. Internal Audit undertook 14 reviews in 2019/20 (Table A). Table A Internal Audit reviews 2019/20

2019/20 Internal Audit Plan outturn

Accounts Receivable Complete Significant

Absence Management through Occu-pational Health Intervention

Complete Limited

Incident Management Complete Limited

Data Quality Outpatients Complete Significant

Governance (including Quality Govern-ance) and Risk Management

Complete Significant

Well-led Complete Advisory

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Recruitment /workforce client-wide project

Complete Consultancy

Policy Monitoring Complete Consultancy

Accounts Payable Complete Significant/ Limited

Integrity of the General Ledger and Fi-nancial Reporting

Complete Significant

Mental Health Act Compliance Complete Limited

Data Security Standards In progress

Estates Maintenance In progress Delayed due to COVID

Security Management In progress Delayed due to COVID

The Committee will review the issues reported through its recommendations tracker to assess whether the gaps in controls identified are addressed. The HoIAO raised a concern that the Trust has not moved quickly to implement recommendations to improve the Board Assurance Framework. The Committee expects this concern to be address through a thorough review of risk management arrangements early in 2020/21. This will incorporate the outcome of the risk appetite workshop facilitated by 360 Assurance at the end of 2019. On receipt of each internal audit report any new recommendations are entered and monitored so that each recommendation is tracked as its implementation date has become due. The details contained on the tracker produce a routine summary report on the status of recommendations to each meeting of the Committee for oversight and scrutiny purposes. During the course of 2019/20, the Committee was pleased to note that internal audit recommendations are usually implemented in the timescales agreed. 4.4 Counter Fraud 360 Assurance provides the Trust with a Local Counter Fraud Service (LCFS). An annual plan of 65 days for 2019/20 was agreed. This plan was exceeded by 14 days with the Committee’s approval. This was because of the need to undertake a complex counter fraud investigation, which .was referred to the police. The Committee has received regular written progress reports from the LCFS throughout the year. The Committee notes the continuing efforts of the LCFS to

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promote awareness of counter fraud issues throughout the Trust and continue developing a strong anti-fraud culture, while also investigating allegations of fraud, corruption or bribery. 4.5 Clinical audit The external auditors have encouraged the Committee to use clinical audit as a source of assurance on the quality of care provided. The Committee has reviewed the clinical audit plan against best practice standards recommended by the Healthcare Financial Management Association.

About 40 per cent of clinical audit work is nationally mandated. The remainder is determined locally and overseen by the Clinical Effectiveness Group and Quality and Governance Committee to ensure that the choice of audit topics reflects the priorities and risks to organisational objectives. 5. Public Disclosure Statements At its May 2020 meeting, the Committee reviewed the draft annual financial statements for 2019/20. We will today (June 2020) hopefully be able to recommend approval to the Trust Board. The process of conducting the audit was smooth. The external auditors complemented the professionalism of the Trust’s finance and quality governance teams, and the quality of working papers. 6. Management Reports The Committee has not felt the need to request separate assurance from management during the course of the year. This is because the Committee is fully satisfied with the effectiveness of the work of the other assurance committees (Quality and Governance; and People, Finance and Performance) and their underpinning governance arrangements. 7. Conclusion and the Year Ahead The Committee has discharged its duties during 2019/20 as outlined in the executive summary of this report. The Committee expects that 2020/21 will be much more challenging year than 2019/20 for the following reasons:

• Recovery from the Covid-19 pandemic and associated productivity challenges will challenge the effectiveness of the Trust’s governance arrangements.

• New ways of working may present risks to probity and data security. • Risk of increased fraud associated with Covid-19.

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• A possible move away from activity-based payments to population-based payments signalled in the NHS 10 year Plan may jeopardise the Trust’s financial stability.

• Implementing the revised risk management strategy is likely to be a significant piece of work.

• The Trust’s BAF failed to anticipate the impact of Covid-19 – the Committee needs to consider the impact of other ‘Black Swan’ events in the future.

8. Recommendations The Committee’s Terms of Reference are attached for annual review (Appendix 1). It is proposed that they be amended to reflect the Committee’s responsibility for data quality and oversight of the work of the Data Quality Group. The Committee has conducted an evaluation of its effectiveness. The results are attached for discussion (Appendix 2). The Committee’s annual work plan is attached (Appendix 3). The work of the Data Quality Group is scrutinised by the Audit Committee. An evaluation of its effectiveness is attached (Appendix 4)

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Appendix 1

AUDIT COMMITTEE TERMS OF REFERENCE Proposed changes are shown in red

1 Constitution

The Board of Directors approves the establishment of a Committee of the Board to be known as the Audit Committee (the Committee). The Committee is a non-executive Committee of the Board of Directors and has no executive powers, other than those specifically delegated in these terms of reference.

2 Duties

2.1 The Committee is responsible for the following aspects of integrated governance, risk management and internal controls:

a) the Audit Committee provides an oversight of the activities of internal audit, external audit and the local counter fraud service and the assurance on internal control, including compliance with the law and regulations governing the Trust's activities.

2.2 In particular, the Committee will review the adequacy and effectiveness of:

a) All risk and control related disclosure statements (in particular the Annual Governance Statement and receive assurance from other committees), together with any accompanying Head of Internal Audit statement, external audit opinion or other appropriate independent assurances, prior to endorsement by the Board.

b) The underlying assurance processes that indicate the degree of the achievement of corporate objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements.

c) The policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements.

d) The policies and procedures for all work related to fraud and corruption as required by NHS Counter Fraud Authority (NHSCFA)

2.3 In carrying out this work the Committee will primarily use the work of Internal Audit, External Audit and other assurance functions, but will not be limited to these audit functions. It will also seek reports and assurances from Directors and Managers as

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appropriate, concentrating on the overarching systems of integrated governance, risk management and internal control, together with indicators of their effectiveness.

2.4 This will be evidenced through the Committee's use of an effective Assurance Framework to guide its work and that of the audit and assurance functions that report to it.

2.5 Internal Audit

The Committee shall ensure that there is an effective internal audit function established by management that meets mandatory Public Sector Internal Audit Standards 2017 and provides appropriate independent assurance to the Audit Committee, Chief Executive and Board. This will be achieved by:

a) Consideration of the provision of the Internal Audit service, the cost of the audit and any questions of resignation and dismissal.

b) Review and approval of the Internal Audit strategy, operational plan and more detailed programme of work, ensuring that this is consistent with the audit needs of the Organisation as identified in the Assurance Framework.

c) Consideration of the major findings of internal audit work (and management's response), and ensure co-ordination between the Internal and External Auditors to optimise audit resources.

d) Ensuring that the Internal Audit function is adequately resourced and has appropriate standing within the organisation.

e) Annual review of the effectiveness of internal audit.

The Head of Internal Audit shall have a direct reporting line to the Committee and its Chair.

2.6

External Audit

The Committee shall review and monitor the external auditors independence and objectivity and the effectiveness of the audit process. In particular the Committee will review the work and findings of the External Auditor appointed by the Trust and consider the implications and management's responses to their work. This will be achieved by:

a) Consideration of the appointment and performance of the External Auditor.

b) Discussion and agreement with the External Auditor, before the audit commences, of the nature and scope of the audit as set out in the Annual Plan.

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c) Discussion with the External Auditors of their local evaluation of audit risks and assessment of the Trust and associated impact on the audit fee.

d) Review all External Audit reports, including agreement of the annual audit letter before submission to the Board and any work carried outside the annual audit plan, together with the appropriateness of management responses.

The External Auditor shall have a direct reporting line to the Committee and its Chair.

The Council of Governors has the responsibility to appoint or remove the Foundation Trust's External Auditors.

2.7 Other Assurance Functions

The Committee shall review the findings of other significant assurance functions, both internal and external to the organisations, and consider the implications for the governance of the organisation.

These will include, but not limited to, any reviews by the Department of Health and Social Care arm’s length bodies or regulators/inspectors – for example, the Care Quality Commission, NHS Resolution etc. and professional bodies with responsibility for the performance of staff or functions – for example, Royal Colleges, accreditation bodies etc.

In addition, the Committee will review the work of other committees within the organisation, whose work can provide relevant assurance to the Audit Committee’s own areas of responsibility. In particular, this will include any clinical governance, risk management or quality committees that are established.

In reviewing the work of a clinical governance Committee, and issues around clinical risk management, the audit Committee will wish to satisfy itself on the assurance that can be gained from the clinical audit function.

2.8 Counter Fraud

The Committee shall satisfy itself that the organisation has adequate arrangements in place for counter fraud, bribery and corruption that meet NHSCFA’s standards and shall review the outcomes of work in these areas.

The Committee will refer any suspicions of fraud, bribery and corruption to the NHSCFA Counter-Fraud Service.

2.9 Standing Orders, Standing Financial Instructions and Standards of Business

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Conduct

a) To review on behalf of the Board of Directors the operation of, and proposed changes to the Standing Orders and Standing Financial Instructions, Codes of Conduct and Standards of Business Conduct; including maintenance of registers of interest.

b) To examine the circumstances of any significant departure from the requirements of any of the foregoing.

c) To review the Scheme of Delegation.

2.10 Financial Reporting

a) The Committee shall monitor the integrity of the financial statements of the organisation and any formal announcements relating to its financial performance. The Committee should ensure that the systems for financial reporting to the Board of Directors, including those of budgetary control, are subject to review as to the completeness and accuracy of the information provided.

b) The Committee shall have annual overview of the financial statements of the organisation and to annually review the accounting policies of the Trust and make appropriate recommendations to the Board of Directors.

c) The Committee shall focus particularly on

• The wording in the Annual Governance Statement

• Changes in and compliance with accounting policies, practices and estimation techniques

• Unadjusted misstatements in the financial statements

• Significant judgements in preparation of the financial statements

• Letters of representation

• Explanation from significant variances

• Significant adjustment from external audit

2.11 Other audit related issues

a) To review performance indicators relevant to the Committee.

b) To examine any other matter referred to the Committee by the Board of Directors and to initiate investigation as determined by the Committee.

c) Identify annual objectives of the Committee, produce an annual work plan in the

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agreed Trust format, measure performance at the end of the year and produce an annual report.

2.12 Whistleblowing

The Committee shall review the effectiveness of the arrangements in place for staff to raise (in confidence) concerns about possible improprieties in financial, clinical or safety matters and ensure that any such concerns are investigated proportionately and independently.

2.13 Data quality

The Committee will maintain a strategic oversight of data quality in the Trust. It will receive and review the minutes and action log from the Data Quality Group.

3 Membership

Full membership of the Committee is limited to Non-Executive Directors, whom the Board appoints on the recommendation of the Chairman of the Trust.

The Chairman may not be a member of the Committee. At least one of the Non-executive Directors should have recent and relevant financial experience.

The formal membership of the Committee shall comprise the following core members:

• Chair of the Committee, Non-executive Director

• Two other Non-executive Directors

• An Associate Non-executive Director

The Audit Committee may sit privately without any non-members present for all or part of the meeting if they so decide.

4. Attendance

It is expected that all members will attend all Committee meetings and an attendance record will be held for each meeting.

The Chief Executive and other Executive Directors should be invited to attend when the Committee is discussing areas of risk or operation that are the responsibility of that Director.

The Director of Finance, Deputy Director of Finance and Internal and External Auditors shall generally be in attendance at routine meetings of the Audit

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Committee.

The counter fraud specialist will attend a minimum of two Committee meetings a year.

The Chief Executive should be invited to attend, at least annually, to discuss with the Audit Committee the process for assurance that supports the Annual Governance Statement.

In line with best practice the Chairman of the Board of Directors is not a formal member but may be in attendance at Committee meetings.

No attendees, other than formal Members of the Committee (per section 3 above), shall have voting rights or be counted in the quorum.

5 Responsibility Of Members

Members of the Committee have a responsibility to:

• attend meetings, having read all papers beforehand; act as 'champions', disseminating information and good practice as appropriate;

• identify agenda items, for consideration by the Chair, to the Lead Director I Secretary at least 10 working days before the meeting;

• prepare and submit papers for a meeting, at least 5 working days before the meeting;

• if unable to attend, send their apologies to the Chair and Secretary prior to the meeting

• when matters are discussed in confidence at the meeting, to maintain such confidences;

• declare any conflicts of interest and potential conflicts of interest in accordance with the Barnsley Hospitals NHS Foundation Trust's policies and procedures;

• at the start of the meeting, declare any conflicts of interest I potential conflicts of interest with the Barnsley Hospitals NHS Foundation Trust's policies and procedures.

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6 Quorum

A quorum for any meeting of the Committee shall be attendance by two core members of Non-Executive Directors.

In the absence of the Committee Chair, one of the other core members shall assume the Chair for that meeting.

7

Frequency of meetings

Meetings of the Audit Committee shall be held at least five times per year and at such other times as the Chairman of the Committee shall require, subject to agreement with the Chairman of the Trust and the Chief Executive.

The External Auditors shall be afforded the opportunity at least once per year to meet with the Committee without Executive Directors present.

The Internal Auditors shall be afforded the opportunity at least once per year to meet the Committee without Executive Directors present.

8 Authority

The Committee is authorised by the Board of Directors to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to cooperate with any request made by the Committee. The Committee is authorised by the Board of Directors to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it is considered necessary.

9 Decision Making

Wherever possible members of the Committee will seek to make decisions and recommendations based on consensus.

Where this is not possible then the Chair of the meeting will ask for Members to vote using a show of hands, provided that nothing in the way of business is conducted is prohibited by the standing orders of the Barnsley Hospital NHS Foundation Trust.

In the event of a formal vote the chair will clarify what members are being asked to vote on - the motion. Subject to meeting being quorate a simple majority of Members present will prevail. In the event of a tied vote, the Chair of the meeting

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will have a second and deciding vote.

Only the Members of the Committee present at the meeting will be eligible to vote. Members not present, deputies and attendees will not be permitted to vote nor will proxy voting be permitted. The outcome of the vote, including the details of those Members who voted in favour or against the motion and those who abstained, shall be recorded in the Minutes of the meeting.

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Appendix 2 EVALUATION OF AUDIT COMMITTEE EFFECTIVENESS 2019/20

Statement

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Theme 1 – Committee Focus

I am clear about the objectives the Committee has set itself each year. 3 4

I understand how the Committee wants to operate in terms of the level of information it would like to receive for each of the items on its annual work plan.

3 4

I have a clear understanding of the Terms of Reference of the Committee.

5 2

The Committee gives equal prominence to quality and financial assurance

5 2 An increasing focus on quality noted, with links to the Quality Committee helping to strengthen this. Verbal updates and minutes from other Committees included on the AC agenda.

Theme 2 – Committee Team Working

The Committee membership has the right balance of experience, knowledge and skills to fulfill the role described in its Terms of Reference.

7

High calibre of NEDs on the AC. It is useful that there is representation from the other assurance committees in order to give a complete oversight of organisational risks.

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Statement

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Comments/ actions

The Committee has structured its agenda to cover, performance targets, financial control and key strategic areas of focus.

4 3

The work plan is reviewed at the end of every meeting to ensure that it is accurate and up to date.

7 Yes, good practice on this at each AC meeting.

It is clear to me why I am a member/ attendee of this Committee and what information I am required to provide to the Committee.

7

I feel sufficiently comfortable within the Committee environment to be able to express my views, doubts and opinions.

6 1

The Committee provides a challenging but comfortable environment (it is not intimidating). Chair and NEDs appear to welcome comments and views from both external and internal audit from our wider client base – which is a real positive from our perspective.

When a decision has been made or action agreed I feel confident that it will be implemented as agreed and in line with the timescale set down.

4 3

Theme 3 – Committee Effectiveness The quality of Committee papers received allows me to perform my role effectively.

3 4 Excellent service from external audit, internal audit and CFS.

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Statement

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Comments/ actions

Members/attendees provide real and genuine discussion and challenge which is of benefit to the effectiveness of the Committee.

4 2

Debate is allowed to flow and conclusions reached without being cut short or stifled due to time constraints.

6 1

Each agenda item is 'closed off' appropriately so that I am clear what the conclusion is; who is doing what, when and how and how it is being monitored.

6 1

The Committee provides a written summary report of key points from its meetings to the Board of Directors.

7

There is a formal appraisal of the Committee’s effectiveness each year which is evidence based and takes into account my views and wider views.

6 1

The Committee actively challenges information provided during the year to gain a clear understanding of progress and achievement.

5 2

Theme 4 – Leadership

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Statement

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The Committee’s Chair has a positive impact on the performance of the Committee.

6 1 Chair is very experienced in governance and assurance across the Public Sector. His role with the CQC also brings an added dimension to his oversight of the Audit Committee.

Committee meetings are chaired effectively and with clarity of purpose and outcome.

6 1

The Chair allows debate to flow freely and does not assert his/her views too strongly.

6 1

General

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Statement

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Comments/ actions

We have previously raised the challenge for all NHS FT audit committees is to keep up the focus on clinical audit and try to ensure it moves into working in a manner akin to external and internal audit (given it is part of the overall assurance mechanism of the Trust). I think good progress has been made in this area in recent years and needs to be maintained (I’m sure your new auditors will monitor this in their 20-21 audit). If clinical audit can continue to move to a more cyclical approach of a Clinical Audit Plan. Whilst noting a lot of audits are nationally mandated, but for locally selected audits what is the decision making process to identify, select and agree these clinical audits for BHFT – e.g. this shouldn’t just be those of interest to a particular clinician). This should be coupled with monitoring of the delivery of the Clinical Audit Plan in year at the AC and then some form of final report for the May/June meeting summarizing work done and assurance that the Committee can then ensure is reflected in the AGS and Annual Report. The quality of papers is strong from our audit colleagues. There is a job of work across the Trust to review papers in the context of consistency, layout, focus etc. therefore this should be picked up Trust wide. I look forward to the revised risk management strategy in July 2020. This will be an opportunity for us to debate and hopefully tackle some long-standing issues: the need for a revised BAF and CRR; and considering the merits of a formal statement of risk appetite. 2020/21 will be a challenging year as we review our response to and recovery from the pandemic.

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Appendix 3 AUDIT COMMITTEE ANNUAL WORKPLAN 2019/20

Agenda Item/ Issue May June July October January Minutes of previous meeting x X x x x Chair’s Log x X x x x Action Log x X x x x Receive annual governance statement x (draft) X Receive the annual report x (draft) X Receive the quality account x (draft) X Receive audited annual accounts and financial statements x (draft) X

Receive BFS accounts – as part of group accounts x (draft) X x

Receive annual internal audit report and associated opinions x (draft) X

Review Internal and External Audit Recommendations Tracker

x X x x x

Private discussions with internal/external auditors as required

x X x x x

Review and agree external audit plans x Review the effectiveness of external audit x Review external audit progress reports x X x x x Review and approve ISA 260 and 700 X Review and agree internal audit plan x x (draft) Review and approve internal audit terms of reference

x

Review of the effectiveness of internal audit x Review Internal audit progress reports x X x x x

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Agenda Item/ Issue May June July October January Review and agree the annual work plan for the Counter Fraud Service

x X x (draft)

Receive counter fraud progress reports x x x x Review the organisation’s annual self-review against counter fraud x

Receive the annual report of the Local Counter Fraud, Bribery and Corruption Services and self-review

x x (draft)

Review the annual clinical audit report and annual plan

x

Review the annual report on NICE and NCEPOD (after review by Q&G Committee)

x

Review the Board Assurance Framework x x x x Review the Corporate Risk Register x x x x Review Register of Conflicts of Interest x x Review Register of Corporate Hospitality Review Assurance Committees’ Chairs’ Logs x x x x Register of Directors’ interests x x Register of Governors’ interests x Review BFS Risk Register x x Review losses and special payments x x x x Review of single tenders and tenders awarded other than the lowest x x x x

Data Quality Updates x x Cyber Security x Review changes to standing orders (et al) x Annual review of governance framework x Agree final annual year end schedule x Self–assess the committee’s effectiveness x Review the terms of reference of the committee X

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Agenda Item/ Issue May June July October January Produce an annual committee report X Review list of managers who are able to employ and dismiss staff in accordance with the Trust’s HR policies and procedures

x

Updated for each meeting – latest update: May 2020

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Appendix 4

Data Quality Group

Annual Review of (Data Quality Group) Effectiveness and Terms of Reference 1st April 2019 to 31st March 2020

a) The purpose of the Data Quality Group is to provide support, drive the broader data

quality agenda and provide the Trust Operations Group and Audit Committee with the assurance that effective data quality best practice mechanisms are in place within the Trust, including training, reporting and data cleansing processes.

1. Executive Summary For the year 2019 – 2020 the chair of the group moved from Kieran Baker Deputy Director of Information to Helen Churms Head of information. The groups key tasks this year have been:

• Managing data quality issues on Lorenzo to support a safe an effective transi-tion of data to Medway.

• Managing the emerging issue of open referrals. • Managing and putting in actions to improve the trusts reported Referrals to

treatment position. • Building and managing a patient tracking list to manage referrals with no

scheduled future appointment. • Managing and overseeing actions as a result of data quality incidents. • Reviewing and agreeing standard operating procedures in relation to RTT. • Overseeing and prioritising the work of the Data quality group. • Supporting clinical and operational services in all matters of data quality.

2. Delivery of functions within ToR Functions within ToR Evidence to support

delivery Outstanding issues / action plan

Compliance with statute, contracting requirements, Foundation Trust Regulator and Trust policies and procedures in matters relating to data quality

The Group is authorised by the Trust Operations Group to investigate any activity within its Terms of Reference.

Various issues have been raised and worked through as part of the Data Quality Agenda.

Open Referrals. RTT training and code status validations.

The Group is authorised to implement any activity that is in line with Data Quality (DQ) policy, which shall be signed off by the Trust Operations Group

Reviewed at May Meeting

To be presented at AC.

Provide a focal point for the resolution and/or discussion of data quality issues

Various issues have been raised and worked through as part

Medway transition.

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of the Data Quality Agenda.

To review data quality across the Trust on a regular basis ensuring low areas of data quality are addressed to individual staff members as required utilising the latest available data (DQ Dashboard).

Data Quality Dashboard on IRIS used to highlight data quality issues.

The DQG may commission other time limited groups for ad-hoc pieces of work relating to the overall data quality agenda including other risk reducing initiatives, engaging with operational team and other departments

Open Referrals task and finish group.

3. Quoracy The terms of reference of the Trust’s Data Quality Group state that the Group will be quorate with a minimum of 6 members consisting of at least one representative from:

• YES Chair/Deputy Chair

• Each of 3 Clinical Business Units

• Outpatients

• Data Quality and Clinical Systems

• Information

4. Review of Terms of Reference Terms of reference were reviewed and will be presented to the July AC. 5. Any Actions Arising from this Effectiveness Review? [ ] NO [ x ]

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REPORT TO THE BOARD OF DIRECTORS (BHNFT) REF: BoD:20/08/06/11

SUBJECT: BARNSLEY FACILITIES SERVICES LIMITED (BFS) - PUBLIC

DATE: 6 AUGUST 2020 PRIVATE AND CONFIDENTIAL

PURPOSE:




PREPARED BY: Francis Patton, Chair BFS & Non-Executive Director BHNFT

SPONSORED BY: Francis Patton, Chair, BFS & Non-Executive Director BHNFT

PRESENTED BY: Francis Patton, Chair BFS & Non-Executive Director BHNFT

STRATEGIC CONTEXT

Barnsley Facilities Services Ltd (BFS), (formerly Barnsley Hospital Support Services Limited BHSS), was established in 2012 as a wholly owned subsidiary of BHNFT and became operational from January 2013. It is intended as a vehicle for the Trust to explore and expand commercial opportunities and enhance income streams for the benefit of patient services.

EXECUTIVE SUMMARY The aim of this report is to provide the Trust’s Board of Directors with a regular update on the activities of BFS and to flag any risks or concerns. The enclosed Log reflects discussions from the BFS Board’s meeting in July. In terms of Covid-19 there has been a lot of work internally supporting our own staff and externally supporting the Trust particularly with Health & Safety issues, Test & Trace and some potential business within the ICS for BFS. Productive meetings were held with Finance, HR, Communications, Marketing & Design, Legal and Pharmacy. From an HR perspective sickness is at 2.55% and training is at 86.6%. The Board received an update against the 2020/21 objectives in the 5-year Strategic Plan which showed good progress to date. Finally, the Board received the suggested 2020/21 Budget and a final paper on the 5-year Strategic Plan which it recommends to the Trust Board RECOMMENDATION

BFS Board recommends that: • The Board of BHNFT notes the attached report and take assurance that the wholly

owned Operated Healthcare Facility is performing to plan and budget. • The Board received the suggested 2020/21 Budget and a final paper on the 5-year

Strategic Plan which it recommends to the Trust Board for approval.

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REPORT TO THE BOARD OF DIRECTORS AND F&P - BFS (BHSS) Chair’s Log - Private Board REF: BoD: 20/08/06/11 CHAIR’S LOG: Chair’s Key Issues and Assurance Model Committee / Group: BFS Board Meeting Date: 20th July 2020 Chair: Francis Patton

Item Issue Receiving Body, i.e. Board or Committee

Recommendation/ Assurance/ mandate to receiving body

1. BFS Covid 19 Update

The people impact of Covid-19 continues to be managed, with key activities as follows: -There have been 124 isolations in BFS due to Covid-19, including 20 staff who are shielding. 101 staff have returned. - Risk assessments are in place for our staff identified as vulnerable and also offered to all of our BAME colleagues (with 10 undertaken and 1 declined). We are working with our 20-shielding staff to assess their suitability to return to work from 1/8/2020. - In line with the Government Working Practice Guidelines we have supported the Trust in undertaking Risk Assessments to ensure the safety of the public and our people. - Test and Trace resulted in 3 isolations at the beginning of the process, and we are positively re-enforcing the distancing guidelines, and raising awareness. Staff are being encouraged to take regular holidays as this is important for their health and wellbeing. - No issues to report with PPE.

Trust Board For Information and Assurance

2. Performance Report

Key highlights from the performance report include: 1. BFS achieved all KPIs across all service areas in

May 2020. 2. Decontamination - Activity has started to increase

slightly in June compared with the last two months,


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BoD August 2020 BFS_Chairs Log



this also includes flexible scope reprocessing. Staff continue to support in other areas which includes linen room, portering, domestics and materials management.

3. Estates Maintenance – May performance has increased against March and April, due to a reduced requirement to support Covid-19 related movements and works. It is envisaged this will fluctuate in terms of the demand against ‘business as usual’ requests and Covid-19 requests, as the Trust continues the reintroduction of services. This will continue to be managed closely working alongside the Trusts Silver and Gold teams to ensure capacity to support.

4. Domestics - The monthly quality score from the Trust was 4.61 (out of a possible 5) in May which is the highest score achieved within the year. The Domestics team continue to work closely with the Trust team to ensure staff are available to service the needs of the Trust. All extra activity has been achieved whilst maintaining the required standards of cleanliness to meet the Trust specification, with minimal disruption to service users.

5. Catering - May saw in-patient activity in the Trust decrease with in-patient meal numbers of 25,405 against a baseline of 36,084, similarly the day-patient activity replicates the decrease in activity. This has since started to increase in June to 28,920 in-patient meals. It is anticipated this will continue to increase along with other services as the hospital activity increases.

6. Capital bids – BFS supported the Trust in over £15m of capital bids across 8 schemes in response to the Covid-19 impact and winter pressures. Whilst the Trust are hopeful of receiving external funding,

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contingency plans are being worked on to re-provide bed capacity lost largely due to the relocation of ICU. This will be challenging within the timescales and recruitment is being reviewed within the Projects Team.

3. Reverse SLA’s

Meetings were held were with Finance to finalise the budget discussion; HR to discuss apprenticeships, mandatory training, occupational health and re-establishing staff side meetings; with communications, marketing and design to discuss website design; legal to discuss claims and a fraud report; outpatient pharmacy to discuss governance advice on e-prescribing and a recent efficiency review.


4.

BFS 2020/21 Aims and Objectives Update

The BFS Business Plan 2020-25 describes BFS Aims & Objectives, with more detail being available for Horizon 1 (year 1 / 2020/21), as part of our annual Business Plan. It should be noted this is up for final sign off at the August Board. The BFS Board received a paper offering assurance of progress across 2020/21 against the agreed objectives as set out in the Plan. There are 34 objectives across the 3 aims – each feeding into 5 key areas of activity – People, Quality, Innovation, Finance & Commercial and Growth. Any outstanding items from the 2019/20 year end business aims and objectives update to BFS Board, have been included as agreed. All items are in progress notwithstanding some delays due to Covid-19, apart from development of a digital strategy which will require co-development with BHNFT (this will be at an appropriate time once significant system changes for the Trust itself are completed).


6. People From a HR perspective Key points to note are: • The cumulative turnover rate was 7.51%. There were 2


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leavers and 3 new starters during June. • The sickness rate at the end of June was 2.55% which is an increase of 0.09% from a figure of 2.46% in May. • The people impact of Covid-19 continues to be managed, (with further details above). • Training compliance is 86.6%. Emphasis in July will continue to be on ensuring those out of date are identified and training undertaken where practical. Face to face mandatory training is still unavailable due to Covid-19 change in working practices, however we are now able to offer some assisted ‘e learning’ in the IT suite for Porters and Domestics. • Four policies were signed off being Death in Service, Shared Parental Leave, Home Working and Maternity. • During the Covid -19 pandemic some Engagement and OD activity was suspended, and through June and July 2020 we have started to re-instate activity, to include: a pulse check survey; staff survey action groups; employee of the month and focus groups. Learning from this period and the need to socially distance has altered our approach to communication and we will continue to adapt as needed.

7. 2020/21 Budget.

The BFS Board received a paper on the ongoing discussions concerning the 2020/21 Budget. The BFS Board agreed to support the paper coming to Trust Board for sign off of the budget plus some key points around how BFS is treated and the principles used for budgeting going forward.

Trust Board For information, assurance and sign off.

8. BFS Strategic Business Plan 2020-2025

BFS Board reviewed the final paper to go to Trust Board concerning the 5-year Strategic Business Plan and the issues raised from its discussion at the Trust Board development day. The BFS Board supported the final version of that paper asking for sign off of the 5-year plan.

Trust Board For Information, assurance and sign off.

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REPORT TO THE BOARD OF DIRECTORS REF: BoD 20/08/13 SUBJECT: Integrated Performance Report: June 2020 DATE: 6 August 2020

PURPOSE:


applicable For decision/approval Assurance For review Governance For information Strategy

PREPARED BY: Andrew Potts – Deputy Director of Operations SPONSORED BY: Bob Kirton – Chief Delivery Officer PRESENTED BY: Andrew Potts – Deputy Director of Operations STRATEGIC CONTEXT Strategic Objective 1 – Patients will experience safe care Strategic Objective 3 – People will be proud to work for us Strategic Objective 4 – Performance Matters EXECUTIVE SUMMARY 1. Patient Access:

In accordance with the national directive, contractual sanctions in respect of performance have been suspended. In view of current performance volatility and continuing uncertainty regarding key factors internal year-end forecasts have not yet been undertaken. Emergency access & Patient Flow: Performance against the Emergency Department 4-hour standard in June was 91.4% compared with 94.3% in May. The Trust’s performance was the 69th best nationally of 110 trusts. The number of ED attendances continued to grow in June although activity remained around 78% of the level in in June 2019. A disproportionate amount of the activity reduction compared with last year has been in low acuity presentations highly likely to be discharged within 4 hours which has adversely affected performance against the 4-hour standard.

The Emergency Department continues to be configured into separate “hot” and “cold” departments with a resultant loss of efficiency. In addition to the loss of the GP streaming function, the Clinical Decision Unit has ceased to function as its accommodation is required for Resuscitation which alone has caused a reduction in performance of around 1.5%. The increased admissions in June, combined with the impact of infection control segregation measures, resulted in lengthier waits for beds which contributed 2.2% of the deterioration in performance. A number of actions are being taken to address these issues including the establishment of a temporary Clinical Decision Unit and reduced turnaround time for Covid19 test results. RTT: During May 73.92% of patients were treated within 18 weeks compared with 80.66% in April. The Trust’s performance was the 12th best nationally. Elective activity in May was largely restricted to urgent activity and all surgical specialties are now non-compliant. Oral Surgery and Orthopaedics are especially challenged with performance of 44% and 56% respectively in May. These specialties have particularly large waiting list backlogs as most of the treatment provided is non-urgent and the guidelines of the relevant professional associations have precluded the recommencement of non-urgent treatment. The undertaking of day-case

Pack Page 131

orthopaedics surgery via the private sector commenced in June. In Oral Surgery, simple extraction and biopsy procedures recommenced in July. Despite continuing increases in the scope and scale of elective surgery, including additional after-hours sessions and use of the private sector, further deterioration in performance against the RTT standard is expected as the backlog of non-urgent treatment continues to grow as urgent surgery is prioritised.

At the end of May there were 10 pathways in excess of 52 weeks compared with 6 at the end of April. Only 14 out of 124 trusts nationally had fewer 52 week plus pathways. Following considerable reductions in the total waiting list size in March and April, as a result of much reduced referral rates, the waiting list size has now stabilised. The total waiting list size at the end of May was 9,267 compared with 9,331 at the end of April. Cancer: The 2 week wait from referral standard was achieved in May although the 31-day standard for first definitive treatment was narrowly missed. It is expected that these two standards will be achieved regularly over the coming months as priority is given in the allocation of clinic and operating theatre to patients with cancer (and other urgent conditions). For May the Trust was the 5th best performing nationally with regard to the 2 week wait standard reflecting the priority given to maintaining as much urgent outpatient capacity as possible during the Covid19 crisis. The 62-day referral to treatment standard was not attained in May and is expected to continue to prove challenging over the next quarter as a result of backlogs in the diagnostic phase of pathways with endoscopy a notable bottleneck as a result of non-emergency endoscopy investigations being suspended for two months per national guidance. The 2-week symptomatic breast referral target was achieved but not the 38-day inter-provider transfer target.

Diagnostic Waits: Performance against the 6-week diagnostic standard improved significantly in June with 36% of investigations performed within target compared with 27% in May when the Trust was the 121st highest performing nationally out of 123 trusts. Urgent endoscopy and non-urgent imaging services were restored in June albeit with much reduced rates of output due to distancing requirements. Increased use of the private sector and provision of after-hours imaging and endoscopy sessions will help reduce the backlog. The total diagnostics waiting list size has stabilised after steep increases during April and May.

2. Quality of Care: 2.1 Patient Safety:

Pressure Ulcers There were 18 Category Two hospital acquired pressure ulcers reported in June with lapses of care confirmed in 9 cases with a case still to be presented to the Pressure Ulcer Forum. There were 4 deep tissue injuries reported of which 2 involved lapses in care relating to inadequate positioning, inadequate off-loading or lack of skin inspection. Pressure ulcer improvement plans have been issued for a number of clinical areas. Incidents: There were 2 incidents resulting in death. One incident involved a cardiac arrest on the Acute Medical Unit which is the subject of a root cause analysis. The other incident involved a lack of clinical assessment on the Acute Medical Unit which is under review. There were 2 reported incidents resulting in severe harm. The incidents comprised a fall in the Acute Stroke Unit resulting in a fractured hip and a medication incident on Ward 19 which is under review. There were no Serious Incidents reported in month.

Falls: Pack Page 132

There were 62 inpatient falls in June and the Trust remains on course to achieve its target of fewer than 785 falls in 2020/21. There were 3 falls with moderate or greater harm in June bringing the total to 4 year to date. The target is 15 or fewer for the year. Perfect ward audits showed 93% compliance with the standard of ensuring that walking aids were within reach and 87% compliance with the standard of blood pressure recordings being taken within 24 hours of admission.

2.2 Patient Experience: During June the Trust received 16 new complaints. The primary theme was clinical treatment. All complaints closed in June were within the agreed timeframe. The average number of working days to investigate complaints was 69 days. Of the complaints closed, 59% were fully or partially upheld.

3. People: Sickness: Sickness – The sickness absence rate in June was 4.2%, the lowest rate since September and only fractionally higher than the 4.1% in June 2019. Excluding Covid19 related absence the rate was 3.8%. Stress/anxiety/depression accounted for the greatest number of episodes of sickness absence. A mental health staff support booklet has been distributed to all members of staff. Mandatory Training: Mandatory training compliance was 85.1% in June, slightly below the 90% target although an increase on the previous month. The full range of topics has now been restored with most courses being delivered by e-learning. Staff Appraisal Rate: The 2020/21 appraisal window, delayed due to Covid19, opened in June and at the end of the month 10.3% of member of staff were recorded as having undergone an appraisal. The window will close on 31 August 2020. Options for undertaking appraisals remotely have been introduced. Staff Turnover: Staff turnover in June declined to 9.9%. The staff group with the highest turnover remains Allied Health at 16.7%. A listening event for Allied Health members of staff is planned to better understand how to reduce turnover.

4. Finance: The Trust has a consolidated break-even position at Month 3. Total income was £0.95m adverse to plan at Month 3. Clinical Income is funded mainly via a block contract at present but Other Income was £0.8m below plan due mainly to reductions in car parking income and recharges out as a consequence of Covid19. Cash balances decreased during June by £0.35m and were £0.55 adverse to plan at Month 3. The decrease was due primarily to increased creditor payments. Capital expenditure for the year on the core programme was £0.682m which is £0.135 less than plan, due mainly to the delay with the ED/CAU scheme which is expected to be recovered in subsequent months. Covid19 related capital expenditure, which will be reimbursed by NHSE, increased in June by £0.043m bringing the total for the year to £0.68m.

RECOMMENDATIONS The Board of Directors is asked to receive and endorse the latest IPR.

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Created by: Healthcare Information and Insight Service

Title of report: Integrated Performance Report

Executive Lead: Bob Kirton

`

June 2020

Pack Page 134

Exe

cuti

ve S

um

mar

y

1. Purpose of the Report:

The purpose of this report is to inform the Trust Board and sub-committees of the latest position against key performance indicators, including operational and

quality requirements mandated nationally, metrics detailed in the NHSi oversight model and those identified within the BHNFT Operational Plan for 2020/21. In

addition, it provides Trust Board with information relating to activity delivered and finance, which are key drivers for sustainability.

This report details the latest validated information available.

A high level view of the Trust’s performance is available in the at a glance summary. Further details on the domains of quality, people, patient access and finance

are available in more depth as part of the wider document.

2. Background and Introduction:

The well-led framework used by NHSi identifies effective oversight by Trust Boards as essential to ensuring Trusts consistently deliver safe, sustainable and high

quality care for patients.

BHNFT provides an integrated performance report to Trust Board each month for assurance. The report outlines key performance against a number of quality,

operational, financial and activity based indicators. The purpose of the report is to ensure Trust Board has timely and robust oversight of performance in key

areas along with actions being taken to address required improvements.

Executive Summary June 2020

Pack Page 135

1 2 3 9 10 16 17 18 19 20 21

Planned Financial Position

Income

Cancer

Diagnostic Waits

Sickness Absence

Mandatory Training

Staff Turnover

Staff Appraisal Rates

Performance against the Emergency Department 4 hour standard was 91.4% in June compared with 94.3% in May. The Emergency Department continues to be configured into separate “Hot” and “Cold” departments with a

resultant loss of efficiency. The Clinical Decision Unit has had to function as Resuscitation which alone has caused a reduction in performance of around 1.5%. The 19% increase in daily ED attendances over the June period

resulted in an increased number of admissions which, combined with the impact of infection control measures on the Acute Medical Unit and wards involving challenging segregation requirements, has resulted in increased

waits for beds which contributed 2.2% of the deterioration in performance in June.

During May 73.92% of patients were treated within 18 weeks compared with 80.66% in April. Elective activity was limited in May by Covid19 related constraints and was largely limited to urgent activity. Almost all specialties

are now non-compliant other than 5 medical specialties. Although the amount of elective surgery and outpatient activity is expected to increase from June further deterioration in performance against the RTT standard is

expected. Following considerable reductions in the total waiting list size in March and April the waiting list size has now stabilised. The total waiting list size at the end of May was 9,267 compared with 9,331 at the end of

April and 12,622 at the end of February. At the end of May there were 10 pathways exceeding 52 weeks compared with 6 at the end of April. The number of 52 week plus pathways is expected to continue to grow given

current capacity constraints and the need to prioritise treatment for patients with urgent conditions.”

Restrictions on service arising because of Covid19 continue to adversely affect cancer waiting times. Although performance against the 2 week waiting time standard for first consultation remains very strong, the 31 day

standard for first definitive treatment was not achieved In May and the Trust remained non-compliant with the 62 day standard for treatment commencement following GP referral.

During June 64% of waits for diagnostic investigations exceeded 6 weeks compared to 73% in May. The re-commencement of GI endoscopy and non-urgent diagnostic imaging has contributed to the improved performance.

The total diagnostic waiting list size has stabilised but there remain extensive backlogs and continuing Covid19 related constraints on output hence and it is not expected that this standard will be achieved during the second

quarter.

Capital Plan

In line with the new financial flow arrangements in place across the NHS for the early part of the 20/21 financial year, the Trust has a consolidated year to date break-even position. This is after receiving additional income top-up from NHS

England (NHSE) of £0.076m.

Total income is £0.952 adverse to plan for the year. The majority of clinical income (£54.663m) is subject to block arrangements as part of the new financial flows introduced for the early part of 20/21. There is a small overall total adverse

variance on clinical income of £0.156m which is mainly due to an under performance on activity with other Trusts which are not covered by the block arrangements. Other income is £0.796m adverse to plan mainly due to reductions in car

parking income and recharges out as a consequence of COVID-19.

Cash balances are £0.551m adverse to plan at £38.573m. The £0.351m in-month decrease in cash is due to a higher level of creditor payments, partially offset by the capital programme slippage.

Capital expenditure for the year on the Core Programme is £0.682m which is £0.135m less than plan, mainly due to ED/CAU scheme expenditure being slightly off profile but expected to recover in later months. Capital expenditure on COVID-19

schemes increased by £0.043m bringing total for the year to £0.680m; the Trust will be reimbursed these costs by NHSE issuing Public Dividend Capital (PDC).

Sickness— is improved on last month by 0.84% and is only slightly higher than this time last year when it was at 4.06%. 0.42% is confirmed Covid (45 staff) with 3.78% other reasons. Top reason (39%) remains stress, anxiety, depression. CBU1

and 2 remain in red, however sickness in these areas continues to decline since the spike in April 2020. CBU3 has gone into green, Corporate and BFS remain in green. With regards to staff groups, Additional Clinical Services remain in red at

6.67% , Nursing & Midwifery Registered at 5.66%. Estates & Ancillary have gone into amber at 3.97%. All other staff groups remain in green. Covid-19 risk assessments for vulnerable workers to stay in work and for staff who are shielding to

return to work from 1 August are being received, with a weekly risk assessment oversight group set up throughout July t o support each CBU with their return to work arrangements for staff . A mental health staff support booklet through Covid,

including signposting to various resources and providers is currently being distributed to all members of staff .

Mandatory Training - Slight improvement on last month, however remains below target. The subject with the highest compliance is Moving & Handling Back Care Awareness (once) 94.3%. The subject with the lowest compliance is Resus

Paediatric ILS 69.4%.

Staff Appraisal Rate - The 2020/21 appraisal window runs until 31 August 2020. Appraisal completions recorded by managers so far in the ESR system for reporting purposes stands at 10.3%.

Staff Turnover— Has improved and is now within the target range. CBU1 and Corporate remain in red, all other CBUs are in green. Highest staff group turnover remains Allied Health Professionals at 16.65% , followed by HealthCare Scientists at

11.28%. A listening event with AHPs is planned to understand further support that can be offered.

Referral To Treatment (18 weeks)

Pat

ien

t A

cce

ssP

eo

ple

Fin

ance

Emergency Access

Planned Cash Position

Patients Partnerships People Performance

BHNFT At-a-Glance June 2020

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1 2 9 10 16 17 18 19 20 21

IPC

Incidents

Patient

Experience

Standard of Care

Mortality

Qu

alit

y

SHMI - Latest data Jan 19-Dec19 - 102

Next SHMI Release - Q4 August 2020

HSMR Rolling 12 month - 95.8 - March 2020

Falls

The trust remains on track to achieve less than 785 falls for the 2020/21.

There were 62 inpatient falls during June.

Three falls resulted in moderate harm or greater bring total year to date to 4.

The Trust fell below the target of 90% compliance, scored 87%, on lying and standing blood pressures recording in the first 24 hours of admission as evidenced in June Perfect Ward report.

The Trust exceeded the target of 90% compliance, scored 93%, on walking aids within reach of patients as evidenced in June Perfect Ward report.

Incidents

Two inpatient falls resulting in moderate harm

• One inpatient fall on ASU resulting in a fractured humerus

• One inpatient fall on ASU resulting in a fractured distal radius

Two incidents resulting in severe harm

• One inpatient fall on ASU resulting in a fractured hip

• One medication incident on ward 19 regarding missed dalteparin – incident under review, more information being obtained

Two incidents resulting in death

• One cardiac arrest on AMU - incident under review & level of harm not yet confirmed, RCA being undertaken

• Lack of clinical assessment on AMU - incident under review, & level of harm not yet confirmed, more information being obtained

There were no serious incidents reported in the month

Pressure Ulcers

There has been 18 category 2 hospital acquired pressure ulcer reported this month. 9 of which have been found to have lapses in care so far. There is one awaiting presentation at the pressure ulcer forum. The lapses in care were related to lack

of react to red and documentation lapses. There were clinical areas that reported hospital acquired pressure ulcers that do not have patients for long periods of stay.

There have been 4 hospital acquire d Deep Tissue injuries (DTI). Of these 2 were found to have lapses in care. These were located on a heel and on a buttock. The lapses in care related to inadequate repositioning, inadequate off-loading and a lack

of skin inspections. Both on heels and were due to a lack of adequate heel off- loading.

Pressure ulcer improvement plans for clinical areas have been issued to relevant teams. The improvement plans are formulated from the findings from the monthly prefect ward pressure ulcer prevention audit and RCA findings. Matrons and Lead

Nurses are required to provide assurance on progress on their improvement plans at the weekly pressure ulcer forum.

Quality

of Care

Pa

tien

t Sa

fety

Clin

ical

Effe

ctiv

en

ess

Complaints

During May the Trust received 16 new complaints. The complaints were allocated as follows: CBU 1 – 6, CBU 2 – 7, CBU 3 – 3 and Corporate Services - 0. The primary theme was all aspects of clinical treatment. The percentage of cases closed

within agreed timeframe or agreed extension for the month was 100%. The average number of working days to investigate complaints was 69 days. 59% of complaints closed within June were upheld or partly upheld. The PA&C Team dealt with

174 concerns and 76 general enquiries (total 250) during the month.

Hospital Acquired Clostridium Difficile

1 case of Hospital acquired Clostridioides difficile was Identified in June 2020, which was attributed to Ward 35.

There were no hospital acquired cases of MRSA Bacteraemia.

VTE

This is an unvalidated position (96.8%)


BHNFT At-a-Glance June 2020

Pack Page 137

2 3 4 6 7

Domain KPI StandardStandard(Month)

Set By Current Qtr. Year to DateYear-End

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

Falls 785 (<) 65 BHNFT 178 178 55 70 47 75 73 77 81 88 60 55 54 62 62

Falls resulting in moderate harm or above 15 (< =) < =1 BHNFT 5 5 2 1 2 0 1 0 3 1 4 1 2 0 3

Hand washing 95% (>) National 97% 97% 97% 96% 99% 99% 97% 97% 96% 96% 96% 98% 98% 98% 96%

Pressure Ulcers category 2 (Lapses in care) G < 53, R >53 4 BHNFT 7 7 5 4 7 6 3 4 10 13 1 3 7 0 9

Pressure Ulcers catergory deep tissue Injury G < 51, R > 51 4 BHNFT 2 2 2 2

Q - Hospital Acquired Clostridium Difficile 19 (<) 1 NHSI 3 3 2 2 4 3 2 1 1 2 3 0 0 2 1

Q- Hospital Acquired MRSA Bacteraemia 0 0 NHSE 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0

Q - Serious Incidents - NHSE 4 4 2 2 3 3 1 4 4 2 2 2 1 3 0

Q- Total Number of Incidents Resulting in Death 0 0 National 3 3 0 0 1 0 0 0 1 0 0 1 1 0 2

Q-Total Number of Incidents Resulting in Severe Harm 0 0 National 4 4 2 3 0 0 1 1 4 0 3 2 0 2 2

Never Events 0 0 National 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0

Q- FFT Positivity Rates -StaffG >85%, A >=80%-85%, R <80% (>

)BHNFT 82.0% 84.0%

Complaints closed within target or agreed extension % G >90%, A >=70%-90%, R <70% (>) BHNFT 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Q- Single Sex Breaches 0 0 National 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Q - Duty of Candour Breaches 0 0 National 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Q - VTE Screening Compliance G>= 95%, R < 95% NHSE 96.3% 96.3% 98.5% 98.2% 98.5% 98.2% 97.4% 96.6% 98.4% 98.0% 97.0% 96.3% 96.2% 95.9% 96.8%

Q - Sepsis-Antibiotics given within Hour of diagnosis G >= 90%, R < 90% National - - 87.8% 85.5% 83.2% 85.8%

Q - HSMR (Rolling 12 months) Latest Data is March 2020 - - - - - 97.9 95.4 94.2 94.8 97.3 98.8 98.4 96.5 95.9 95.8

Crude Mortality (Number of Deaths) - - - 322 322 79 65 69 80 81 104 104 95 84 100 137 104 81

Crude Mortality (COVID19 Deaths) - - - 136 136 8 70 41 25

SHMI (Rolling 12 months) Latest Data is December 2019 - - - 101.0 99.4 102.0

RAG Description

RED Failed Target

AMBER Failed by <5% (This tolerance can only be applied to local targets)

GREEN Achieved Target

< Less Is Good

> More is good

Q KPI is in the Quality Schedule for 2019/20 to be defined and included in IPR from May 2019

Quality Performance Scorecard

Patient Safety

Patient Experience

Clinical

Effectiveness

Patients will experience safe care


5Pack Page 138

People and Patient Access Scorecard

Domain KPI StandardStandard(Month)

Set By Current Qtr. Year to DateYear-End

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

People will be proud to work for us

Staff Turnover (Rolling 12 months) G <=10%, A >10%-10.5%, R >10.5% (<) BHNFT 10.3% 10.3% 10.1% 10% 10.4% 10.5% 10.8% 10.6% 10.5% 10.8% 10.9% 10.8% 10.5% 10.5% 9.9%

Staff Appraisal Rate G >90%, A >=85%-90%, R <85% (>) BHNFT 34.5% 34.5% 86.5% 91.2% 92.8% 93.0% 93.0% 93.2% 92.9% 92.6% 92.2% 91.9% 90.5% 2.6% 10.3%

Mandatory Training G >90%, A >=85%-90%, R <85% (>) BHNFT 85.2% 85.2% 91.2% 90.7% 90.3% 89.8% 90.4% 90.6% 91.2% 90.6% 90.0% 88.8% 85.8% 84.6% 85.1%

Sickness Absence (In Month)G <=3.75%, A >3.75%-4.25%, R >4.25%

(<)BHNFT 4.89% 4.89% 4.02% 4.31% 3.85% 3.97% 4.29% 4.50% 5.05% 5.16% 4.73% 4.72% 5.43% 5.04% 4.20%

Performance matters - Key Performance Indicators

RTT Incomplete Pathways (May 2020, Q1, 20/21 YTD) 92% (>) National 77.3% 77.3% 94.3% 93.5% 93.3% 93.8% 93.6% 93.7% 92.7% 92.5% 92.1% 88.7% 80.7% 73.9%

RTT 52 Week Breaches 0 National 16 16 0 0 1 4 1 0 0 0 0 3 6 10

RTT Total Waiting List Size 12086 BHNFT 9331 9331 12933 12818 13616 13574 13584 12547 12229 12226 12622 11598 9331 9267

Diagnostic patients waiting more than 6 weeks 1 %(<=) National 59.30% 59.30% 0.07% 0.29% 0.10% 0.10% 0.00% 0.00% 0.29% 0.07% 0.18% 1.16% 36.15% 73.01% 63.83%

Q - Cancer 2 Week Waits 93% (>) National 96.0% 96.0% 85.8% 87.8% 93.3% 93.7% 91.9% 92.9% 92.9% 94.9% 96.5% 97.1% 92.7% 99.3%

Q - Symptomatic Breast 2 Week Waits 93% (>) National 98.4% 98.4% 48.4% 57.9% 82.8% 98.1% 94.6% 92.6% 94.1% 91.8% 97.3% 96.6% 94.1% 100.0%

Q - 31 Day - 1st Definitive Treatment 96% (>) National 97.5% 97.5% 97% 100% 97% 100% 100% 100% 100% 99% 98% 93.5% 100% 94%

Q - 31 Day - Subsequent Treatment (Surgery) 94% (>) National - - 100% 100% 100% 100% 100% 100% 100% 80% 75% 82% 100% 100%

Q - 31 Day - Subsequent Treatment (Chemotherapy) 98% (>) National 100.0% 100.0% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Q - 38 Day - Inter-Provider Transfer 85% (>) BHNFT 58.6% 58.6% 70% 58.3% 44.0% 76.2% 61.1% 44.4% 68.8% 42.9% 70.6% 55.0% 53.8% 62.5%

Q - 62 Day - GP Referral to Treatment 85% (>) National 81.1% 81.1% 73.3% 88.8% 78.5% 93.5% 85.1% 87.0% 91.1% 82.4% 87.9% 88.6% 84.7% 76.0%

Q - 62 Day - Screening Referral to Treatment 90% (>) National 63.6% 63.6% 100% 100% 100% 100% 88% 94% 90% 86% 92% 64% 50% 66.7%

Q - 62 Day - Consultant Upgrade to Treatment 85% (>) National 96.0% 96.0% 75% 94% 100% 83% 80% 38% 89% 77% 100% 94% 94% 100%

Emergency % Patients Waiting <4 Hours 95% (>) National 93.4% 93.4% 95.6% 93.5% 91.3% 96.3% 95.2% 85.7% 80.7% 86.9% 91.4% 91.0% 95.3% 94.3% 91.4%

Average Length of Stay - Elective (Spell) G <=3.45, A >3.45-3.91, R >3.91 (<) BHNFT 0.90 0.90 2.94 3.00 2.67 2.56 2.41 1.79 2.13 2.04 2.15 2.20 0.88 0.90 0.91

Average Length of Stay - Non-Elective (Spell) G <=3.45, A >3.45-3.91, R >3.91 (<) BHNFT 3.51 3.51 3.06 3.04 3.07 3.09 3.18 3.18 3.48 3.67 3.55 3.80 3.57 3.26 3.71

Re-admissions % (Validated) 8% BHNFT 8.9% 8.3% 8.4% 7.2% 7.6% 8.7% 8.0% 8.5% 7.1% 6.8%

Cancelled Operations - Breaches of the 28 day rule 0 0 National 0 0 0 0 0 0 1 0 2 0 0 11 0 0 0

Cancelled Operations - Sitrep Reportable 0.8% BHNFT 0.0 0.0 0.4% 0.7% 0.5% 0.6% 0.4% 0.4% 1.0% 0.5% 0.6% 0.9% 0.0% 0.8% 0.3%

DNA Outpatient DNA Rates G <=6.9%, R >6.9% (<) 6.9% BHNFT 6.4% 6.4% 6.7% 6.6% 6.7% 7.1% 6.8% 6.5% 7.5% 7.5% 6.5% 7.1% 5.8% 6.1% 7.0%

RAG Description

RED Failed Target

AMBER Failed by <5% (This tolerance can only be applied to local targets)

GREEN Achieved Target

< Less Is Good

> More is good

Q KPI is in the Quality Schedule

NOTE: National Indicators are considered as being either Achieved or Failed. These are therefore RAG rated as Green or Red.

Local indicators can have amber tolerances set and these have been agreed with the services.

Operational

Efficiency

Workforce

Elective Access

Cancer


6Pack Page 139

Performance Matters (KPIs)Operational Efficiency

The Trust failed to deliver the Emergency access standard in the month of January at 91.1%. Activity is now 14% above plan for emergency department attendances and 6% above plan for non-elective admissions. Year to date, delivery is at 94.7% with a organisational effort focusing on the delivery of the 95% standard at year end

Comments:

Re

-ad

mis

sio

ns

The proportion of operations cancelled by the hospital was 0.3% in June, below the target level of 0.8%. Further elective operating capacity was restored in June with all

specialties other than Orthopaedics now having regular operating sessions. Typically, there are 3-4 elective theatres are operational each weekday. There were no breaches

in May of the 28 day standard for rescheduling of surgery appointments cancelled by the hospital. The recent expansion of critical care capacity has addressed the principal

cause of previous breaches of this standard.

Endoscopy and non-urgent diagnostic imaging were restored in June contributing to improved performance against the diagnostic tests standard. During June 64% of waits

for diagnostic investigations exceeded 6 weeks compared to 73% in May. The total diagnostic waiting list size has stabilised but there remain extensive backlogs and

continuing Covid19 related constraints on output and it is not expected that this standard will be achieved during the second quarter.

Outpatient non-attendance rates continue below the historical average.

DN

A R

ate

s


6.7% 6.6% 6.7% 7.1% 6.8% 6.5% 7.5% 7.5%

6.5% 7.1% 5.8% 6.1%

7.0%

0%

5%

10%

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

De

c-1

9

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

DNA Rates

New Follow Up Total Standard 2017/18

Cancelled Operations target is '0'

0.4%

0.7%

0.5% 0.6%

0.4% 0.4%

1.0%

0.5%

0.6%

0.9%

0.0%

0.8%

0.3%

-0.1%

0.1%

0.3%

0.5%

0.7%

0.9%

1.1%

1.3%

1.5%

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

De

c-1

9

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

% o

f C

ance

lled

Op

era

tio

ns

Cancelled Operations

28 Day Breaches % Cancelled Ops Standard

Cancelled Operations Target '0'

8.5% 8.9% 8.3% 8.4%

7.2% 7.6%

8.7% 8.0%

8.5%

7.1% 6.8%

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

De

c-1

9

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Cumulative Validated Re-admissions

0% 0% 0% 0% 0% 0% 0% 0% 0% 1%

36%

73%

64%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Pe

rce

nta

ge o

ver

6 w

ee

ks

Diagnostic Tests over 6 Weeks

Standard Actual % 20/21

7Pack Page 140

Performance Matters (KPIs)


Emergency Access and Patient Flow (1)

ED 4

Ho

ur

Wai

tC

om

me

nta

ry

The Emergency Department continues to be configured into separate “Hot” and “Cold” departments with a resultant loss of

efficiency. The Clinical Decision Unit has had to function as Resuscitation which alone has caused a reduction in performance of

around 1.5%. The 19% increase in daily ED attendances over the June period resulted in an increased number of admissions which,

combined with the impact of infection control measures on the Acute Medical Unit and wards involving challenging segregation

requirements, has resulted in increased waits for beds which contributed 2.2% of the deterioration in performance in June.

95.64% 95.56%

93.45%

91.26%

96.32% 95.20%

85.67%

80.72%

86.92%

91.43% 91.03%

95.28% 94.31%

91.39%

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

0

2000

4000

6000

8000

10000

12000

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Within 4Hrs Total Activity Target 4h Emergency Access PerformanceStandard

8Pack Page 141




A&E benchmarking

Am

bu

lan

ce H

and

ove

rsIn

pat

ien

t A

cuit

y -

Am

ber

(EW

S sc

ore

5-6

)

Inpatient acuity remained at normal levels in June following the Covid19 related spike in April.In

pat

ien

t A

cuit

y -

Red

A

&E

4 H

ou

r W

ait

- B

en

chm

arki

ng

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

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

No. Ambulance Handover Times (Pre-validated YAS)

No. between 15 & 30 mins No. between 30 & 60 mins No. between 60 & 120 mins No. over 120 mins Not recorded

EWS = Amber only

0

5

10

15

20

25

Ap

r-1

9

Ap

r-1

9

May

-19

Jun

-19

Jun

-19

Jul-

19

Au

g-1

9

Au

g-1

9

Sep

-19

Oct

-19

Oct

-19

No

v-1

9

Dec

-19

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Mar

-20

Ap

r-2

0

May

-20

May

-20

Jun

-20

Occ

up

ancy

(1

2p

m)

Red

0

5

10

15

20

25

30

Ap

r-1

9

Ap

r-1

9

May

-19

Jun

-19

Jun

-19

Jul-

19

Au

g-1

9

Au

g-1

9

Sep

-19

Oct

-19

Oct

-19

No

v-1

9

Dec

-19

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Mar

-20

Ap

r-2

0

May

-20

May

-20

Jun

-20

Occ

up

ancy

(1

2p

m)

Amber

The recording of ambulance handover times continues to be affected by Covid19 related disruption. Almost all recorded handovers were within 1 hour and the majority were within 30 minutes.

9Pack Page 142




Len

gth

of

Stay

(Sp

ell)

The elective average length of stay remained low in June following a steep

reduction in April. This reflects the change in casemix arising from Covid19

related limitations on the scope of service including the suspension of joint

replacement surgery.

Tru

st B

ed

Occ

up

ancy

(M

ed

ical

)

0

1

2

3

4

5

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

LoS

(Day

s)

EL_LOS NEL_LOS

100

200

300

400

May

19

Jun

19

Jul 1

9

Au

g 1

9

Sep

19

Oct

19

No

v 1

9

Dec

19

Jan

20

Feb

20

Mar

20

Ap

r 2

0

May

20

Medical bed occupancy increased in June closer to normal levels after the steep reduction in April.

10Pack Page 143



Regulatory Performance - 18 Week Referral to Treatment

As stated

RTT 18 Week Performance - May 2020Validated Position

CommentsSpecialty <18 >18 Total %

CARDIOLOGY 345 24 369 93.50%DERMATOLOGY 395 124 519 76.11%E N T 326 154 480 67.92%GASTROENTEROLOGY 508 13 521 97.50%GENERAL MEDICINE 119 3 122 97.54%GENERAL SURGERY 1356 523 1879 72.17%GERIATRIC MEDICINE 85 0 85 100.00%GYNAECOLOGY 738 163 901 81.91%OPHTHALMOLOGY 527 80 607 86.82%ORAL SURGERY 402 505 907 44.32%OTHERS 582 42 624 93.27%RESPIRATORY MEDICINE 227 17 244 93.03%RHEUMATOLOGY 77 10 87 88.51%TRAUMA AND ORTHOPAEDICS 722 559 1281 56.36%UROLOGY 441 200 641 68.80%Total 6850 2417 9267 73.92%

RTT

Inco

mp

lete

WL

Size

Incompletes - Standard 92%

During May 73.92% of patients were treated within 18 weeks compared with

80.66% in April. Elective activity was limited in May by Covid19 related

constraints and was largely limited to urgent activity. Almost all specialties are

now non-compliant. Although the amount of elective surgery and outpatient

activity is expected to increase from June further deterioration in performance

against the RTT standard is expected. Following considerable reductions in the

total waiting list size in March and April the waiting list size has now stabilised.

The total waiting list size at the end of May was 9,267 compared with 9,331 at

the end of April and 12,622 at the end of February.

Co

nsu

ltan

t 1

8 W

ee

k R

efe

rral

to T

reat

me

nt

90% 94.27% 93.53% 93.35% 93.83% 93.57% 93.70% 92.66% 92.48% 92.15% 88.75%

80.66%

73.92%

60%

70%

80%

90%

100%

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

erc

en

tage

Po

siti

vity

Incomplete Pathways

Actual Standard

12933 12818 13616 13574 13584

12547 12229 12226 12622 11598

9331 9267

0

2000

4000

6000

8000

10000

12000

14000

16000

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

RTT Total Waiting List Size

11Pack Page 144



Regulatory Performance - Cancer

graph

Bre

ast

Sym

pto

mat

ic

All

Can

cer

2 W

eek

Wai

ts

Two Week Wait

The two week wait validated position for May was compliant with 99.3% against a

national target of 93.0%. All tumour groups achieved target and only 3 breaches in each

of Breast, Lower GI and Gynaecology due to patient choice (x2) and COVID – patient self-

isolating (x1).

Breast Symptomatic

May’s validated position was compliant at 100% against the national target of 93.0%.

Inte

r p

rovi

de

r Tr

ansf

er

40%

50%

60%

70%

80%

90%

100%

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Pe

rce

nta

ge P

osi

tivi

ty

Actual Standard

75%

80%

85%

90%

95%

100%

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

De

c-1

9

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Pe

rce

nta

ge P

osi

tivi

ty

Actual Standard

38 Day Inter-Provider Transfers

May’s position of 62.5% against a target of 85% shows a slight increase on recent months. 6 breaches in total where patients were transferred beyond the day 38 target within Head & Neck (x2) due to complex pathway (day 126) and inefficient pathway (day 43). Lower GI (x1) due to COVID delay (day 71). Upper GI (x2) due to diagnostic delay/capacity issues (days 42 and 44). Urology (x1) due to unexceptional pathway. Due to changes to the Cancer Alliance data request the parameters around calculation of the Inter Provider Transfer (IPT) have been adjusted. The compliance against 38 days IPT is now calculated on patients that have been treated ‘in month’. This has been back dated to April 2019 for consistency of approach.

12Pack Page 145



Regulatory Performance - Cancer

Graph to follow from Cancer services

Graph to follow from Cancer services

62 D

ay C

ance

r Ta

rget

s62

Day

Can

cer

Targ

ets

62 Day GP Referral to Treatment

May performance for 62 day GP referral to treatment was non-compliant with 76.0% against a national target of 85%. 11 breaches n total (3x local/8x shared)

Local breaches within Breast (x1) due to COVID capacity issues relating to surgery (treat day 63) and Urology (x2) both due to COVID trust cancelation (treat days 86)

Shared breaches within

• Head & Neck (x2) due to COVID related delay due to risk assessment and inefficient pathway compounded by complex diagnostics.

• Upper GI (x3) Outpatient capacity inadequate at treating provider, complex patient (comorbidities) and complex planning for treatment (transferred within target resulting in Sheffield allocated full breach)

• Lower GI (x2) COVID treatment change due to guidance/risk stratification led to multiple inter provider transfers and COVID clinical pathway pause to treatment (transferred within target resulting in

Sheffield allocated full breach)

• Urology (x1) Outpatient capacity inadequate at treating provider compounded by change in treatment plan.

62 Day Screening Referral to Treatment

The May validated position for 62 day screening was non-compliant at 66.7% against a target of 90%.

Three local breaches within Breast due to COVID trust cancelation (x2) and COVID capacity issues

relating to surgery

62 Day Consultant Upgrade to Treatment

Performance for May Consultant Upgrades was compliant with 100% against a national target of 85%.

Three breaches which were all transferred within target but treated beyond target meaning the

treating provider receives the full allocation of the breaches.

• Urology – transferred day 14 / treat day 70

• Head & Neck - transferred day 28 / treat day 96

• Head & Neck – transferred day 35 / treat day 81

60%

65%

70%

75%

80%

85%

90%

95%

100%

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

De

c-1

9

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Pe

rce

nta

ge P

osi

tivi

ty

62 Day - Urgent GP Referral to Treatment

Actual Standard

0%

20%

40%

60%

80%

100%

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

De

c-1

9

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Pe

rce

nta

ge P

osi

tivi

ty

62 Day - Screening Programme

Actual Standard

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

May

-19

Jun

-19

Jul-

19

Au

g-19

Sep

-19

Oct

-19

No

v-19

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Pe

rce

nta

ge P

osi

tivi

ty

62 Day - Consultant Upgrades

Actual Standard

13Pack Page 146

High Level Summary Sickness— is improved on last month by 0.84% and is only slightly higher than this time last year when it was at 4.06%. 0.42% is confirmed Covid (45 staff) with 3.78% other reasons. Top reason (39%) remains stress, anxiety, depression. CBU1 and 2 remain in red, however sickness in these areas continues to decline since the spike in April 2020. CBU3 has gone into green, Corporate and BFS remain in green. With regards to staff groups, Additional Clinical Services remain in red at 6.67% , Nursin g & Midwifery Registered at 5.66%. Estates & Ancillary have gone into amber at 3.97%. All other staff groups remain in green. Covid-19 risk assessments for vulnerable workers to stay in work and for staff who are shielding to return to work from 1 August are being received, with a weekly risk assessment oversight group set up throughout July t o support each CBU with their return to work arrangements for staff . A mental health staff support booklet through Covid, including signposting to various resources and providers is currently being distributed to all members of staff . Staff Turnover— Has improved and is now within the target range. CBU1 and Corporate remain in red, all other CBUs are in green. Highest staff group turnover remains Allied Health Professionals at 16.65% , followed by HealthCare Scientists at 11.28%. A listening event with AHPs is planned to understand further support that can be offered. Mandatory Training - Slight improvement on last month, however remains below target. The subject with the highest compliance is Moving & Handling Back Care Awareness (once) 94.3%. The subject with the lowest compliance is Resus Paediatric ILS 69.4%. Staff Appraisal Rate - The 2020/21 appraisal window runs until 31 August 2020. Appraisal completions recorded by managers so far in the ESR system for reporting purposes stands at 10.3%.

14Pack Page 147

People - Trend Analysis Si

ckn

ess

(Tru

st w

ide

)St

aff

Turn

ove

r (1

2 M

on

ths)


Please the latest Sickness absence benchmarking data is only available up to December 2018

15Pack Page 148

Performance MattersActivity

19/20 20/21 20/21

Actual Plan Actual Variance %

Elective Daycases 7,195 7,412 1,493 -5919 -80%

Elective Inpatients 941 1,021 362 -659 -65%

Elective Total 8,136 8,434 1,855 -6579 -78%

Non Elective Total 10,701 10,717 6,937 -3780 -35%

Maternity Pathway Total 1,554 1,623 1,438 -185 -11%

A&E Total 25,760 26,140 16,898 -9242 -35%

Outpatients Total 87,619 88,142 25,694 -62448 -71%

* Please note excess bed days are not included in these figures. 2020/21Activity Plan

2020/21 Activity Actual

2020/21 Activity Plan 2020/21 Activity Plan

2020/21 Activity Actual 2020/21 Activity Actual

Act

ivit

y

Day

Cas

es

Obstetric outpatient attendances are excluded as they are covered by the Maternity Pathways

Ele

ctiv

e In

pat

ien

ts

No

n-E

lect

ive

Inp

atie

nts


16Pack Page 149

Performance MattersActivity

2020/21 Activity Plan 2020/21 Activity Plan

2020/21 Activity Actual 2020/21 Activity Actual

Comments:

2020/21 Activity Plan

2020/21 Activity Actual

Ou

tpat

ien

ts

Due to the impact of Covid-19 most areas of activity are under plan. The exceptions are:

• Direct Access Pathology tests are15,773 over plan

• Advice and Guidance contacts are 188 over plan

• Telephone consultations are 22,864 over plan

Mat

ern

ity

Pat

hw

ay

ED A

tte

nd

ance

s


17Pack Page 150

SUMMARY

Trust Ove

rall

dat

aset

sco

re

Eth

nic

cat

ego

ry

Gen

eral

Med

ical

Pra

ctic

e C

od

e

NH

S N

um

ber

Po

stco

de

of

Uu

sual

Ad

dre

ss

Sou

rce

of

Ref

erra

l fo

r A

& E

Ove

rall

dat

aset

sco

re

Trea

tmen

t Fu

nct

ion

Co

de

Ad

mis

sio

n M

eth

od

Dis

char

ge D

ate

Pri

mar

y D

iagn

osi

s (I

CD

)

Sou

rce

Of

Ad

mis

sio

n C

od

e

Ove

rall

dat

aset

sco

re

Trea

tmen

t Fu

nct

ion

Co

de

Mai

n S

pec

ialit

y C

od

e

Co

nsu

ltan

t C

od

e

Gen

der

Sou

rce

of

Ref

erra

l

National data item average - - 79.5 90.5 87.7 90.9 72.6 - 96.7 97.5 97.8 89.6 96.7 - 96.7 95.6 92.2 94.4 92.5

Barnsley NHS FT 97.6 99.4 96.5 98.4 99.3 100 100 96 100 100 100 98.3 100 98.9 100 100 93.5 100 95.3

The Rotherham NHS FT 92.1 88.8 99.8 100 99.5 100 0 97 100 100 100 94.8 100 99.8 100 100 100 100 99.8

Chesterfield Royal NHS FT 91.7 99.8 99.4 100 99.5 99.7 100 96.9 100 100 100 98.2 100 100 100 100 100 100 100

Sheffield Teaching NHS FT 96.6 99.6 97.3 100 99.1 99.9 100 99.8 100 100 100 99.1 100 99.5 100 100 97.5 100 100

Doncaster & Bassetlaw FT 99.6 99.2 96.1 99.5 97.1 99.9 100 99.7 100 100 100 98.2 100 99.6 100 100 99.7 100 100

Mid Yorks Hospital 94.3 99.6 100 99.8 99.2 100 97.6 96.8 100 100 100 98.7 100 98 100 100 82 100 100

Definitions

Ethnic category - as stated by the patient

General Medicine Practice code - the organisation code of the GP Practice that the patient is registered with

NHS number - unique patient identifier

Source of referral for A&E - the source of referral of each A & E episode

Treatment Function Code - recorded to report the specialised service within which the patient is treated.

Admission Method - The method of admission to a hospital provider spell. For example, elective, emergency, maternity.

Discharge Date - The date a patient was discharged from a hospital provider spell.

Primary Diagnosis (ICD) - the International Classification of Diseases (ICD) code used to identify the primary diagnosis.

Source Of Admission Code - to a Hospital Provider Spell or a Nursing Episode when the patient is in a Hospital Site or a Care Home.

Consultant Code - code uniquely identifying a consultant

Gender - patient's current gender.

Source of Referral for Outpatients - source of referral of each Consultant Out-Patient Episode

The Trust now has a well-established Data Quality Group that aims to ensure the Trust’s core electronic patient record system is up-to-date and accurate. This group comprises operational and ICT staff and

reports directly into senior operational groups on progress and ensures delivery of action plans associated with emergent and pre-existing data quality issues.

The Data Quality Maturity Index (DQMI) is a quarterly NHS Digital publication intended to highlight the importance of data quality in the NHS. The most recent data is August 2019.

Postcode of usual address - the postcode of the address nominated by the patient where the address association type is 'Main Permanent Residence' or 'Other Permanent Residence'

Main Speciality Code - the specialty in which the consultant is contracted or recognised. Main speciality classifies clinical work divisions more precisely for a limited number of specialties.

Comments - Barnsley is better than the national average across all areas of mandated data. Outpatient consultant codes will improve when we implement

Medway as Lorenzo allows none standardised consultant codes (J Codes).

DQ

MI

ED Admitted Patient Care Outpatients


18Pack Page 151

At A Glance IPR RAG ratings 2020/21

Indicators Target Director Heads/ Leads RAG Overall RAG for Area

% Patients Waiting <4 Hours 95%

Chief Delivery

Officer & Deputy

CEO

R/G

% incomplete pathways waiting <=18W 92%

Chief Delivery

Officer & Deputy

CEO

R/G

Cancer 2 WW, Symptomatic Breast 2 WW, 31 Day - 1st Def Treatment, 1 Day

- Subs Treat (Surgery), 31 Day - Sub Treat (Chemo), 38 Day - Inter-Provider

Trans, 62 Day - GP RTT, 62 Day - Screening RTT, 62 Day - Consultant Upgrade

to Treatment

various

Chief Delivery

Officer & Deputy

CEO

Cancer Manager

Deputy Director

Ops

ADOs

R/G

Diagnostic patients waiting more than 6 weeks 1 %(<=)

Chief Delivery

Officer & Deputy

CEO

ADOs

Deputy Director of

Ops

R/G

Sickness Absence (In Month) G <=3.75%, A >3.75%-4.25%, R >4.25% (<) R/A/G

Mandatory Training G >90%, A >=85%-90%, R <85% (>) R/A/G

Staff Appraisal Rate G >90%, A >=85%-90%, R <85% (>) R/A/G

Staff Turnover (Rolling 12 months) G <=10%, A >10%-10.5%, R >10.5% (<) R/A/G

G >=0%, A-5%-<0%, R <-5% (>) R/A/G

G >=0%, A-5%-<0%, R <-5% (>) R/A/G

G >=0%, A-5%-<0%, R <-5% (>) R/A/G

G >=0%, A-5%-<0%, R <-5% (>) R/A/G

Falls 65 (<) per month R/G

Falls resulting in moderate harm or above 1 (< =) per month R/G

Pressure Ulcers category 2 (Lapses in care) 4 per month R/G

Deep Tissue Injury 4 per month R/G

Single sex breaches 0 R/G

Hand washing 95% (>) R/G

Hospital acquired C Diff 1 per month R/G

Hospital acquired MRSA 0 R/G

Total Serious Incidents - R/G

Total Number of Incidents Resulting in Death 0 R/G

Total Number of Incidents Resulting in Severe Harm 0 R/G

Never events 0 R/G

Duty of Candour 0 R/G

FFT Rate Trust wide target still to be agreed R/G

Complaints closed within target or agreed extension % G >90%, A >=70%-90%, R <70% (>) R/G

VTE Screening Compliance >=95% R/G

Sepsis-Antibiotics given within Hour of diagnosis

(reported quarterly)>=90% R/G

HSMR (Rolling 12 months) Latest Data - -

SHMI (Rolling 12 months) Latest Data - -

Clinical effectiveness is split

across more than one

indicators

The area has now been split

into 2 standard of care and

mortality

Overall R/G to be decided by

Director/HeadMo

rtal

ity

Medical

Director

Head of

Patient Safety

& Quality

improvement

Head of Quality &

Clinical

Governance

Medical

Director

Head of

Patient Safety

& Quality

improvement

Patient safety is to be split

across more than one area.

This has now been broken

down into separate areas -

Quality of care, IPC, Incidents

and Patient experience

If more than 50% of the

indicators are red then

overall should be red.

Overall R/G rating to be set

by director(s).

IPC

Director of

Nursing

& Quality

Assistant Director

of

Infection

Prevention &

Control

Inci

den

ts Director of

Nursing

& Quality

Medical Director

Deputy Director of

Nursing

& Quality

Head of Nursing

Quality

Head of Quality &

Clinical

Governance

Pa

tien

t

Exp

erie

nce

Director of

Nursing

& Quality

Qu

alit

y

Patient Safety

Qu

alit

y

of

Car

e Director of

Nursing

& Quality

Clinical Effectiveness

Stan

dar

d

of

Car

e

There is no overall RAG for

finance, all areas are

reported separately.

Income

Planned Cash Position

Capital Plan


people, all areas are reported

separately.

Mandatory Training

Staff Appraisal Rates

Staff Turnover

Fin

ance

Planned Financial Position

Finance at a glance page of IPRDirector of

Finance

Deputy Director

of Finance

Pe

op

le

Sickness Absence Director of

Workforce

& Organisational

Development

Associate Director

of HR & OD

Pat

ien

t A

cce

ss

Emergency Access ADO

Deputy ADO

Deputy Director of

Ops


patient access, all areas are

reported separately.

Cancer is split across several

indicators if more than 50%

of the indicators are red then

overall should be red.

Referral To Treatment (18 weeks)

Cancer

Diagnostic Waits

Pack Page 152

Performance - "At a glance"

Performance - Financial Overview

Month

Plan

Month

ActualVariance Variance % Plan YTD Actual YTD Variance

Variance

%

Month

Plan

Month

ActualVariance Variance % Plan YTD

Actual

YTDVariance

Variance

%

ACTIVITY LEVELS (PROVISIONAL) Statement of Financial Position (SOFP) £'000 £'000 £'000 £'000 £'000 £'000

Elective inpatients 341 164 (177) -51.91% 1,021 362 (659) -64.54% Capital Spend - Core Programme (496) (463) 33 6.71% (850) (682) 168 19.76%

Day Cases 2,610 829 (1,781) -68.24% 7,412 1,493 (5,919) -79.86% Capital Spend - COVID-19 (43) (680)

Outpatients 29,418 9,624 (19,794) -67.29% 87,414 25,110 (62,304) -71.27% Inventory 3,731 3,308 423 -11.34%

Non-elective inpatients 3,349 2,594 (755) -22.54% 10,725 6,939 (3,786) -35.30% Receivables 8,015 7,586 429 -5.35%

A&E 8,618 6,564 (2,054) -23.83% 26,140 16,898 (9,242) -35.36% Payables (includes accruals) (28,198) (27,122) (1,076) 3.82%

Other (excludes direct access tests) 8,880 14,215 5,335 60.08% 26,062 36,573 10,511 40.33% Other Net Liabilities (20,541) (20,589) 48 -0.23%

Total activity 53,216 33,990 (19,226) -36.13% 158,774 87,375 (71,399) -44.97%

Cash & Loan Funding £'000 £'000 £'000

INCOME £'000 £'000 £'000 £'000 £'000 £'000 Cash 39,124 38,573 (551) -1.41%

Elective inpatients 970 310 (660) -68.08% 2,910 662 (2,248) -77.25% Loan Funding (67,376) (67,376) 0 0.00%

Day Cases 1,488 572 (916) -61.57% 4,464 963 (3,501) -78.43%

Outpatients 2,929 1,144 (1,785) -60.94% 8,787 2,915 (5,872) -66.83% KPIs

Non-elective inpatients 7,014 5,798 (1,216) -17.34% 21,042 15,892 (5,150) -24.47% EBITDA % 3.17% 3.48% 0.32% 10.02% 3.17% 3.47% 0.30% 9.58%

A&E 1,232 966 (266) -21.59% 3,696 2,521 (1,175) -31.80% Surplus / (Deficit) % 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Other Clinical 4,700 9,525 4,825 102.67% 14,100 31,890 17,790 126.17% Receivable Days 7.7 7.7 0.0 -0.62%

PSF, FRF, MRET & Top-Up 1,373 1,394 21 1.49% 4,117 4,193 76 1.85% Payable (excluding accruals) Days 37.1 27.4 -9.7 -26.22%

Other 1,604 1,324 (280) -17.45% 4,814 3,942 (872) -18.12%

Total income 21,310 21,032 (278) -1.30% 63,930 62,978 (952) -1.49%

OPERATING COSTS £'000 £'000 £'000 £'000 £'000 £'000

Pay (14,514) (15,275) (761) -5.24% (43,578) (45,603) (2,025) -4.65%

Drugs (1,375) (1,140) 235 17.09% (4,125) (3,130) 995 24.12%

Non-Pay (4,746) (3,885) 861 18.15% (14,202) (12,059) 2,143 15.09%

Total Costs (20,635) (20,300) 335 1.63% (61,905) (60,792) 1,113 1.80%

EBITDA 675 733 58 8.58% 2,025 2,186 161 7.95%

Depreciation (473) (512) (39) -8.24% (1,419) (1,537) (118) -8.31%

Non Operating Expenditure (202) (221) (19) -9.63% (606) (649) (43) -7.11%

Surplus / (Deficit) 0 (0) (0) 0 0 0

Performance - Financial Overview


Page 20 of 21Pack Page 153

Performance Matters - Finance

June 20 Summary

Summary Performance:


Commentary Key to RAG Rating The RAG rating applied to Variance % is based on the following criteria: • Green equating to 0% or greater • Amber behind plan by up to 5% • Red greater than 5% behind plan

The key points derived from this table are as follows: • In line with the new financial flow arrangements in place across the NHS for the early part of the 20/21 financial year, the Trust has a consolidated year to date break-even position. This is

after receiving additional income top-up from NHS England (NHSE) of £0.076m.

• Total activity in-month is down on plan across all points of delivery, except other, due to focusing activity on business critical areas in response to COVID-19. Other activity is above plan due to a large increase in telephone consultations partly offset by other elements of activity. The in-month position is consistent with previous months.

• Total income is £0.952 adverse to plan for the year. The majority of clinical income (£54.663m) is subject to block arrangements as part of the new financial flows introduced for the early part of 20/21. There is a small overall total adverse variance on clinical income of £0.156m which is mainly due to an under performance on activity with other Trusts which are not covered by the block arrangements. Other income is £0.796m adverse to plan mainly due to reductions in car parking income and recharges out as a consequence of COVID-19.

• Operating costs are £1.113m favourable to plan in total for the year. Pay is £2.025m adverse mainly due to additional costs incurred as a consequence of COVID-19 to safely staff the service and backfill staff members in isolation. Non-pay costs are £3.139m favourable mainly due to lower activity as a result of COVID-19 in non critical business areas offsetting any additional costs incurred as a consequence of COVID-19.

• Capital expenditure for the year on the Core Programme is £0.682m which is £0.168m less than plan, mainly due to ED/CAU scheme expenditure being slightly off profile but expected to recover in later months. Capital expenditure on COVID-19 schemes increased by £0.043m bringing the total for the year to £0.680m; the Trust will be reimbursed these costs by NHSE issuing Public Dividend Capital (PDC).

• Cash balances are £0.551m adverse to plan at £38.573m. The £0.351m in-month decrease in cash is due to a higher level of creditor payments, partially offset by the capital programme slippage.

• As a consequence of the NHSE and CCG block prepayments , deferred income at £21.396m continues to make up the majority of the "other net liabilities" balance.

• Payable days (excluding accruals) are 27.4 which is 9.7 days favourable to plan and continues to show the managed reduction in the creditors position. Payable days have been calculated excluding accruals, because whilst accruals include certainties in respect of future payments, the timing of these payments is uncertain. Expenditure has been calculated as operating costs, less pay, add back lead units and agency, and capex.

Page 21 of 21Pack Page 154

REPORT TO THE PUBLIC BOARD OF DIRECTORS REF: BoD: 20/08/06/14

SUBJECT: BOARD ASSURANCE FRAMEWORK (BAF) REPORT DATE: 6 AUGUST 2020

PURPOSE:



PREPARED BY: Margaret Saunders, Director of Corporate Governance SPONSORED BY: Margaret Saunders, Director of Corporate Governance PRESENTED BY: Margaret Saunders, Director of Corporate Governance STRATEGIC CONTEXT The Board Assurance Framework (BAF) enables the Board to monitor how the internal governance arrangements are supporting the achievement and delivery of the strategic objectives of the Trust and aids in identifying risks. Specifically, the BAF maps to the Trust’s Strategic Objectives as follows:

• Strategic Objective 1 – Patients: will experience outstanding care • Strategic Objective 2 – Partners: we will work with partners to deliver better, more

integrated care • Strategic Objective 3 – People: will be proud to work for us • Strategic Objective 4 (i) Operational & (ii) Finance – Performance: we will achieve our

goals sustainably

EXECUTIVE SUMMARY The BAF has been reviewed and updated for the period June 2020 to 22 July 2020 with the Executive Team, Quality and Governance (Q&G) and People, Finance and Performance (P, F & P) Committees. Updates have been made to risks: 1025 – ED waiting time targets 1199 – Workforce costs 1201 – Non-recruitment to vacancies 1835 – On-going Lorenzo performance issues - Closed 1865 – Zero-day vulnerability 1868 – Consultant provision for Stroke Services 1966 – High levels of non-elective activity – Closed 2098 – Implementation of Medway 2121 – Brexit 2167 – Recruitment of a Nutrition nurse to meet NICE guideline 31 2375 – Covid-19 2404 – Patient care – new risk

Pack Page 155

It is intended that the Board will consider the Trust draft Risk Management Strategy, Policy and Procedure 2020 – 2023 at its Strategic Focus Group – Workshop in September 2020. This is in preparation for seeking approval from the Board at a later date to introduce a revised risk management approach including a review of both BAF content and format and utilisation of the Datix risk management system to support production and reporting of the BAF. RECOMMENDATIONS

The BAF has been reviewed and updated in accordance with agreed process. The Board is requested to note the details and receive assurance.

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1

Barnsley Hospital NHS Foundation Trust

Board Assurance Framework 2020/21

Keys to Risk Rating

Scored Likelihood x Consequence

Consequence

Likelihood Negligible (1) Minor (2) Moderate (3) Major (4) Catastrophic (5)

Almost Certain (5)

Likely (4)

Possible (3)

Unlikely (2)

Rare (1)

Key to Assurance Rating

H Risk controls in place are rated as providing high assurance

M Risk controls in place are rated as providing medium assurance

L Risk controls in place are rated as providing low assurance

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2

Strategic Objective 1

Patients: will experience outstanding care

Director Lead

Medical Director & Director Nursing & Quality

Board Committee

Quality & Governance

Impact of failing to achieve the strategic objective

Patients may have a poor experience of care and may be at risk of avoidable harm

CRR Ref

Description of Risk

Director Lead

Al

ignm

ent t

o Co

mm

ittee

Dec 2019

May 2020

July 2020

1868

Risk identified regarding consultant provision for the Stroke Service due to vacancies.

Medical Director Q&G 3x2

3x2

3x2

2167

Risk relating to compliance with NICE guideline 31 – Nutrition Support in Adults. Review identified gap at BHNFT and requirement for Nutrition Nurse. Business Case in development. Risk identified by CBU3 but applicable across Trust.

Director of Nursing and

Quality Q&G 3x2

3x2

3x2

2404

Risk of non-Covid-19 patient care being compromised leading to breaches, delays, worse outcomes and failure to achieve performance targets and Constitutional Standards.

Chief Delivery Officer/

Deputy CEO

Q&G N/A

4 x 5

4 x 5

Risk controls in place Assurance rating

2167

A business case is being developed in CBU3 with the assistance and input of the Deputy Associate Director of Nursing for surgery for a band 7 1.0 whole time equivalent (WTE) nutrition Nurse. If approved then this post would fulfil the requirements of this specialist role across the Trust and meet NICE guidance 32 for this parameter. In the interim the dietetic team are leading on ward staff training for MUST screening and are available Monday-Friday for tube troubleshooting. The gastroenterology team are also supporting ED and inpatient areas with nutritional issues and tubes. The business case has been approved at Nutrition Group and is awaiting CBU sign off, prior to ET. April 2020 Reviewing job description as recruitment unsuccessful. July 2020 - recruitment on-going. Band 7 recruitment was unsuccessful with a development role band 6 post is going to advertisement

M M M

2404

See Gold Action Log A60. See ET papers Covid19 – Reduction of Clinical Services papers 01.04.20 and Reprioritisation Guidelines received 08.04.20. Trust Recovery Plan linked to Barnsley and SY&B recovery plans Regional approach to provision of surgery on a prioritised basis.

M M M

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3

Source of Assurance

CRR Ref

Description of Assurance Date Received Positive or Negative

Internal or External

1868 Regular review at ET May 2018 Positive Internal 2404 Fortnightly review at ET July 2020 Positive Internal

Narrative to support exception reporting


Partners: we will work with partners to deliver better, more integrated care

Director Lead

Chief Delivery Officer & the Medical Director

Board Committee

People, Finance & Performance


BHNFT will be unable to provide sustainable health and care services for the local population due to ineffective partnership working.

CRR Ref

Description of Risk

Director Lead

Alig

nmen

t to

Com

mitt

ee

Dec 2019

May 2020

July 2020

Gaps in Risk Control CRR Ref

Description of Gap Action to Address Gap in Risk Control Date

1868 Continuing difficulty providing locum cover.

Service Manager working with the Clinical Lead to look at the service moving forward. March 2020 - Consultant staffing remain under review. No issues raised as a result of the change over to the new HASU model. Unclear at this stage when review will take place, given current operational issues. March 2020 - Consultant staffing remain under review. No issues raised as a result of the change over to the new HASU model. Unclear at this stage when review will take place, given current operational issues. March 2020 - Consultant staffing remain under review. No issues raised as a result of the change over to the new HASU model. Unclear at this stage when review will take place, given current operational issues. July 2020 - No change in recruitment due to pandemic. No incidents reported regarding staffing in the stroke service in the last 6 months

On-going

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4

2121

The risks to the Trust and BFS of a possible 'no deal' Brexit scenario and monitoring the Government's ongoing preparations should the UK leave the EU without any deal in March 2019. Based on a paper from the Secretary of State for H&SC dated 23rd August 2018 and a number of technical papers from Her Majesty's Government there are a number of issues highlighted that are possibly relevant to the Trust and BFS:

• Continuity of supply (medicines, equipment, consumables)

• Although unlikely - continuity of utility services (power/gas interconnectors)

• Workforce planning - EU citizens - doctors/nurses exempt from cap - however it may impact on other staff categories.

• Workplace rights - agency staff, WTD, TUPE, Equality Act

• Financial services (banking & insurance)

• Business VAT • Student funding (EU and Erasmus+) • Quality, safety of human tissue,

blood, blood products and organs • R&D: Regulatory information and

trials on medicines and medical devices.

Chief Delivery Officer P, F & P 3x4

3x4

3x2

2375

Risk of the Covid-19 global pandemic actually and potentially impacting on all Trust activities. There is an immediate need to ensure full organizational oversight of all impacts

Chief Delivery Officer

Q&G & P, F & P 3x5

3x5

5x4

1693

Risk identified surrounding adverse publicity to the Trust. Possible adverse publicity and reputational damage through different routes of exposure to the Trust. Impacting on patient choice and potential financial income and regulatory action.

Director of Communications P, F & P 3x2

3x2

3x2

Risk controls in place CRR Ref

Description of Risk Control Dec 2019

May 2020

July 2020

2121

The Local Resilience Forum (LRF) stood down Operation Yellowhammer planning and response prior to the 2019 Christmas period. The Trust will continue to adopt a ‘minimal hold position’ as expected nationally and stand down at a local level however work will continue nationally up to 31 December 2020. Further information will be provided in due course regarding the agreements made by the Department of Health and Social Care (DHSC) and central government. The Trust will continue with a Single Point of Contact (SPOC) and email address which will be used for any future questions/queries. Any work nationally will continue to be aligned to the 7 work streams agreed within the published operational guidance with any individual work stream escalation information circulated via normal channels i.e. Procurement, Human Resources (HR), and Medicine Management etc. Trusts are requested to retain any intelligence and organisational memory from previous arrangements. June 2020 - Risk constantly monitored during COVID-19 incident response. Update and review with AEO 26/6 risk rating static in that due to the run up to the final transition date in December 2020 all areas of the operational framework are to be dynamically risk assessed and managed. Medium term impacts are considered low.

M M

M

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5

2375

Executive team updated by Operational lead NHSE/I returns collated as requested Robust on call arrangements in place Weekly update to on call staff to ensure operational teams are aware of the parameters set put by NHSE/I Gold command in place from Thursday in place from Thursday 19 March 2020.

July 2020 Covid-19 Recovery Plan cross referenced with the Covid-19 Risk Register

M M

M

1693

Comprehensive Communications Planner to track and plan for positive and potential adverse publicity. Monthly Communications Planner presented to the Executive Team. The Trust has in place a number of processes for the effective management of its overall reputation. Reactive statements prepared in advance for high risk matters Proactive positive stories placed to counter negative publicity Stakeholder briefings produced to inform of negative publicity (internal and external)

H H

H

Gaps in Risk Control

CRR Ref


Source of Assurance

CRR Ref



2121 Briefing paper to September 2019 Board. Brexit Contingency Planning arrangements in place and reviewed. Continued Board Updates as contingency planning develops.

May 2019 Positive Internal

2375 Gold/silver governance, monthly updates provided to June committees July 2020 Positive Internal

1693 Monthly Communications Planner presented to the Executive Team January 2019 Positive Internal


People: will be proud to work for us

Director Lead

Director of Workforce

Board Committee


CRR Ref

Description of Risk

Director Lead

Al

ignm

ent t

o Co

mm

ittee

Dec 2019

May 2020

July 2020

1201

Risk of non-recruitment to vacancies and development of staff in post; Inability to recruit to vacancies within the Trust and non-development of staff may lead to insufficient staffing/skill mix.

Director of Workforce P, F&P 3x3 3x3

3x3

1199

Risk identified regarding workforce costs; the details and impact are as follows: Controlling staffing costs to meet the 3 year strategy and meet business objectives. These include sickness absence, agency spends and staff pay bill.

Director of Workforce P, F &P 3x2 3x2

3x2


People may choose to work at other local provider Organisations.

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6

Risk controls in place CRR Ref


May 2020

July 2020

1201

Executive vacancy/agency control panel May 2020 Update: Update to mitigation, explaining mitigation in place and staff in post data to reduce risk score. Implemented new retention initiative 'stay discussions' introduced in June 19 to improve retention. July 2020 update – Agreement to take forward plans to set out in draft Organisational Development Strategy in respect of staff development

M M

M

1199

Executive vacancy/agency control panel Development of Sickness absence reduction plan Reporting of Workforce Dashboard within Performance Framework. Update June 2019: The Trust is part of the South Yorkshire and Bassetlaw collaborative aiming to reduce bank and agency expenditure for Nursing and Medical staff. Significant reductions in expenditure realised. August 2019 Update: The Trust has implemented NHS Professionals. May 2020 update - the Trust continues to utilise the services of NHS Professionals to in order to control and mitigate temporary workforce costs.

Reviewed July 2020. Work undertaken to understand approach undertaken by high performing Trusts in respect of sickness absence management, review to be undertaken via PEG.

M M

M



Source of Assurance

CRR Ref



1201 Nurse Staffing Report December 2018 Positive Internal

1199 CBU Insight report May 2018 Positive Internal

1199 Workforce Report December 2018 Positive Internal

Strategic Objective 4 i) Operational

Performance: We will achieve our goals sustainably

Director Lead

Director of Finance & Chief Delivery Officer

Board Committee


Impact of failing to achieve the strategic objective i) Operational

BHNFT will be unable to deliver all access standards.

CRR Ref

Description of Risk

Director Lead

Al

ignm

ent t

o Co

mm

ittee

Dec 2019

May 2020

July 2020

1025

There is a risk of a sustained failure to deliver on the ED waiting times target or not to achieve the 95% year end position, impacting on quality of service and organisation reputation

Chief Delivery Officer P, F &P 4x3 4x3

5x3

2205

The Breast Imaging Service is at risk due to increased demand from symptomatic and breast screening services. There are 2 key contributing factors: one has been an increase in out of area referrals and the second is national workforce shortages.


4x4

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7

2344

There is a risk that patients have not received follow up treatment and or monitoring which may have resulted in harm and or poor experience. 55,000 patient pathways with open referrals without further activity have been identified as part of the migration to Medway work in the last 2 years.


5x3

1865

Risk identified regarding zero-day (also known as zero-hour or 0-day) vulnerability; this is a disclosed computer-software vulnerability that hackers can exploit to adversely affect computer programs, data, additional computers or a network. It is known as a "zero-day" because once the flaw becomes known, the software's author has zero days in which to plan and advise any mitigation against its exploitation.

Director ICT P, F & P 3x3 3x3

3x2

2098 Lorenzo replacement Medway causes operational/financial/reputational and clinical safety risks during replacement.


2x5

2122 Impact on operational services due to a cyber-security incident due to lack of external support for all computer systems.


2x4

Risk controls in place Assurance rating CRR Ref

Description of Risk Control Nov 2019 May 2020 July 2020

1025

The target was successfully achieved in September and October despite a national deterioration in performance. In November 2019 the target was missed due a significant rise in attendees, early onset of flu and consequent impact on driving activity up. Investment continues in ED staffing, extra beds have been secured as part of escalation and onsite management arrangements have been reinforced. An update presentation was given at December 2019 F&P Committee. The Trust continues to perform in the top quartile of trusts nationally and continues to be monitored in 20/21. July 2020 - The Trust, despite missing the target in 19/20, performed well nationally. In 20/21 the Trust achieved the target in April and just missed it in May 2020. The Trust overall is adjusting to the pressures of covid and now the return of higher numbers of patients. Issues with flow have been identified and a number of actions are being adopted to improve the situation, these will be regularly monitored at ET.

M M M

Pack Page 163

8

2205

A number of actions are being taken to address this issue: -On-going recruitment of a breast screening radiologist. -Advertising for a consultant mammographer. -Successfully recruited to a locum screening consultant. -Support to a second radiologist returning from maternity leave. -Recruitment and training of further reporting radiographers. -Contact has been made with the ICS to support a collaborative approach to working for screening services. -Working with a neighbouring Trust to support the grade 3&4 complex screening patients. -Working with a neighbouring Trust to agree an SLA or permanent support. July 20 - Final stages of negotiations with neighbouring Trust to sign SLA for additional permanent support that will provide a sustainable service. Currently neighbouring Trust is supporting the service virtually. Routine screening has been suspended due to COVID-19. The Trust are working with the ICS on potential regional solutions for Breast Screening.

M M M

2344

An external review was commissioned and a plan agreed to deal with the existing open pathways and to address the causes of poor data quality which lead to open pathways. The plan is overseen by the Data Quality Group with periodic updates to the Executive Team, the People, Finance and Performance Committee and the Quality and Governance Committee. The plan involves: -validation of the open pathways with clinical assessments and harms reviews undertaken as appropriate. -implementation of a new patient administration system which is less conducive to error. -improved validation and quality assurance processes - improve staff training including the appointment of a dedicated trainer July 2020 - Update provided to the Executive Team on 8 July 2020. Validation of the first cohort of 26,605 open pathways is on course to be completed by the end of July 2020. In the event of confirmed instances of loss to follow-up clinical assessments and harms reviews are being undertaken as appropriate by the responsible Clinical Business Unit. A new patient administration system being implemented on 12 July 2020. An RTT trainer has been appointed to develop and run an applied training programme commencing 13 July 2020. A second, and more specific, data diagnostic exercise has been undertaken by North of England Commissioning Support (NECS) and an action plan will be developed in response to the report including the next phases of open pathway validation.

M M M

1865

Ensure subscription to international standard antivirus software. Ensure subscription and follow-up of any CARECERT warnings and notifications. Ensure system patching of any security patches for operating systems. Patching plan in place. 360 Assurance audit to be completed June 2020. July 2020 Audit completed with significant assurance. July 2020 – Pen test commissioned with nation security cybersecurity centre certified organisation due during July 2020. Scope signed off by SIRO

Compliant position for data protection toolkit achieved 31 March 2020 this will be submitted to NHSI/D in September 2020.

M M M

2098

Full governance/project initiation document process with clinical leadership to ensure effective delivery and engagement. May 2020 Update Medway Steering Group re-established and successful Medway training launch. Continuing clinical engagement and communication strategy in place. July 2020 – Medway live from 11 July 2020 Microsoft Teams has helped transform the way we communicate whilst people are working away from the hospital site and we’ll be leveraging this to help facilitate our training. The NHS Digital TSSM is still fully engaged at Key Project Gateways to provide full external assurance regarding the position of the project. A fully documented report has been provided with green-amber rating. Highest achievable assurance at this point in the project. Mitigation in place through full support from the supplier and good governance through a well-established Medway steering group

M M M

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9

2122

Currently all clinical and business critical systems have external support. Minor non-critical systems are supported internally. A regular review and assessment is carried out to ensure that business critical computer solutions are supported externally and a risk assessment completed on minor unsupported solutions. May 2020: Full annual cybersecurity assessment by National cybersecurity Centre accredited supplier commissioned for during June 2020. Awaiting the full report to build an appropriate action plan. COVID-19 Risk Assessment completed no further risks identified. July 2020 Significant assurance provided from 360 Assurance on DPT compliance position- Board approved position.

M M M



1025 Insufficient beds and staffing to meet the requirements of peak activity. Issues in social care (staffing) that is leading to a reduced offer of support impacting on the ability to discharge patients efficiently

Performance Review meetings Weekly ED Delivery Board meeting Patient Flow Improvement Plan

Mar 2020

2205 National shortage of Breast Radiologists, pressures on all Breast screening services.

Working with the ICS to develop regional solutions. July 20 - Final stages of negotiations with neighbouring Trust to sign SLA for additional permanent support that will provide a sustainable service. Currently neighbouring Trust is supporting the service virtually.

July 2020

2344 Issues relating to Lorenzo and inconsistency in data input. Medway will improve this issue Mar 2020

1865 Cyber Security Ransomeware Cyber Security Ransomeware plan Jan 2020

Source of Assurance

CRR Ref



1025

Performance Review meetings December 2018 Positive Internal

1025 Weekly ED and flow meeting including oversight of the Patient Flow Improvement Plan January 2019 Positive Internal

2344

Issues relating to Lorenzo and inconsistency in data input update report presented to ET and P, F & P in May 2020, see Chair’s Log ICT Report. July 2020. Update provided to the Executive Team on 8 July 2020. Validation of the first cohort of 26,605 open pathways is on course to be completed by the end of July 2020. In the event of confirmed instances of loss to follow-up clinical assessments and harms reviews are being undertaken as appropriate by the responsible Clinical Business Unit. A new patient administration system being implemented on 12 July 2020. An RTT trainer has been appointed to develop and run an applied training programme commencing 13 July 2020. A second, and more specific, data diagnostic exercise has been undertaken by North of England Commissioning Support (NECS) and an action plan will be developed in response to the report including the next phases of open pathway validation.

July 2020 Positive Internal

1865 ICT report to People, Finance and Performance Committee May 2020 Positive Internal

1865 Assurance Audit completed by Carecert supplier for intrusion detection Sept 2018 Positive External

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10

1865 Pen Test Commissioned with nation cybersecurity centre certified organisation due during July 2020. Scope signed off by SIRO.

July 2020 Positive Internal

1865 CareCert Cybersecurity Audit. Action Plan from cyber essentials accredited audit of cyber safeguards now in place. Expected to be completed by 31 March 2019. August 2018 Positive External

2098 Medway - TSSM External Assurance Report March 2020 Positive External

2122

COVID-19 Risk Assessment of all Cybersecurity and IT Risks. Significant Assurance provided from 360 Assurance on our Data Protection Toolkit compliance position - Board approved position.

July 2020 Positive External

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11

Strategic Objective 4 ii) Finance

Performance: We will achieve our goals sustainably

Director Lead

Director of Finance & Chief Delivery Officer

Board Committee


Impact of failing to achieve the strategic objective ii) Finance

BHNFT will fail to achieve the financial plan which has been set.

CRR Ref

Description of Risk

Director Lead

Al

ignm

ent t

o Co

mm

ittee

Dec 2019 May 2020

July 2020

1943

Failure to develop recurrent CIP schemes impacting on the ability to deliver the overall Trust financial plan.

Director of Finance P, F & P 3x2 3x2

3x2

1791 Insufficient cash funds to meet the operational requirement of the Trust.


1x4

1713

Failure to deliver the financial plan including CIP programme and clinical activity in accordance with contractual agreements. Failure would adversely impact on the financial stability of the Trust, resulting in the need for further borrowing to support the continuity of services and failure to achieve PSF (cross references to Risks: 1025, 1832, 1849)


2x4

2222

Trust currently has approximately £67M of loans from the DHSC, due for repayment within 2020/21. The Trust is unable to meet the repayment.


1x4

Risk controls in place

CRR Ref


May 2020

July 2020

1943

Cost improvement steering group monitoring the delivery of the plan supported by the Project Management Office. There are a number of schemes identified. On-going review of CBU and Corporate opportunities, including working collaboratively across the system.

M M

M

1791 Micro manage cash flow. Recovery of financial position - delivery of key actions. Work closely with CCG and the Distressed Funding Team at NHS Improvement and Department of Health.

L L

H

1713

A range of control measures in place, including:

• Urgent identification of additional CIP / reduction in expenditure run-rate • Continued work on opportunities arising from coding audits (non-counting and coding) • Successful implementation of NHSP with subsequent agency reduction; especially to be managed during winter with no escalation to high cost agencies. • Continued negotiation with Barnsley CCG.

H H

H

2222

On-going discussion with NHSI and DHSC re deferral of payments to a future date. This is a recognised risk across the system and there are on-going discussions nationally. The loans should be converted to Public Dividend Capital (PDC) in 20/21.

M M

M

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12



1943 Risk of number of non-recurrent CIP schemes.

Challenge to all Trust Clinical Business Units (CBUs) & departments via the monthly CIP steering group and performance meetings. Continued work on workforce productivity to release recurrent savings. Continued work within the ICS framework to realise long term savings and sustainable models of care for South Yorkshire.

May 20

1713 Lack of Trust control over financial performance of external partners Monthly monitoring May 20

Source of Assurance

CRR Ref



1943

Integrated Performance Report /Finance Report May 20 Positive Internal

1943 CIP report May 20 Positive Internal

1713 Monitoring Progress Reports e.g. ICS performance papers at People, Finance and Performance Committee Meetings May 20 Positive Internal

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1

EXECUTIVE SUMMARY

CONCLUSION/RECOMMENDATIONS

STRATEGIC CONTEXT

REPORT TO THE BOARD OF DIRECTORS BoD: 20/08/06/14ii

SUBJECT: CORPORATE RISK REGISTER DATE: 6 AUGUST 2020

PURPOSE:



PREPARED BY: Kim Traynor, Risk Management Co-ordinator SPONSORED BY: Margaret Saunders, Director of Corporate Governance PRESENTED BY: Margaret Saunders, Director of Corporate Governance

The Board of Directors has delegated the quarterly review of the Corporate Risk Register (CRR) to the Audit Committee as part of the strategic approach to risk management of the Trust with the Quality and Governance (Q&G) and People, Finance and Performance (P, F& P) Committees receiving quarterly updates.

The appendix provides an overview of the current extreme risks on the Corporate Risk Register (CRR) as at 22 July 2020 (the date that the report was produced). Work has been undertaken with all relevant Directors to update the risks accordingly bringing together the strategic and high level risks which if not addressed would compromise the Trusts ability to achieve its corporate objectives. The appendix provides details of the extreme risks (risk rated 15-25) on the CRR which are reported every quarter to the Board of Directors. The risks below were approved for closure by the Executive Team: 1835 - Risk identified regarding on-going Lorenzo performance issues as Lorenzo is no longer live at the Trust following the implementation of Medway becoming fully operational from 13 July 2020. 1966 - Risk regarding high levels of non-elective activity as the Trust continues to put in place best practice pathways and models to ensure improved management of none elective patients. The Trust is working closely with partners to continue to develop the approach ensuring it is line with the Trust vision of outstanding and integrated care 2261 - Risk of waste water/sewage leak within the hospital as all reasonable mitigating actions are complete.

Board is requested to review the CRR and receive assurance.

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Subject: CORPORATE RISK REGISTER Ref: BoD: 20/08/06/14ii

1. STRATEGIC CONTEXT

1.1 The Board of Directors has delegated the monthly review of the Corporate Risk Register

to the Quality & Governance Committee as part of the strategic approach to assurance. The Audit Committee provides oversight and review of the processes supporting the Corporate Risk Register.

2. INTRODUCTION

Reviews were undertaken with all relevant Executive Leads to provide updates on the risks held on the corporate risk register.

2.1 There are 97 risks currently active on the Corporate Risk Register; 24 of which specifically relate the Covid-19 pandemic. Details of the Covid-19 risks are included in a separate report.

2.2 There are four risks graded as Extreme Risk (15+) and 23 graded as High Risk (8-12) out of the other 73 corporate risks. 21 of these risks are regarding counter fraud in line with a change in the counter fraud legislation (a requirement that the Trust hold all counter fraud risks on the corporate risk register).

2.3 All extreme risks (15+) are reported to the Quality & Governance and People, Finance & Performance Committees on a quarterly basis.

2.4 The Corporate Risk Register has been reviewed in order to provide an update as of July

2020.

2.5 This review considered:

• The need to re-score the current risks following an assessment of the controls in operation for the year to date and the operational delivery achieved as of 22 July 2020.

• The setting and monitoring of target risk scores going forward for the remainder of the financial year.

• Identification of any known new risks. • Identification of any strategic risks that may impact on the risk to achieving the Trust’s

objectives.

2.6 The Trust’s timeframes for reviewing risks are Extreme – monthly, High – bi-monthly, Moderate – quarterly and Low – Six months. Since the last report, the following changes have been made:

Risks updated: See the table at the end of the report for progress of extreme risks. The updates for the high risks are as follows:

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Risk 1025 – Chief Delivery Officer Risk relating to not meeting the 4 hours waiting time target in ED July 2020 update - The Trust, despite missing the target in 19/20, performed well nationally. In 20/21 the Trust achieved the target in April and just missed it in May 2020. The Trust overall is adjusting to the pressures of Covid-19 and now the return of higher numbers of patients. Issues with flow have been identified and a number of actions are being adopted to improve the situation, these will be regularly monitored at ET. Risk 2445 – Chief Delivery Officer Risk relating to the construction delay for the new ED/CAU July 2020 update - revised timescales for completion of phase 2 now March 2021. Risk monitored via ED/CAU Steering Group/Project Board on an on-going basis with senior management and executive oversight. Risk 2357– Chief Delivery Officer Risk regarding duplication of handover July 2020 update – IT resource awaited, following implementation of Medway, to support utilisation of hand over in ProWard. Risk 2251– Chief Delivery Officer Risk regarding fire emergency bleep July 2020 update – incidents being reported on Datix: one incident reported in June. Total of 12 incidents reported. All on test bleeps, all arriving late. Risk 2261 – Chief Delivery Officer Risk of waste water/sewage leak within the hospital July 2020 update – As all reasonable actions have been closed it is recommended that this risk is closed.

Risk 2174 – Chief Delivery Officer Risk regarding lack of clinical lead for the cancer of unknown primary MDT July 2020 update – meetings have been progressing with the Palliative Care team and the Upper GI CNS team to explore the possibility of a named CUP lead and more robust service. We are currently in conversation with the CCG to understand there thoughts due to the impact on the Trust, Hospice and Community Services. We have also been in touch with the Cancer Alliance Clinical Delivery Group Lead clinician who is happy to help support the set up and conversation across the Barnsley footprint. Risk 1539 – Director of Finance Risk regarding some medical equipment not being replaced July 2020 update – risk reviewed and remains the same.

Risk 1713 – Director of Finance Risk regarding 2019/20 financial plain including CIP programme July 2020 update – risk reviewed and remains the same.

Risk 2223 – Director of Finance Risk regarding impact from Unison legal claims July 2020 update – risk reviewed and remains the same. Risk 2050 – Director of Finance Risk regarding the underlying financial deficit July 2020 update – risk reviewed and remains the same.

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Risk 1201 – Director of Human Resources Risk regarding potential risk of non-recruitment July 2020 update – Agreement to take forward plans to set out in draft Organisational Development Strategy in respect of staff development.

Risk 1865 – Director of ICT Risk regarding zero-day vulnerability July 2020 update: Pen Test Commissioned with nation cybersecurity centre certified organisation due during July. Scope signed off by SIRO.

Risk 2098 – Director of ICT Risk regarding risks from Lorenzo replacement, Medway Mitigation in place through full support from the supplier and good governance through a well-established Medway steering group. Risk 2122 – Director of ICT Cyber security Externally Unsupported Systems July 2020 update - Significant Assurance provided from 360 Assurance on our DPT compliance position - Board approved position. Risk 2450 – Director of ICT Risk regarding print management New Print Management Contract was agreed at ET and is now signed. Supplier has given assurances it will be onsite for commencement before existing contract terminates. This risk will not be lower until the kit has arrived as there is a possibility the kit will be delayed due to COVID-19 Manufacturing/supply issues. Risk 2427 – Director of ICT Risk regarding ICT issues – Careflow vitals

Risk 2164 – Medical Director Risk regarding adequate safety netting processes for incidental findings July 2020 update – the current position for completion of ICE filing is 85%. Once 100% has been achieved; the CBUs will monitor and track performance locally. Histopathology continues to be on paper. Risk 2358 – Director of Quality and Nursing Risk regarding mask fit testing July 2020 update – There is improved consistency in the type of mask being sent to the Trust and the majority of staff have been fit tested for the masts that we have received. There are on-going sessions available for new starters and flexible workforce. There are significantly fewer Covid positive patients within the Trust and therefore the likelihood of AGP’s (which required FFP3 masks) have also diminished. Risk 2195 – Director of Nursing and Quality Risk regarding the management of procedures and clinical guidelines July 2020 update – TAD launched and training delivered to staff. Post go live meeting with T&F group team delayed due to Covid. Risk score remains the same as documents have not been moved from all speciality sharepoint or intranet sites so variation in format, consistency, control and distribution exists. Substantive admin support to project agreed by ET and post go live meeting will focus on the next steps required to address these issues.

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Risk 2323 – Director of Nursing and Quality Risk regarding safeguarding capacity July 2020 update – risk likelihood reduced. The safeguarding lead for children's will be leaving this post for a new job which will leave a gap until the new lead starts. Risk 2334 – Director of Nursing and Quality Risk regarding on-going recruitment to registered nurse vacancies July 2020 update – risk reviewed and remains unchanged. Mitigation added. Risk 2335 – Director of Nursing and Quality Risk regarding Acute Response Team being made ward based July 2020 update – 3 ANPs trainee posts have been recruited; continue to monitor. Risk 2362 – Director of Nursing and Quality Risk regarding enhanced care requirements July 2020 update – the risk likelihood has been reduced due to fewer patients in hospital therefore hasn't been an issue. Will monitor as the hospital reopens and activity resumes.

Risks added: There have been 28 risks added to the corporate risk register in the 20/21 financial year to date. These are allocated to the following risk registers

Apr-20 May-20 Jun-20 Total Chief Delivery Officer 8 1 9 Director of Corporate Governance 2 2 Director of ICT 1 2 1 4 Director of Finance 1 1 Director of Human Resources 3 2 5 Medical Director 1 1 Nursing Director 3 1 2 6 Total 19 5 4 28

Risk removed/closed Apr-20 May-20 Jun-20 July-20 Total Chief Delivery Officer 1 1 2 Director of ICT 1 1 Nursing Director 1 1 2 Total 3 1 1 5

3. CONCLUSION

3.1 Each month all risks will be reviewed by the risk owners and updated as necessary. 3.2 The Committee is asked to note the updated version of the Corporate Risk Register as at

21 July 2020.

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ID Description Mitigation Service Unit

Risk level (current)

Progress Notes

2033 There is a Risk of: Loss of functionality of Pathology equipment which may lead to a delay in the production of patient pathology reports to support diagnosis and treatment with possible detrimental effect upon the patient in terms of clinical outcomes. Increased costs to support ageing equipment. Some equipment remaining outside of the existing MSC, with no support or replacement plan Increase pressure on staff Caused by: Inability to replace ageing equipment – Pause on MSC due to NHSI pathology directive Breakdown of ageing equipment. Increased downtime following breakdown - Equipment no longer being produced resulting in reduced availability of spare parts. Historically some equipment was not part of MSC (e.g. Immunology) Increased time spent on maintenance, responding to phone calls from users when testing delayed Resulting in: Inability to provide robust and timely test results which will impact on patient management and Trust targets. Additional cost of sending work to external sites for analysis where no in house back up is available Loss of reputation of the department resulting in issues recruiting and retaining staff Unable to develop service in line with new technologies. Increased sickness and difficulty retaining staff

The mitigation is a re-procurement of the blood sciences equipment contract with full implementation in 2021. The project is under the oversight of the BRILS pathology Board; regular updates go to the respective Trusts executive team meetings.


Extreme Risk (15-25)

July 2020: The contract is signed, estates works completed and the contractor is back on site (after a covid pause). The readjusted plan was presented to ET in July and the work is expected to be completed on both sites by the end of October.

2205 The breast screening service is at risk due to the lack of specialist screening radiologists.

A number of actions are being taken to address this issue: -On-going recruitment of a breast screening radiologist. -Advertising for a consultant mammographer. -Successfully recruited to a locum screening consultant. -Support to a second radiologist returning from maternity leave. -Recruitment and training of further reporting radiographers. -Contact has been made with the ICS to support a collaborative approach to working for screening services. -Working with a neighbouring Trust to support the grade 3&4 complex screening patients. -Working with a neighbouring Trust to agree an SLA or permanent support.



July 20 - Final stages of negotiations with neighbouring Trust to sign SLA for additional permanent support that will provide a sustainable service. Currently neighbouring Trust is supporting the service virtually. Routine screening has been suspended due to COVID-19. The Trust are working with the ICS on potential regional solutions for Breast Screening.

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2344 There is a risk that patients have not received follow up treatment and or monitoring which may have resulted in harm and or poor experience. 55,000 patient pathways with open referrals without further activity have been identified as part of the migration to Medway work in the last 2 years, in addition to this there are a further 70,000 that are older than 2 years that have no further activity. A series of reports and validation exercises have commenced but there is a significant risk of lost to follow up patients and the potential risk of 52 week breaches. 52 week breaches have already been found in Ophthalmology and more recently Urology. Lost to follow patients have been found in Ophthalmology, Dermatology and there are a number of potential lost to follow up's in other specialities that are currently being reviewed. The capacity of existing teams to validate this number of referrals is also a concern as this is additional workload on top of the day to day business. The Medway Steering Group have made a decision that any referrals that are still open with no further activity that they will be closed going into Medway, and a report of these patients will be kept. This presents a further risk of patient pathways not been validated in a timely manner increasing the clinical risk of any lost follow up's.

An external review was commissioned and a plan agreed to deal with the existing open pathways and to address the causes of poor data quality which lead to open pathways. The plan is overseen by the Data Quality Group with periodic updates to the Executive Team, the People, Finance and Performance Committee and the Quality and Governance Committee. The plan involves: -validation of the open pathways with clinical assessments and harms reviews undertaken as appropriate. -implementation of a new patient administration system which is less conducive to error. -improved validation and quality assurance processes - improve staff training including the appointment of a dedicated trainer



July 2020 - Update provided to the Executive Team on 8 July 2020. Validation of the first cohort of 26,605 open pathways is on course to be completed by the end of July 2020. In the event of confirmed instances of loss to follow-up clinical assessments and harms reviews are being undertaken as appropriate by the responsible Clinical Business Unit. A new patient administration system being implemented on 12 July 2020. An RTT trainer has been appointed to develop and run an applied training programme commencing 13 July 2020. A second, and more specific, data diagnostic exercise has been undertaken by North of England Commissioning Support (NECS) and an action plan will be developed in response to the report including the next phases of open pathway validation.

2375 Risk of the Covid-19 global pandemic actually and potentially impacting on all Trust activities. There is an immediate need to ensure full organizational oversight of all impacts

Daily operational meeting Action logs to capture information Silver command approach in place 24/7 Executive team updated by Operational lead NHSI/ E returns collated as requested Robust on call arrangements in place Weekly update to on call staff to ensure operational teams are aware of the parameters set put by NHSE/I Gold command in place from Thursday in place from Thursday 19 March 2020



March 2020 - The situation is escalating on a daily basis worldwide. The trust is ensuring that all staff, patients and visitors’ health and welfare are the priority as decisions are made/enacted. The Trust is working with system partners to national direction. There is a separate risk register providing further detail. July 2020 Covid-19 Recovery Plan cross referenced with the Covid-19 Risk Register

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BoD Front Sheet - template


SUBJECT: HEALTH EDUCATION ENGLAND SELF ASSESMENT REVIEW


PURPOSE:




PREPARED BY: Louise Pemberton, Medical Education Manager

SPONSORED BY: Jackie Murphy, Director of Nursing and Quality Dr Simon Enright, Medical Director

PRESENTED BY: Jackie Murphy, Director of Nursing and Quality Dr Simon Enright, Medical Director

STRATEGIC CONTEXT

People- The educational experience learners receive in the organisation from apprentice to Junior Doctors impacts on the future workforce planning of the organisation

EXECUTIVE SUMMARY

The Quality Framework identifies the standards that organisations are expected to have in place to provide a quality learning environment for the learners they have responsibility for. Every organisation is expected to have assessed which standards are fully or partially in place via the use of an annual self-assessment review (SAR). There is an expectation, via the Learning and Development Agreement (LDA), that organisations will refresh their SAR every year as good practice. This is the 2nd Year HEE have requested an organisational assessment in regards to Education and Training and this is an update on the assessment the Trust filed in 2019. Covid disrupted training towards the end of the financial year and all education teams within the trust are now looking at different ways to deliver quality education whilst meeting social distancing requirements. This is proving challenging for skill-based training sessions due to the reduced capacity available in training rooms. The majority of sessions are now being delivered via a variety of online platforms. HEE conduct quarterly monitoring the learning environment meetings with the trust and these are attended by medical education and student support teams. These meetings are used to identify areas where support is required and also to discuss areas of best practice. RECOMMENDATION

The education departments across the Trust will continue to monitor placement provision mapping against HEE Quality framework and highlighting potential concerns in delivery and meeting with stakeholders as required. The next 12 months will be challenging to ensure that quality is retained whilst moving to different ways of delivering education and training in the new environment.

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Self-Assessment Report (SAR) 2020

Declaration

Trust Name

Name of Board Level Director responsible for Education and Training within your organisation:

Report compiled by (responsible for completion):

Date seen at or scheduled for Board meeting?

Approved by/ on behalf of the trust Board (Name):

Dates need to be in the format 'DD/MM/YYYY', for example 27/03/1980.

06/08/2020

Barnsley NHS Foundation Trust

Dr Simon Enright – Medical Director

Louise Pemberton – Medical Education Manager

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Date approved by/ on behalf of the trust Board:


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HEE Priorities Please consider HEE's priorities for 2019/2020 for both medical and healthcare professionals.

HEE Domain 1 Learning Environment and Culture, HEE priority for 2019/20 reporting in this domain is:

In your organisation, in which clinical service areas does clinical workload regularly impact adversely on your ability to deliver clinical training?

What strategies do you employ to maintain both clinical service and training on a daily basis?

In medical specialties – especially during winter months the clinical workload affects the release of staff for training. This is across all learning groups. The open quality condition in relation to medical training is related to the release of trainees to attend medical clinics for training purposes. During periods of high bed occupancy and winter months where staff sickness is higher release is difficult to achieve due to minimum staffing numbers being breached.

The vision for Barnsley is to prioritise training over service at all times during day time hours. HEE pay us to train, and in certain areas where we have not always been strong in ensuring training over service we have made multiple steps to develop work streams to provide curriculum mandated training provision. We are utilising other locally employed staffing groups to support training activity during the delivery of clinical service. The medical education team are exploring training clinics and theatre sessions to ensure training is protected whilst also delivering clinical services.

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HEE Domain 2 Educational Governance and Leadership, HEE priority for 2019/20 reporting in this domain is: Many clinical services are undergoing review and change as part of the NHS Long Term Plan & People Plan, what governance steps have you put in place to ensure the required notification of any change in service is given to both HEE and the HEIs to ensure continued clinical placements within your organisation?

Please describe how your organisation ensures the governance of education. Please email a copy of the organisational diagram or visual that describes the governance and team structures relating to education and training to the North Quality Analyst Team at [email protected].

HEE Domain 3 Supporting and Empowering Learners, HEE priority for 2019/20 reporting in this domain is:

Please describe how your organisation provides support to medical trainees who submit Exception Reports or Code of Practice concerns?

We work in partnership with SYB , HEE and HEI’s to agree workforce models, placements, training and education. We meet with these teams regularly and all placements are quality assured. At this stage there are no expected or likely changes that would affect clinical placements at the Trust, that would require us to notify HEE/HEI. If this changed the governance for this would be communicated through our Director of Medical Education – Dr S. Siddiqui.

Education and training is a priority at the trust and is reported through board through Dr Simon Enright for medical training, Jackie Murphy Director of nursing for nursing and other health professions, Director of HR represents all other learners in the trust. Training and Education is a standing agenda item at CBU business meetings and People and Engagement Group.

Trainees raising exception reports or code of practice concerns are supported in a variety of ways. The educational supervisor would discuss the report / issue with the trainee and ensure that any issues are raised with the appropriate people. Hours and rest – Guardian of Safe Working / Medical Staffing team / Clinical Director Code of Practice – Medical Staffing / Head of School. Trainees are provided at induction with information regarding how to raise any concerns or issues and the different avenues they can follow to do this. They have access to an electronic system that allows them to raise exceptions easily. We encourage trainees to highlight issues and respond.

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How do you encourage trainees to identify Educational Exception Reports (e.g. loss of specific training session to cover clinical service gap) from ERs relating to working beyond regular hours?

How have you used the 'Rest Monies' allocated to you from central funding to support doctors in training?

Please describe how your organisation provides support to learners to ensure they can access rest facilities, IT resources and pastoral support during their placement.

How do you support academic learners?

We ask trainees to identify the issue when raising the report. The report can be logged as either Hours or Educational. We discuss this with the trainees at local teaching to ensure that any missed opportunities are identified so the college tutor and director of medical education can investigate. Trainees are encouraged to report missed educational activity to ensure this can be investigated and measures put in place to encourage and enable future attendance.

We have used the allocation to upgrade and refurbish the central Dr’s mess. This has included a full refurbishment the addition of IT facilities and a comfortable place to rest. We have also made improvements to Dr’s rest rooms in clinical areas such as ED and paediatrics.

Learners are provided with a full induction at the beginning of their placement which includes information in relation to locations of rest facilities provided around the Trust. The induction ensures that each learner has appropriate IT access for their placement needs. Each learner is provided with the details of their supervisor who can provide support as required they are also provided with contact details of appropriate staff they could approach for advice as required.

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HEE Domain 4 Supporting and Empowering Educators, HEE priority for 2019/20 reporting in this domain is:

MEDICAL TRAINING: Please provide details of the specific SPA time you allocate to individual trainers undertaking the roles of named Educational and Clinical Supervisor. Job planned 'one hour per week per trainee under named supervision' is the accepted standard and this is covered by the placement tariff sent with the LDA. Does your organisation meet this standard; if not, what tariff do you apply?

MULTIPROFESSIONAL TRAINING: Please provide details of the protected annual time for continued development you allocate to those providing educational roles over and above the time required annually for their continuing clinical development. What in house courses/support do you provide; what external courses do you regularly use?

HEE Domain 5 Delivering Curricula and Assessments, HEE priority for 2019/20 reporting in this domain is:

With the introduction of new workforce roles (e.g. Physicians Associates) and increased numbers of Advanced Practitioners in training, together with an increased reliance on Locally Employed Doctors on service rotas, how do you ensure that doctors in training receive their required curricular opportunities and where necessary how are these needs prioritised?

Each named educational /clinical supervisor receives an allocation of 0.25pa – 1 hour per week per trainee they supervise up to a maximum of 0.75pa – 3 hours per week as per accepted standard

We provide training for supporting supervision and assessment of learners in practice for non-medical professions around a half day per year. Trainee nursing associates have 15 hours per week protected as part of their training contract.

We have invested in Physician Associates, Locally employed Doctors and Advanced Nurse Practitioners as alternatives to medical staff for exactly the reason that they will help the trust deliver on this vision that day time work is training time as the highest priority. Clearly, while large positive steps have been taken we have a lot of work to do still to ensure these new workforce roles are embedded in teams and compliment and contribute to the training environment.

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The NHS People Plan identifies the need for increased placement numbers to accommodate the planned growth in student numbers to meet future workforce demand. What plans do you have in place to accommodate increased student placements? What impact do you envisage this will have on your ability to maintain the learning experience provided to current students and to clinical service provision?

HEE Domain 6 Developing a Sustainable Workforce , HEE priority for 2019/20 reporting in this domain is:

The People Plan identifies as a priority the need to tackle both 'The Nursing Challenge' (Chapter 3) and to create the workforce needed to deliver '21st Century Care' (Chapter 4). What plans for 2019-21 does your organisation have to meet these challenges from an educational and training perspective?

We have already started expanding placement opportunities and investing in different ways of delivery educational experience and clinical training. We are utilising the simulation facilities to open up different ways of ensuring we deliver clinical experience in a meaningful way. The increases in student numbers will be managed by careful timetabling to ensure opportunities are available to all whilst ensuring we maintain service provision.

The trust works in partnership with local universities to ensure a pipeline and placement opportunities. Expanding placement opportunities by Increasing the number of TNA’s in the Trust Increasing the number of nurses undertaking the Open University graduate route into the profession. Ensure all placements are quality assured. Enhance educational support by introducing an additional training support post to the Trust. Exploring the possibility of clinical educator posts in more areas For medical Undergraduates we plan to timetable students to attend out of hours activity to help manage capacity. BHNFT has invested in supporting and developing Physicians Associates (PA). We have recruited at both undergrad and post grad level and now have significant number of PA’s deployed on the wards. As part of this we have put in place processes to support their education and training, including appraisal and supervision. The Trust sees this a very important step in support the future configuration of wards and delivering services going forward. We deliver their education and training in a similar way to that of a Junior Doctor.

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Organisation top three successes and top three challenges

Please use this section to summarise three high-level successes your organisation is most proud of achieving, and list any challenges or prominent issues that HEE should be aware of.

More info Description of success Description of Challenge

1.

2.

3.

Our recently developed Clinical Leadership programme to support and develop the next generation of clinical leaders within the organisation

Delivering training in a post covid environment given priorities to get performance back on track. Our ability to deliver socially distanced learning given capacity constraints of the estate. This will mean we will need to put on more training sessions which then impacts on trainer capacity

Developing the pediatric pathway to provide placements in Paeds ED, CAU and on the ward. We have previously had difficulty attracting nurses to work in Paeds at the Trust, the enhanced learning environment and support to students and learners has resulted in improved experiences and more nurses are wanting careers in the Trust.

Encouraging and supporting new nursing and midwifery staffing models alongside the changes required to deliver healthcare in the pandemic and into the recovery phase (including the likelihood of a second wave which would require further change). Placements may change as services flex according to patient need.

Improvement in ‘growing our own’ from apprenticeships, nursing associates to graduates particularly using the OU route

Supporting AHP colleagues who are adopting cross Organisational roles particularly supporting the discharge to assess models.

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Please use this section to summarise three items of Best Practice your organisation is most proud of achieving, and the impact this has had within your organisation. Please Note: Best Practice will be shared with other organisations.

Description of Best Practice Impact of Best Practice

1.

2.

3.

Medical Education fellows in ED Improved teaching and access to teaching by creating virtual and electronic teaching resources.

A fully established midwifery workforce which enables us deliver the requirement for continuity of carer and a high quality service for women and their families.

Increased confidence in the service by users

Embedded Physician’s Associates into clinical workforce. Fully supported with educational/supervision. Organised teaching programme with protected time to attend

Strengthening clinical workforce, support for junior doctors. Improving patient flow and patient experience

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Nursing and Midwifery Students (NMC) Organisation assurance statement and exception reporting against HEE Quality Domains and Standards In this section, we are asking you to consider HEE Quality Domains and Standards and declare any areas where Standards are not met. Link to the HEE Quality Framework 2019-2020

If your organisation does not provide education and training to this professional group, please select 'Not Applicable' and move on to the next section.

Domain 1 Learning Environment and Culture, please see HEE Quality Framework page 9 & 10.

Please don't select more than 2 answer(s) per row.

Met Not Met Action Plan

Available

1.1 Learners are in an environment that delivers safe, effective, compassionate care that provides a positive experience for service users.

X

1.2 The learning environment is one in which education and training is valued and learners are treated fairly, with dignity and respect, and are not subject to negative attitudes or behaviours.

X

1.3 There are opportunities for learners to be involved in activities that facilitate quality improvement (QI), improving evidence-based practice (EBP) and research and innovation (R&I).

X

1.4 There are opportunities to learn constructively from the experience and outcomes of service users, whether positive or negative.

X

Not Applicable

Applicable

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1.5 The learning environment provides suitable educational facilities for both learners and educators, including space, IT facilities and access to quality assured library and knowledge.

X (Action Plan 1)

1.6 The learning environment promotes inter- professional learning opportunities.

X

Domain 2 Educational governance and leadership, please see HEE Quality Framework page 11 & 12.


Met Not Met Action Plan Available

2.1 The educational governance arrangements measure performance against the quality standards and actively respond when standards are not being met.

X

2.2 The educational leadership uses the educational governance arrangements to continuously improve the quality of education and training.

X

2.3 The educational governance structures promote team-working and a multi-professional approach to education and training where appropriate, through multi-professional educational leadership.

X

2.4 Education and training opportunities are based on principles of equality and diversity.

X

2.5 There are processes in place to inform the appropriate stakeholders when performance issues with learners are identified or learners are involved in patient safety incidents.

X

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Domain 3 Supporting and empowering learners, please see HEE Quality Framework page 13 & 14.



3.1 Learners receive educational and pastoral support to be able to demonstrate what is expected in their curriculum or professional standards to achieve the learning outcomes required.

X

3.2 Learners are supported to complete appropriate summative and formative assessments to evidence that they are meeting their curriculum, professional standards or learning outcomes.

X

3.3 Learners feel they are valued members of the healthcare team within which they are placed.

X

3.4 Learners receive an appropriate and timely induction into the learning environment.

X

3.5 Learners understand their role and the context of their placement in relation to care pathways and patient journeys.

X

Domain 4 Supporting and empowering educators, please see HEE Quality Framework page 15.



4.1 Those undertaking formal education and training roles are appropriately trained as defined by the relevant regulator or professional body.

X

4.2 Educators are familiar with the curricula of the learners they are educating.

X

4.3 Educator performance is assessed through appraisals or other appropriate mechanisms, with constructive feedback and support provided for role development and progression.

X

4.4 Formally recognised educators are appropriately supported to undertake their roles.

X

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Domain 5 Delivering curricula and assessments, please see HEE Quality Framework page 16.

Please don't select more than 2 answer(s) per row. Met Not Met Action Plan

Available

5.1 The planning and delivery of curricula, assessments and programmes enable learners to meet the learning outcomes required by their curriculum or required professional standards.

X

5.2 Placement providers shape the delivery of curricula, assessments and programmes to ensure the content is responsive to changes in treatments, technologies and care delivery models.

X

5.3 Providers proactively engage patients, service users and learners in the development and delivery of education and training to embed the ethos of patient partnership within the learning environment.

X

Action Plan 2

Domain 6 Developing a sustainable workforce, please see HEE Quality Framework page 17.



6.1 Placement providers work with other organisations to mitigate avoidable learner attrition from programmes.

X

6.2 There are opportunities for learners to receive appropriate careers advice from colleagues within the learning environment, including understanding other roles and career pathway opportunities.

X

6.3 The organisation engages in local workforce planning to ensure it supports the development of learners who have the skills, knowledge and behaviours to meet the changing needs of patients and service.

X

6.4 Transition from a healthcare education programme to employment is underpinned by a clear process of support developed and delivered in partnership with the learner.

X

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Where a standard is 'not met', please select which professional groups 'not met' relates to:

Please don't select more than 6 answer(s) per row. Domain

1 Domain

2 Domain

3 Domain

4 Domain

5 Domain

6

Adult Nursing

Child Nursing

Community Nursing

Health Visitors

Learning Disabilities Nursing

Mental Health Nursing

Midwifery

Nursing Associates

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Medical Training (General Medical Council) Organisation assurance statement and exception reporting against HEE Quality Domains and Standards In this section, we are asking you to consider HEE Quality Domains and Standards and declare any areas where Standards are not met. HEE Quality Framework 2019-2020.





Available


X


X


X


X

Not Applicable

Applicable

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X


X





X


X


X


X


X

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X


X


X


X


X





X


X


X


X

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X


X


X





X


X


X

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X



1 Domain

2 Domain

3 Domain

4 Domain

5 Domain

6

Postgraduate

X

Undergraduate

Physicians Associates

Dental Training (General Dental Council)


Organisation assurance statement and exception reporting against HEE Quality Domains and Standards In this section, we are asking you to consider HEE Quality Domains and Standards and declare any areas where Standards are not met. Link to the HEE Quality Framework 2019-2020.

Not Applicable

Applicable

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Available











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1 Domain

2 Domain

3 Domain

4 Domain

5 Domain

6

Dentists

Dental Therapists

Dental Technicians

Dental Nurses

Dental Hygienists

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Pharmacy Training (General Pharmaceutical Council)


Organisation assurance statement and exception reporting against HEE Quality Domains and Standards In this section, we are asking you to consider HEE Quality Domains and Standards and declare any areas where Standards are not met.




Available


X


X


X


X

Not Applicable

Applicable

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X


X





X


X


X


X


X

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X


X


X


X


X





X


X


X


X

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X


X


X





X


X


X


X

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1 Domain

2 Domain

3 Domain

4 Domain

5 Domain

6

Pharmacy Technicians

Pharmacists

Pharmaceutical Scientists

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All Other Learners


Organisation assurance statement and exception reporting against HEE Quality Domains and Standards In this section, we are asking you to consider HEE Quality Domains and Standards and declare any areas where Standards are not met.




Available


X


X


X


X

Not Applicable

Applicable

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X


X





X


X


X


X


X

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X


X


X


X


X





X


X


X


X

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X


X


X





X


X


X

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X



1 Domain

2 Domain

3 Domain

4 Domain

5 Domain

6

Clinical Psychology

Dieticians

Estates (i.e. clinical engineers)

Healthcare Scientists: Life Sciences, Physiological Sciences, Physical Sciences, Clinical Bioinformatics

Occupational Therapy

ODP

Orthotists and Prosthetists

Ophthalmologists

Orthoptists

Other Apprentice

Other Therapist (art, drama, music etc.)

Paramedics

Physiotherapy

Podiatry

Radiography Diagnostic

Radiography Therapeutic

Sexual Health Advisors

Sonographers

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Speech and Language Therapy

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19/20 Financial Accountability Report Details of LDA Funding

A separate copy of the LDA Financial Section (Schedule E) was included in the email sent with the SAR. In this section please describe how the trust has utilised the HEE funding received via LDA payments.

I can confirm that funding listed in the LDA (Schedule E) has been utilised for it's intended purpose? (Y/N)

If you selected No, please specify:

Additional in year funding already provided

Have you received any further funding not included in the LDA?

Y

N/A

Y

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In this section please list any additional funding received from HEE, for example any regional or national funding received outside of the LDA payments. Please state the amount received, provide a high-level description of what this additional funding is for and please describe how the trust has utilised this funding.

1

2

3

4

5

£82,372 Workforce Development: CPD Nursing Associates (£56,000) Reporting Radiography (£26,372)

£107,750 Educational Support: FP Admin (£11,200) 5 TPD posts in various specialties (£60,641) and one HoS Post (£35,909)

£370,362 Postgraduate: Curriculum Delivery (£5,200) Education Contract Posts (£15,941) GP Salary Support (£160,844) GPST Scheme (£148,614) Less Than Full Time (£15,875) Supported Return to Training (£4,908) SuppoRTT/Supported Return to Training (£18,980)

-£12,580 Non-Medical: Healthcare Sciences (£7,393) Non-medical Tariff (-£39,604) Pharmacy (£28,230) Placement Fee (£10,901) Trainer Grant (-£19,500)

£3,429 Undergraduate Medical: Placement activity funding (£3,429)

Please state the amount received Please describe what this additional funding was for?

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Thank you Thank you for completing the Self-Assessment Report.

Key for selection options 1 - Trust Name

Aintree University Hospital NHS Foundation Trust Airedale NHS Foundation Trust Alder Hey Children's NHS Foundation Trust Barnsley Hospital NHS FT Blackpool Teaching Hospitals NHS Foundation Trust Bolton NHS Foundation Trust Bradford District Care NHS Foundation Trust Bradford Teaching Hospitals NHS FT Bridgewater Community Healthcare NHS Foundation Trust Calderdale & Huddersfield NHS FT Cheshire and Wirral Partnership NHS Foundation Trust City Health Partnerships Countess of Chester Hospital NHS Foundation Trust Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust East Cheshire NHS Trust East Lancashire Hospitals NHS Trust Greater Manchester Mental Health NHS Foundation Trust Harrogate & District NHS FT Hull University Teaching Hospitals NHS Trust Humber NHS Foundation Trust Lancashire & South Cumbria NHS Foundation Trust Lancashire Teaching Hospitals NHS Foundation Trust Leeds and York Partnerships NHS FT Leeds Community Healthcare NHS Trust Leeds Teaching Hospitals NHS Trust Liverpool Heart & Chest Hospital NHS Foundation Trust Liverpool University Hospitals NHS Foundation Trust Liverpool Women's NHS Foundation Trust Manchester University NHS Foundation Trust Mersey Care NHS Foundation Trust Mid Cheshire Hospitals NHS Foundation Trust Mid Yorkshire Hospitals NHS Trust Noble's Hospital, Isle of Man North Cumbria University Hospitals

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North West Boroughs Healthcare NHS Foundation Trust Northern Lincolnshire and Goole NHS Foundation Trust Pennine Care NHS Foundation Trust Rotherham Doncaster and South Humber NHS Foundation Trust Royal Liverpool and Broadgreen University Hospitals NHS Trust Sheffield Children’s Hospital NHS FT Sheffield Health and Social Care NHS Foundation Trust Sheffield Teaching Hospitals NHS Foundation Trust South West Yorkshire Partnership NHS Foundation Trust Southport and Ormskirk Hospital NHS Trust St Helens and Knowsley Teaching Hospitals NHS Trust Stockport NHS Foundation Trust Tameside and Glossop Integrated Care NHS Foundation Trust The Christie NHS Foundation Trust The Clatterbridge Cancer Centre NHS Foundation Trust The Rotherham NHS Foundation Trust The Walton Centre NHS Foundation Trust University Hospitals of Morecambe Bay NHS Foundation Trust Warrington and Halton Teaching Hospitals NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust Wrightington, Wigan And Leigh NHS Foundation Trust York Teaching Hospital NHS Foundation Trust

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(dd/mm/yyyy)

SAR 2020 Incidents and Coroner's Case Support

Page 1: Organisation Details

Trust Name:

Report signed off by (name):

Date signed off:

Barnsley NHS FT

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Datix is the system used internally for the reporting of incidents

Feedback is gathered automatically through Datix when an incident has been investigated and closed. This is sent to the reporter via email. Some incidents face to face feedback is given.

Reported internally on Datix and externally on STEIS

Page 2: Supporting Learners at Coroners' Court and following Serious Incidents

To help HEE better understand how your organisation supports learners please complete the questions below.

Clinical Incidents

What system is used for reporting clinical incidents?

How is feedback on an incident given to the reporter?

What system is used for reporting Serious Untoward Incidents/ Never Events?

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Support for learners involved in a Serious Incident: How does the Trust identify learners involved in a serious incident?

What is the target timescale for identifying learners involved in a serious incident?

Who in the education team is notified about a learner involved in a serious incident (e.g. DME, FPD, ES, names CS, Clinical Lead, etc...)?

Who offers support to a learner involved in a serious incident (e.g. DME, FPD, ES, Named CS, Clinical Lead, Manager, PALS, Trust Legal Team, etc...)?

Describe briefly how support to a learner involved in a serious incident is delivered?

Describe briefly arrangements for debriefing/ support for other staff involved in a serious incident?

Does your Trust hold Schwartz rounds of similar events?

What guidance does the Trust offer about reflection on serious incidents?

During the initial information gathering stage members are identified who have been involved with the care.

The trust does not have a target timescale. The clinical governance team work to ensure staff directly involved are identified and informed quickly.

Medical Education manager and Director of Medical Education.

The investigating team, College tutor, Educational Supervisor.

Support is provided in a pastoral format but also clinically to ensure any training needs are identified and monitored.

Yes

The support is offered for all staff. Formal debriefs are not facilitated for all Sis. The manager of an area may hold a debrief or a formal debrief may be recommended by the patient safety panel.

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Writing statements and giving evidence

Who advises and supports learners in the following:

Writing statements for an inquiry into a serious incident, root cause analysis, complaint, etc?

Giving evidence to an inquiry into a serious incident, root cause analysis, complaint, etc?

Coroner's statement and inquests Support for learners involved in a Coroner's case:

How does the Trust identify learners involved in a Coroner's case?

What is the target timescale for identifying learners involved in a Coroner's case?

Who in the education team is notified about a learner involved in a Coroner's case (e.g. DME, FPD, ES, names CS, Clinical Lead, etc...)?

Who offers support to a learner involved in a Coroner's case (e.g. DME, FPD, ES, Named CS, Clinical Lead, Manager, PALS, Trust Legal Team, etc...)?

Learner is supported by their supervisor the clinical governance team, medical education team and the trust legal department

Learner is supported by their supervisor the clinical governance team, medical education team and the trust legal department

During the initial information gathering stage members are identified who have been involved with the care.

The trust does not have a target timescale. The clinical governance team work to ensure staff directly involved are identified and informed quickly

Medical Education manager and Director of Medical Education

Medical Examiners office, Legal department, DME, Educational supervisor

The trust does not have formal guidance. The learning from every SI is shared trust wide. Staff directly involved will be supported to reflect by their supervisor and the investigating team.

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Trust mandatory training

Describe briefly how support to a learner involved in a Coroner's case is delivered?

Who offers advises and supports learners in writing statements for a Coroner's case (e.g. ES, DME, Trust Services, Legal Department, etc...)?

Who advises and supports learners in giving evidence to a Coroner's case?

How do the answers to the previous questions differ if the learner has moved to another Trust?

Do you publicise the advice about Coroner's hearings on the HEE Website?

What training does your Trust offer on Duty of Candour?

Support is provided in a pastoral format but also clinically to ensure any training needs are identified and monitored. Legal team would support the learner

Trust legal services, DME, College Tutor

Trust legal services, DME, College Tutor

Support would be the same but the supervisor in the new trust would be advised so support could also be given locally

No

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Page 3: Thank you Thank you for completing the Incidents and Coroners' Case Support questionnaire.

Key for selection options 1 - Trust Name:

Aintree University Hospital NHS Foundation Trust Airedale NHS Foundation Trust Alder Hey Children's NHS Foundation Trust Barnsley Hospital NHS FT Blackpool Teaching Hospitals NHS Foundation Trust Bolton NHS Foundation Trust Bradford District Care NHS Foundation Trust Bradford Teaching Hospitals NHS FT Bridgewater Community Healthcare NHS Foundation Trust Calderdale & Huddersfield NHS FT Cheshire and Wirral Partnership NHS Foundation Trust City Health Partnerships Countess of Chester Hospital NHS Foundation Trust Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust East Cheshire NHS Trust East Lancashire Hospitals NHS Trust Greater Manchester Mental Health NHS Foundation Trust Harrogate & District NHS FT Hull University Teaching Hospitals NHS Trust Humber NHS Foundation Trust Lancashire & South Cumbria NHS Foundation Trust Lancashire Teaching Hospitals NHS Foundation Trust Leeds and York Partnerships NHS FT Leeds Community Healthcare NHS Trust Leeds Teaching Hospitals NHS Trust Liverpool Heart & Chest Hospital NHS Foundation Trust Liverpool University Hospitals NHS Foundation Trust Liverpool Women's NHS Foundation Trust Manchester University NHS Foundation Trust Mersey Care NHS Foundation Trust

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Mid Cheshire Hospitals NHS Foundation Trust Mid Yorkshire Hospitals NHS Trust Noble's Hospital, Isle of Man North Cumbria University Hospitals North West Boroughs Healthcare NHS Foundation Trust Northern Lincolnshire and Goole NHS Foundation Trust Pennine Care NHS Foundation Trust Rotherham Doncaster and South Humber NHS Foundation Trust Royal Liverpool and Broadgreen University Hospitals NHS Trust Sheffield Children’s Hospital NHS FT Sheffield Health and Social Care NHS Foundation Trust Sheffield Teaching Hospitals NHS Foundation Trust South West Yorkshire Partnership NHS Foundation Trust Southport and Ormskirk Hospital NHS Trust St Helens and Knowsley Teaching Hospitals NHS Trust Stockport NHS Foundation Trust Tameside and Glossop Integrated Care NHS Foundation Trust The Christie NHS Foundation Trust The Clatterbridge Cancer Centre NHS Foundation Trust The Rotherham NHS Foundation Trust The Walton Centre NHS Foundation Trust University Hospitals of Morecambe Bay NHS Foundation Trust Warrington and Halton Teaching Hospitals NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust Wrightington, Wigan And Leigh NHS Foundation Trust York Teaching Hospital NHS Foundation Trust

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(dd/mm/yyyy)

SAR 2020 Equality & Diversity


Trust Name:


Date signed off:

Barnsley NHS FT

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Colin Brotherston-Barnett

Page 2: Equality and Diversity The HEE Quality Framework states clearly that education and training opportunities should be based on principles of diversity and inclusion.

The HEE equality, diversity and inclusion strategy reflects HEE's commitment to this important area of work and features strategy for HEE employees, as well as the opportunity to gather regional activity and influence wider. An example of this is the HEE workforce strategy, used to inform our work in developing a comprehensive system-wide understanding of workforce needs for the future. Diversity and inclusion will be integral in how we look to influence the healthcare system to achieve greater representation and social mobility.

As well as applying these principles across all professional groups, there is also a specific work stream and duty to consider and capture information for doctors in training. The GMC continue their work in equality and diversity, reflecting their standards; promoting excellence.

For medical education, the GMC and local offices continue to consider differential attainment; different rates of attainment between different groups of doctors. This work includes ethnicity and country of primary medical qualification.

Prompt: In the responses below, please consider:

Organisation wide themes Examples of good practice from across professional groups As well as specific consideration and comment on differential attainment for doctors in training

Name of Trust Equality, Diversity and Inclusion Lead (or equivalent):

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Robust 1-1 and appraisal system which is impact assessed. Trust study leave process which is open to everyone and assessed on role and job requirments.

1. How do you ensure that learners with different protected characteristics are welcomed and supported into the trust, demonstrating that you value diversity as an organisation?

2. How do you liaise with your trust Equality, Diversity and Inclusion Lead to:

Answer

• Ensure trust reporting mechanisms and data collection take learners into account?

• Implement reasonable adjustments for disabled learners?

• Ensure your policies and procedures do not negatively impact learners who may share protected characteristics?

• Analyse and promote awareness of outcome data (such as exam results, assessments, ARCP outcomes) by protected characteristic?

3. How do you support learners with protected characteristics to ensure that known barriers to progression can be managed effectively?

Electronic Staff record has a field for declaring disability for all staff

Regular communications to advise staffthat adjustments can be made to support staff at work.

All our procedures and policies are equality impact assessed.

Equality, Diversity and Human Rights Policy Workplace adjustments guidance for managers and staff. The staff disability network, regular communications to advise staff that adjustments can be made to support staff at work.

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Passport to Management training. BHNFT is part of Your Voice Barnsley which is our equality and service users forums. All staff have to do mandatory ED&I training and bespoke sessions are held to occasionally to reflect feedback from staff

Passport to management training on ED&I and Bullying and harassment is offered to staff Guidance on workplace adjustments available to all staff

Workforce race Equality Standard Workforce disability standard Equality Diversity System NHS diversity and inclusion partners programme

Action planning takes place to mitigate any equalities from the WREN and the WDES and EDS2 Recruitment processes are monitored for protected characteristics.

4. How do you educate learners on equality and diversity issues that may relate to themselves, their colleagues, or the local population of the trust?

5. How do you support your educators to develop their understanding of, and support for, learners with protected characteristics?

6. Is there monitoring or strategies in place to look at those accessing progression opportunities, and those progressing into more senior roles?

What is the Trust view on data on progression in the trust?

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We have just delivered a session on Trans equality and launched our new trans equality policy for staff and patients NHS rainbow badge scheme

Trans equality training NHS rainbow badge scheme Passport to Management includes ED&I

Are there any responses or resulting objectives to data held by the Trust?

7. Does the Trust invest in additional Equality and Diversity training for some or all staff (i.e. more than statutory training)?

Are there any training or initiatives (in place or being considered) to learn from cases that have an E&D theme?

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Page 3: Thank you Thank you for completing the Equality and Diversity Questionnaire.



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Barnsley Hospital


(dd/mm/yyyy)

SAR 2020 Library Quality Process


Trust Name:


Date signed off:

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Page 2: Library Quality Process

We recommend that you consult with your Library and Knowledge Services Manager or Lead to complete this section. Please provide narrative and evidence (for 1, 3 and 4) on the following 4 areas for your Library and Knowledge Service. Please also highlight any issues or concerns, including any areas which are not being met. If your Library and Knowledge Service is provided via a service level agreement, please consult with the providing Library and Knowledge Services Manager. Additional prompts have been added under each heading.

1. Describe how your Trust is implementing the HEE Library and Knowledge Services Policy (https://hee.nhs.uk/sites/default/files/documents/NHS%20Library%20and%20Knowledge%20Services%20in%20England%20Policy.pdf namely: To ensure the use in the health service of evidence obtained from research, Health Education England is committed to:

Enabling all NHS workforce members to freely access library and knowledge services so that they can use the right knowledge and evidence to achieve excellent healthcare and health improvement.

Developing NHS librarians and knowledge specialists to use their expertise to mobilise evidence obtained from research and organisational knowledge to underpin decision-making in the National Health Service in England.

Prompt: We advise you to consult with your Library and Knowledge Services Manager or Lead when compiling your response. You could provide evidence from your Library and Knowledge Services’ strategy or annual action/implementation/business/service improvement plan.

All members of staff have access to the library services and all new member of staff are now being made aware of library services with a section at induction. The library is now open 24/7 thanks to a successful HEE bid, so members of staff can access the physical library space when required. The library offers information to trust staff in a variety of ways, such as through literature searches, the ability to request titles and point-of-care tools such as DynaMed Plus and BMJ Best Practice.

Library staff are now developed in line with needs of the organisation and have attended various training and courses. The library has made developments in their delivery of knowledge mobilization and now offer Randomised Coffee Trials, Knowledge Harvesting and the Knowledge and self-assessment tool.

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2. HEE's Library and Knowledge Services Policy is delivered primarily through local NHS Library and Knowledge Services.

Please identify the budget allocated to your Library and Knowledge Service in the current financial year.

If possible please identify the sources of this funding, differentiating for example between educational tariff funding and any contribution from your organisation.

Prompt: Your Finance department and/or your Library and Knowledge Service Manager should be able to supply this information.

General budget from Trust is £19,041. Medical Education department also fund DynaMed Plus (£12,200) and pay for approx.. £3,000 of books annually.

As stated above, Medical Education.

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• Refurbishment- We refurbished the physical space and have no created a comforting and welcoming environment for learners and staff members.

• Institutional Repository in Heritage- we developed an institutional repository showcasing research by BHNFT staff-http://bdgh.nhslibraries.com/HeritageScripts/Hapi.dll/search2?SearchTerm=ONLINE+BARNSLEY+REPOSITORY&Fields=U&Media=%23&Dispfmt=B&SearchPrecision=10&DataSetName=LIVEDATA

• Trainee Nurse Associates Information Skills Programme- The library has been involved with the development of a programme to support trainee nurse associates. All TNAs of the second cohort (18) have received searching session as 1-1 or small groups, as well as a group critical appraisal and referencing session. The library lead has written this up as a journal article to showcase this.

• As stated in section 2, the service has been proactive in incorporating knowledge mobilization principles and practices in to our service offer.

3. Please tell us about any areas of Library and Knowledge Services good practice that you would like to highlight.

Prompt: We advise you to consult with your Library and Knowledge Services Manager or Lead when compiling your response. You could provide evidence of impact on clinical practice, impact on management decision-making (including cost savings) and any innovation submissions originating from your Library and Knowledge Service.

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http://bdgh.nhslibraries.com/HeritageScripts/Hapi.dll/search2?SearchTerm=ONLINE+BARNSLEY+REPOSITORY&Fields=U&Media=%23&Dispfmt=B&SearchPrecision=10&DataSetName=LIVEDATA



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Barnsley Hospital Library Service were rated 98% compliant with LQAF in 2018 (an increase on the 83% in 2017. There was no return required in 2019 and the library service are working towards submission for the new system (Quality Improvement Outcomes Framework) for a June 2020 submission.

4. The Learning and Development Agreement that Health Education England has with your organisation states that for 2018- 19 the LKS should have achieved a minimum of 90% compliance with the national standards laid out in the NHS Library Quality Assurance Framework. LKS that scored below 90% submitted an action plan to Health Education England in March 2019 describing their planned improvements. If you submitted an action plan, please describe the improvements you have made against the plan.

Prompt: We advise you to consult with your Library and Knowledge Services Manager or Lead when compiling your response.

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Page 3: Thank you

Thank you for completing the Library Quality Process questionnaire.

Key for selection options

1 - Trust Name: Aintree University Hospital NHS Foundation Trust Airedale NHS Foundation Trust Alder Hey Children's NHS Foundation Trust Barnsley Hospital NHS FT Blackpool Teaching Hospitals NHS Foundation Trust Bolton NHS Foundation Trust Bradford District Care NHS Foundation Trust Bradford Teaching Hospitals NHS FT Bridgewater Community Healthcare NHS Foundation Trust Calderdale & Huddersfield NHS FT Cheshire and Wirral Partnership NHS Foundation Trust City Health Partnerships Countess of Chester Hospital NHS Foundation Trust Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust East Cheshire NHS Trust East Lancashire Hospitals NHS Trust Greater Manchester Mental Health NHS Foundation Trust Harrogate & District NHS FT Hull University Teaching Hospitals NHS Trust Humber NHS Foundation Trust Lancashire & South Cumbria NHS Foundation Trust Lancashire Teaching Hospitals NHS Foundation Trust Leeds and York Partnerships NHS FT Leeds Community Healthcare NHS Trust Leeds Teaching Hospitals NHS Trust Liverpool Heart & Chest Hospital NHS Foundation Trust Liverpool University Hospitals NHS Foundation Trust Liverpool Women's NHS Foundation Trust Manchester University NHS Foundation Trust Mersey Care NHS Foundation Trust Mid Cheshire Hospitals NHS Foundation Trust Mid Yorkshire Hospitals NHS Trust Noble's Hospital, Isle of Man North Cumbria University Hospitals North West Boroughs Healthcare NHS Foundation Trust Northern Lincolnshire and Goole NHS Foundation Trust Pennine Care NHS Foundation Trust Rotherham Doncaster and South Humber NHS Foundation Trust Royal Liverpool and Broadgreen University Hospitals NHS Trust Sheffield Children’s Hospital NHS FT Sheffield Health and Social Care NHS Foundation Trust Sheffield Teaching Hospitals NHS Foundation Trust South West Yorkshire Partnership NHS Foundation Trust Southport and Ormskirk Hospital NHS Trust St Helens and Knowsley Teaching Hospitals NHS Trust Stockport NHS Foundation Trust

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Tameside and Glossop Integrated Care NHS Foundation Trust The Christie NHS Foundation Trust The Clatterbridge Cancer Centre NHS Foundation Trust The Rotherham NHS Foundation Trust The Walton Centre NHS Foundation Trust University Hospitals of Morecambe Bay NHS Foundation Trust Warrington and Halton Teaching Hospitals NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust Wrightington, Wigan And Leigh NHS Foundation Trust York Teaching Hospital NHS Foundation Trust

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(dd/mm/yyyy)

SAR 2020 Patient Safety, Simulation and Human Factors


Trust Name:

Report signed off by (Name):

Date signed off:

Barnsley NHS FT

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Dr Simon Enright – Medical Director

Page 2: Patient Safety

1. Who is the Lead for Patient Safety in your organisation?

What support do they receive in delivering this role? e.g. job-planned time, resources etc.

2. Please advise up to three areas relating to patient safety agenda that you have worked on in the last two years and you are most proud of? Could these be applied regionally and be shared with HEE?

Answer 1

2

3

VTE Assessment

Implementation of VitalPAC electronic observation system

Human Factors training and Quality Improvement

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3. In which areas would you like support from HEE? e.g. educational events, funding, specific areas of training such as quality improvement.

Funding of Quality improvement training locally

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The trust has appointed 2 simulation leads and 3 education middle grade posts who report into the DME

Dr Jane Acty

The medical education team assess funding requests and complete ROI papers to Executive team on any investment.

Page 3: Simulation Prompt: we advise you to consult with your Simulation Manager or Lead when compiling your response.

1. What is the governance structure in place within your organisation with regard to simulation- based education training?

Who is the responsible Simulation Lead within the organisation?

2. Please describe your process for accessing education funding received for simulation and/or TEL bids and who is responsible for this?

3. Does your Trust offer multidisciplinary faculty training including specific simulation-based education debriefing in line with ASPiH standards?

The trust offers MD faculty training which is debriefed in line with required standards. The training is delivered in-situ or in the simulation lab.

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Emergency medicine and Anesthetics have led the way with implementing Sim based education within their teams. We have implemented in-situ simulations in Paediatrics this year.

All staff are able to book and utilize the simulation facilities. The team aim to work with all professional groups over the next year to promote learning.

This is something we have as a priority over the next 12 months.

4. Which directorates or inter-professional groups are actively engaged with simulation-based education within your organisation?

How do you encourage equitable access to simulation for all staff? Add how is this monitored?

5. Please describe strategic engagement and representation in simulation activity in the organisation i.e. board level, clinical governance, patient safety, incident reviews, quality improvement?

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Deborah Firth

Time and resources

Page 4: Human Factors

Who is the Lead for Human Factors in your organisation?

What support do they receive in delivering this role? e.g. job-planned time, resources etc.

Please describe the extent to which your HF training covers the following domains: People – the individual & teamwork

Environment – the physical aspects of a workspace

Equipment and technology

Tasks and processes

Organisation

Covered

Covered

Covered

Covered

Covered

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Applicable to all organisation and is once only training mapped to the National training requirements. It can be accessed via e-learning or face-to face

For the training delivered in the reporting period please also consider and describe the following:

The audience to which HF training is being delivered, including details of multi-professional staff.

Frequency of training, or whether ad hoc events.

Who are the faculty that deliver the training? Please describe their “HF expertise”, professional background, specialty, whether they have job-planned time to deliver HF training.

What is the wider Trust context within which HF training is delivered. Is there a link between patient safety incidents, SI investigations, root cause analysis?

To what extent is HF training seen as part of a wider patient quality and safety agenda or integrated into clinical governance structure/process?

What Human Factor Training requirements do you have as a Trust?

A training needs analysis was completed and from this a three year training plan was devised. The reporting of the training compliance is through the Electronic Staff Records and Work force information.

Frequency of training – on average there are 5 courses per month. This includes one session on corporate induction for new starters to the organisation. There is also the option for clinical teams to have human factors training together.

The faculty is one person who has completed the online TeamStepps. The individual is a Registered Nurse with a PGCE qualification.

The training uses real never events and serious incidents that have occurred within the Trust to make the training relevant

Training was identified with the Trusts Quality Goals for 2017-2020 with the aim that 25% of the identified workforce to be trained

Ergonomics and research methods Not covered

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Page 5: Thank you Thank you for completing the Patient Safety, Simulation and Human Factors survey.



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SAR 2020 Staff, Associate Specialist, and Specialists Doctors

Page 1: Declaration

Trust Name


Date signed off:

Barnsley NHS Foundation Trust

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Page 2: 2020 Staff, Associate Specialist and Specialty Doctors (SAS) and Locally Employed Doctors (LEDs)

Use of funding to Support Staff, Associate Specialist and Specialty Doctors (SAS) and Locally Employed Doctors (LEDs) Faculty development

Please provide answers to the following questions. You may wish to include funding details, as required. For further information in relation to LEDs please review the following NACT document LEDs across the UK http://www.nact.org.uk/documents/national-documents/.

It is recommended that if the trust has a nominated lead for SAS doctors and/ or LEDs, they should complete this section.

1. Nominated leads for SAS doctors and LEDs

Name of nominated lead for SAS doctor development (if there is no nominated lead, state “None”):

Name of nominated lead for LED development (if there is no nominated lead, state “None”):

2. Number of SAS doctors and LEDs in the trust

Answer

Number of Specialty Drs:

Number of Associate Specialists:

Number of Staff Grades:

62

3

0

Dr Judith Fox

None

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http://www.nact.org.uk/documents/national-documents/

3 / 9

TOTAL number of SAS doctors:

Number of LEDs (e.g. Trust Grade, Clinical Fellow):

3. Study leave budgets

Amount (£)

Trust study leave funding allocation per SAS doctor (£):

Trust study leave funding allocation per LED (£):

How do these allocations compare to the study leave funding allocation for consultants?

Please outline any examples of good practice or challenges regarding study leave budget allocations:

4. HEE SAS Development Funding received during the financial year 2018/19

Amount (£) Details (if req)

SAS Development Fund – Individual courses (£):

65

23

£3,000 per 3 year period

£3,000 per 3 year period (or pro rata if fixed term)

11,963.63

The funding allocation is the same as the Consultants.

I am not aware of any challenges in relation to SAS doctors. The funding allocation aligns well with other Trusts in the region. We are in the process of changing over to an electronic system which should speed up the application process and increase efficiency and ease of tracking of individual budgets and study leave days taken

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SAS Development Fund – Trust- hosted courses (£):

Funding for SAS tutor/ lead role (£):

Funding for SAS administrator role (£):

Any other funding received from SAS Development Fund (please give details):

TOTAL funding received from HEE (£):

5. Identification of SAS doctor development needs

Development needs:

Please describe the process by which the development needs of SAS doctors within your organisation were individually and collectively identified:

£16,592.22

Development needs - individual: These are identified in the following ways: From individual discussions with SAS doctors about their own career and personal professional development SAS doctors identifying their needs from appraisal and departmental discussions Development needs - collective: From discussions at the 2 monthly formal meetings for Trust SAS doctors (SAS development is a regular Agenda item) organised and chaired by the SAS Tutor. From discussions and recommendations at the Y&H SAS Leads' meetings which are attended by the Lead Associate Dean for SAS doctors From my (SAS Tutor) personal reading, attendance at SAS tutor training events and other educational events.

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6. CESR

Answer

Number of doctors currently being supported by the trust to work towards CESR application:

Number of doctors who completed a successful CESR application during the year April 2018 to March 2019:

Currently no formal support programme although this is supported by the Trust’s executive and there is a plan to develop over next year (postponed due to Covid-19). At present 3 doctors are working towards their CESR application

3

How were priorities decided in regard to applications to the HEE SAS Development Fund?

The aim is to provide optimal individual and collective development opportunities within an acceptable budget (overseen by the Associate Dean).The process for applying for individual funding should be fair, open and effective. For individual requests for funding the activity should be relevant and developmental and follow national guidance and, if required, guidance from the Associate Dean. The activity may have been discussed at appraisal or within the doctor's department but not always. All requests are considered and discussed with the individual doctor. Each successful applicant is currently allowed up to £1500 per annum. In this Trust the annual spend for individual development has been approximately the same over the last few years taking into account the increase in the total number of SAS doctors employed by the Trust. In practice, very few requests are rejected. For collective generic development account is taken of the diversity and wide range of experience of SAS doctors and of their professional requirements. The annual programme, which normally comprises 6 - 8 days of training, should include one or more activities which are beneficial to each and every SAS doctor in the Trust. The annual programme always includes a course related to teaching and supervision e.g 'Train the Trainer' and a course focusing on quality improvement. Other activities which appear regularly on the programme include topics under the broad headings of leadership and management, communication and wellbeing. In order to ensure that all Trust hosted training events are fully subscribed,, spare places are advertised on the regional SAS website and also by email to all the SAS Tutors in the Y&H region.

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7. SAS doctors as Clinical and Educational Supervisors

Answer

Number of SAS doctors who are GMC-approved Clinical Supervisors:

Number of SAS doctors who are GMC-approved Educational Supervisors:

Who decides which trainees have a SAS doctor as their named Clinical or Educational Supervisor?

What governance arrangements are in place for SAS doctors who are Clinical and Educational Supervisors?

8. SAS doctors in leadership roles

Answer

Number of SAS doctors who are in leadership roles:

Please give details of the roles being undertaken:

9. Has the SAS Charter been implemented in the trust?

4

None

4

SAS Tutor, Simulation Lead, LNC Representative, Departmental Audit Lead

This would be decided by the college tutor and department as part of their educational planning.

Direct supervision for Clinical/Educational supervisors is via the specialty College Tutors and ultimately Director of Medical Education. Feedback on ES/CS by trainees via GMC survey, NETS HEE survey (confidential feedback). Informal feedback via College Tutor. Meetings at departmental level within speciality

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Please give details of any examples of good practice or challenges in implementing the SAS Charter:

Good Practice Challenge

1

2

3

10. Please give details of any programmes or initiatives in place to support the development of LEDs:

Autonomous practice policy Coding of SAS activity

SAS doctors on interview panels to recruit SAS doctors

Currently no autonomous practitioners although there is an agreed process for application and consideration has been given to one individual

8 SAS appraisers including a senior appraiser. Trust moving towards proportional representation

Office facilities for all SAS doctors

The Charter has been presented to and supported by the Executive Team. Most of the elements have been implemented although challenges still exist in particular around office accommodation (this affects all clinical groups in the Trust inc SAS doctors)

SAS Tutor meetings with the Clinical Lead and SAS doctors in each department for approximately 1 hour to discuss the SAS Charter and other SAS development requirements. An active regional SAS Leads' committee including attendance by the Associate Dean where good practice and difficulties can be shared. There is also a mentoring scheme for new SAS Tutors. A regional conference and a CESR conference are held every 2 years. The Y&H Teaching Fellowships. These started in 2019 and last for 1 year. The remit is for each successful applicant to organise a teaching/training programme on a particular topic with a view to delivering it in Trusts across the region or further afield. The PA time required is funded by HEE Y&H. Training and mentoring are provided. I was a member of the Faculty and it was gratifying to experience how the Teaching Fellows had developed over the year not only an expertise in teaching and training but also in leadership, management and networking. With the increase in confidence some of them had taken on or were considering taking on additional wider roles. The Trust Medical Leadership Development programme for Consultants and SAS doctors Induction appraisal for newly appointed SAS doctors and LEDs. This is an introduction to the appraisal and revalidation process and it familiarises each new doctor with the form used by the Trust and the evidence and reflection required to complete it.

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Please outline any examples of good practice in developing SAS doctors or LEDs which you would like to highlight:

Good Practice - Please outline any examples of good practice in developing SAS doctors or LEDs

which you would like to highlight:

Challenges - Please outline any particular challenges in developing SAS doctors or LEDs:

1

2

3

4

5

Development of appraisal process for LEDs (nationally recognised work)

SAS doctors being seen as purely service providers

Encouragement for SAS doctors to be part of Trust governance processes

Mentoring of SAS doctors

SAS doctors on recruitment panels for SAS doctos

Lack of specialty specific development opportunities particularly in anesthetics and the surgical specialties with challenges in implementation of RCS guidance.

Development of SAS doctors as appraisers Lack of career progression opportunity within the Specialty doctor grade although there has been recent interest in the Associate Specialist role which is being considered in at least two specialties

SAS doctors’ part of Trust committees e.g. JLNC and clinical working groups

Achieving CESR

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Any other comments you would like to make regarding development of SAS doctors & LEDs:

Hopefully the new contract will focus more on development of SAS doctors and career progression within the grade (opening of a senior specialty doctor grade).

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10 /

Page 3: Thank you

Thank you for completing the SAS doctors and LEDs Self-Assessment Report.

Key for selection options

1 - Trust Name Aintree University Hospital NHS Foundation Trust Airedale NHS Foundation Trust Alder Hey Children's NHS Foundation Trust Barnsley Hospital NHS FT Blackpool Teaching Hospitals NHS Foundation Trust Bolton NHS Foundation Trust Bradford District Care NHS Foundation Trust Bradford Teaching Hospitals NHS FT Bridgewater Community Healthcare NHS Foundation Trust Calderdale & Huddersfield NHS FT Cheshire and Wirral Partnership NHS Foundation Trust City Health Partnerships Countess of Chester Hospital NHS Foundation Trust Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust East Cheshire NHS Trust East Lancashire Hospitals NHS Trust Greater Manchester Mental Health NHS Foundation Trust Harrogate & District NHS FT Hull University Teaching Hospitals NHS Trust Humber NHS Foundation Trust Lancashire & South Cumbria NHS Foundation Trust Lancashire Teaching Hospitals NHS Foundation Trust Leeds and York Partnerships NHS FT Leeds Community Healthcare NHS Trust Leeds Teaching Hospitals NHS Trust Liverpool Heart & Chest Hospital NHS Foundation Trust Liverpool University Hospitals NHS Foundation Trust Liverpool Women's NHS Foundation Trust Manchester University NHS Foundation Trust Mersey Care NHS Foundation Trust Mid Cheshire Hospitals NHS Foundation Trust Mid Yorkshire Hospitals NHS Trust Noble's Hospital, Isle of Man North Cumbria University Hospitals North West Boroughs Healthcare NHS Foundation Trust Northern Lincolnshire and Goole NHS Foundation Trust Pennine Care NHS Foundation Trust Rotherham Doncaster and South Humber NHS Foundation Trust

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Royal Liverpool and Broadgreen University Hospitals NHS Trust Sheffield Children’s Hospital NHS FT Sheffield Health and Social Care NHS Foundation Trust Sheffield Teaching Hospitals NHS Foundation Trust South West Yorkshire Partnership NHS Foundation Trust Southport and Ormskirk Hospital NHS Trust St Helens and Knowsley Teaching Hospitals NHS Trust Stockport NHS Foundation Trust Tameside and Glossop Integrated Care NHS Foundation Trust The Christie NHS Foundation Trust The Clatterbridge Cancer Centre NHS Foundation Trust The Rotherham NHS Foundation Trust The Walton Centre NHS Foundation Trust University Hospitals of Morecambe Bay NHS Foundation Trust Warrington and Halton Teaching Hospitals NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust Wrightington, Wigan And Leigh NHS Foundation Trust York Teaching Hospital NHS Foundation Trust

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REPORT TO THE BOARD OF DIRECTORS

REF: BoD: 20/08/06/16

SUBJECT: MEDICAL DIRECTOR’S QUARTERLY REPORT

DATE: 6 August 2020 (Q1: 2020/21)

PURPOSE:

Tick as applicable

Tick as applicable

For decision/approval Assurance For review Governanc

e

For information Strategy

PREPARED BY: Andrew Wiles – Business Manager Dr Simon Enright – Medical Director Medical Directorate Department Heads

SPONSORED BY: Dr Simon Enright – Medical Director PRESENTED BY: Dr Simon Enright – Medical Director

STRATEGIC CONTEXT

To provide an overview on a number of the Medical Director’s activities and to record particular events, meetings or publications that the Medical Director would like to bring to the Board of Directors’ attention.

EXECUTIVE SUMMARY This report provides an update from the following departments within the Medical Director’s portfolio: • Patient Safety • Clinical Audit, NICE and NCEPOD • Medical Education • Research and Development • Medical Appraisal and Responsible Officers Awareness Group (ROAG) • Miscellaneous / Key Projects (Medical Staffing and Mortality are discussed in detail in their own reports to Trust Board and Quality and Governance) The Directorate has focussed attention away from core work in each of the departments, to support the COVID response, however we have maintained progress in all areas. The new ways of working and innovations that have been required as a result of the pandemic will be assessed and, if they are shown to be better, taken forward to improve the way in which we work. The Directorate is now supporting the Trust to get back on track with its core business. If there should be a second wave, and taking into account the effect winter may/will have, we are now better equipped to deal with this as a result of the learning COVID has given us. RECOMMENDATION(S) The Board of Directors is asked to receive, review and note the attached report.

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Subject: MEDICAL DIRECTOR’S QUARTERLY REPORT Ref: BoD: 20/08/06/16

1. INTRODUCTION 1.1 Strategic Context

1.1.1 To provide a brief overview on the different areas and activities within the Medical Director’s remit and to record particular events, meetings or publications that the Medical Director would like to bring to the Board of Directors attention.

1.1.2 Due to disruption to normal reporting caused by Covid-19, we have not reported to Board since January 2020

1.2 COVID-19 Response

1.2.1 The normal activities of the Medical Directorate, like all services, has been severely disrupted by COVID-19. The departments within the directorate have worked to support the Trust during this time. This has included: • Swabbing – the Patient Safety Team along with the Governance Team

were central in delivering the staff swabbing service over the past five months. A lot of time and effort, including weekend working, has been put into making sure that the swabbing service is responsive and allows the Trust to both isolate staff who are shown to be positive for the virus, but also quickly getting staff back to work for those who are shown to be negative.

• Doctors Hub – it was felt that we needed to support Clinical Services in a different way from a Medical Staffing perspective. The Medical Staffing and Education Teams and Managers, supported by Clinical Leads, implemented a Junior Doctor hub to coordinate the response. The aim of this was to allocate the staffing resource to the areas and services that needed it the most. Care was taken to do this in an appropriate way to make sure that doctors were not working beyond their level of expertise. This has worked very well and has given us a good understanding of what is needed should there be a second wave of the pandemic.

• Research and Development (R&D) – the activity of the R&D department was severely affected by the crisis. Clinical staff were allocated to departments to help from a nursing perspective. However, as the pandemic progressed the need for R&D to be part of the research response increased. The department was very successful in recruiting COVID patients to be part of the studies into the virus. At one point during the pandemic the Barnsley Hospital NHS Foundation Trust (BHNFT) R&D department had recruited and were actively monitoring more patients than any other hospital in the region.

• General Support – other department including, Clinical Audit, have supported the Trust in other ways, fulfilling administrative tasks where services have struggled to cope given the increase sickness numbers during the pandemic. Others have picked up extra on-call shifts and generally supported other departments in the Trust.

• Ethics Group – the Medical Director along with the Director of Nursing and Quality set up an ethics group to assess the impact of COVID from an ethical perspective. The potential for services to be overwhelmed as a result of COVID was a real risk in the early stages of the pandemic and this could have necessitated difficult ethical decisions about delivery of care. The group have met regularly (initially weekly) and

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helped to advise clinical and managerial teams. Fortunately, the Trust’s response meant that services were well equipped to deal with the activity that COVID generated, the ethics group therefore mainly acted as a support function. The benefits of having an ethics group have been established and the meetings are well attended. At present the group reports through the executive team meetings. We will be taking forward the group which will continue to meet on a regular basis, albeit less frequently.

1.3 Teams and Personnel

1.3.1 Rebecca Turner – Becky has joined us from Mid Yorkshire, in the position of Medical Staffing Manager. Becky has been crucial to the COVID-19 response and the deployment of Doctors to support services

1.3.2 Max Cannon – has recently been appointed as Job Planning Manager, having done the role on an interim/part time basis for the past 8 months. The role has now been made full time to support the delivery of Job Planning across the Trust.

2. PATIENT SAFETY AND QUALITY IMPROVEMENT

2.1 Q1 Summary 2.1.1 The team like many others made significant changes to their working

practices in Q1 in response to the pandemic 2.1.2 During Q1 the Patient Safety Team joined with the Clinical Governance

team and implemented the staff testing drive through facility which can now be seen outside block 3 of the hospital. During this time the teams tested circa 2200 staff or members of their household and provided a responsive and timely service regardless of day, time or weather conditions. The team will be handing over the facility to the Clinical Business Units (CBU) from the 20th July 2020.

2.1.3 The Patient Safety team were also part of the initiative to contact over 3000 BHNFT Patients who required shielding information and managed circa 150 telephone enquiries on shielding letters from BHNFT patients. This work was supported by the Trust PA’s who kindly agreed to receive and pass on the calls to the Patient Safety Team.

2.1.4 The Quality Improvement (QI) team have been a part of Silver Command throughout the pandemic and are looking forward to returning to QI at the end of August.

2.1.5 At the beginning of Q2 the Patient Safety and QI team commenced Medway Go Live with the CareFlow Vitals (CFV) aspect of the Medway implementation. From a CFV perspective it went very smoothly.

2.1.6 The team are proud to have delivered a functioning Medical Examiner Service on schedule starting from Q1 despite the pandemic with every death having received a review. The detail is reported through our mortality reports to the Quality and Governance Committee and Board of Directors.

2.2 Key Priorities and Work Streams

2.2.1 The team is now focused on a return to business as usual (albeit under different circumstances). As Q2 progresses the team are picking up the more usual aspects of their work. There are over 20 work streams and key priorities are: • Delivery of Quality Improvement.

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• Optimisation of CareFlow Vitals with the 4.2 upgrade testing cycle starting in August.

• Supporting the ED team with improving their record on Sepsis.

Governance: Patient safety key metrics on Sepsis, Resuscitation, AKI, NEWs2 and CFV report into the Deteriorating Patient Group

2.3 Quality Improvement: 2.3.1 Despite being a part of the Silver Command function the QI team were

able to launch the ‘learning capture’ tool and are now collating the feedback under the ‘no going back’ strapline. The learning capture tool is also being adopted by other Trusts.

2.3.2 The “Advanced QI for Leaders” monthly meetings set up for 2020 with the Improvement Academy will recommence and be delivered remotely.

2.3.3 A way of delivering Virtual training is being explored and the first draft virtual ‘Introduction to QI’ has been shared with members of the Proud to Improve Group. It received very positive feedback.

2.3.4 Intranet resources are being prepared for the QI Hub page.

Governance: Quality Improvement reports from the ‘Proud to Improve’ Group to the Clinical Effectiveness Group

2.4 Care Flow Vitals (previously VitalPac) 2.4.1 Preparation is underway for the next system upgrade to version 4.2 and

testing commences in August due to go live in October. Governance: Care Flow Vitals reports from the Steering Group to the Deteriorating Patient Group

2.5 Sepsis, AKI and VTE

2.5.1 The Sepsis CQUIN has been replaced with reporting as part of the national standard contract: • Sepsis reporting was paused for Q1 • Emergency Department (ED) are due to present to Executive Team

(ET) on their plans for improving compliance. • A training video produced by the AKI lead has been adopted by ‘Think

Kidneys’ and is available on their website including a quiz at the end. • VTE Assessment compliance has been sustained at >95% during Q1

and the focus of the work is now on learning from RCA’s. • RCA’s on hospital acquired VTE’s were maintained during Q1 and

have been presented to the VTE committee

Governance: Sepsis reports to the Deteriorating Patient Group. VTE reports to the Thrombosis Committee

2.6 Medical Examiners (ME) Office and Learning from Deaths

2.6.1 The ME office is now fully implemented, and a location found in June for the team to work from.

2.6.2 The service has remained fully functional during the pandemic 2.6.3 The Mortality Overview group and Learning from Mortality Group have

maintained all aspects of their work during Q1.

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Governance: ME Office reports from the Mortality Overview Group and Learning from Deaths Group to the Clinical Effectiveness Committee where the combined Mortality Report is given scrutiny.

3. CLINICAL AUDIT

3.1 Clinical audit activity and progress from Q1 (April to June) 2020 3.1.1 Number of registered on-going/active projects (as at 10 July 2020):

Priority

CBU 1 Nationally mandated

2 Locally mandated

3 Local high priority

4 Low priority Total

1 31 29 16 19 95 2 35 1 18 14 68 3 14 - 28 21 63 Trustwide 9 5 4 1 19

89 35 66 55 245

3.1.2 Number of projects completed/closed/removed from programme: Priority

CBU 1 Nationally mandated

2 Locally mandated

3 Local high priority

4 Local low priority Total

1 6 1 1 - 8 2 2 - 1 6 9 3 - - 5 9 14 Trustwide 2 - - - 2

10 1 7 15 33 3.2 NICE update

3.2.1 During Q1 (2019/20), 38 pieces of NICE guidance were published or updated. There were 23 applicable to the Trust:

Type Published Applicable Interventional Procedure Guidance 3 0 Technology Appraisals 12 3 NICE Guidance 20 19 Medical Technologies Guidance 1 0 Diagnostics Guidance 1 0 Quality Standards 1 1

Total: 38 23

Governance: The progress of audit work is regularly reported through to CEG and the NICE and Clinical Guidelines groups; following this through to Q&G and Trust Board via Chair’s logs.

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4. MEDICAL EDUCATION 4.1 Postgraduate

4.1.1 The team supported the opening and running of the Junior Doctor Hub which was created to ensure coordination of Junior Doctors during the pandemic. The hub coordinated Junior Doctor staffing ensuring areas were well staffed and supported. The hub has now stepped down as rotas have returned to normal and the room has reverted to the new Junior Doctors sitting room.

4.1.2 The team is currently converting induction into a digital format in preparation for August induction.

4.1.3 The team successfully won a bid for financial assistance to help create local induction videos for new starters. The creation of these will commence shortly this will enable inductions to be delivered in more convenient and socially distanced ways going forward.

4.2 Foundation

4.2.1 The foundation trainees have all completed their Annual Review Clinical Progress (ARCP) and successfully achieved their outcome to move on to their next stage of training from August 2021.

4.2.2 The trust appointed 26 Interim Foundation Year 1 posts, in response to the national decision to graduate final year students early, to enable increased support to trust’s through the pandemic. The Interim F1s commenced in May and will work until the end of July.

4.3 Undergraduate

4.3.1 The trust appointed 20 4th Year Medical Student Assistants to assist during the pandemic. These student assistants were based across clinical areas, patient safety and R&D. When the anti-body testing service was set up the students manned the service 7 days a week for the period it was running.

4.3.2 Undergraduate Lead interviews were held and ten Undergraduate leads in specialities across the Trust were appointed. These are the final clinical faculty appointments in the new Medical Education structure. The team plan to run a development programme for this group in the next quarter.

4.3.3 The team would like to thank the Junior Doctors and Medical Students for their support and hard work throughout the last period.

5. RESEARCH AND DEVELOPMENT

5.1 Board Update 5.1.1 The R&D team presented a finance options paper to the Executive team in

June 2020. This paper is due to be presented to the People, Finance and Performance Committee in September 2020.

5.2 Covid-19

5.2.1 Covid-19 has impacted significantly on the R&D department. All Trust research activity was suspended by the Clinical Research Network (CRN) and the R&D team were instructed to divert their resource away from routine work onto COVID research studies.

5.2.2 Four COVID studies were prioritised by the team including: • PRIEST - Pandemic Respiratory Infection Emergency System Triage.

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• CCP - Clinical Characterisation Protocol for Severe Emerging Infection. Principal Investigator: Nicola Lancaster

• RECOVERY trial - Randomised Evaluation of COVID-19 Therapy. Principal Investigator: Dr Ken Inweregbu

• GenOMICC - Genetics of susceptibility and mortality in critical care. Principal Investigator: Dr Ken Inweregbu

5.2.3 We have had great success over a number of weeks adapting working practices and maximising on the ‘peak’ of the virus to ensure we achieved excellent recruitment to studies. We were the top recruiting hospital across the region in April, falling to third in June. We have successfully reached our CRN recruitment target for 20/21. However, this came at a cost as we have not received any additional funding for this work from the CRN. The assumption being that as other studies were suspended, we would have capacity to undertake recruitment at no additional cost.

5.2.4 The work on COVID studies is ongoing and ultimately could impact on our overall workload and therefore on costs which is something we need to be mindful of and take decisions over in due course.

5.2.5 The suspension of existing non-commercial and commercial studies will take some time and effort to re-start. The CRN are prioritising areas we should focus on initially e.g. cancer, but essentially, they are leaving most of the re-start decisions to local R&D teams and as such we have to decide where there may be capacity to re-start within clinical areas.

5.2.6 We have developed a risk register for our studies so that we can identify which we are most concerned about in order to flag these issues to the Research Committee, the Trust, the CRN and our commercial partners in plenty of time, highlighting where we may fall short of predicted recruitment numbers and income for this financial year. We have also developed performance criteria to assess those studies that are underperforming with a view to closing them.

5.2.7 We have successfully recruited two new Research Nurses who will commence post in August. We are replacing a nurse who has retired, and we also have additional funding for another nurse through the YH ARC relationship.

Governance: the R&D department reports the progress of its work annually through the People Finance and Performance Committee. The department are also part of the Clinical Effectiveness Group.

6. MEDICAL APPRAISAL AND RESPONSIBLE OFFICER ISSUES

6.1 Appraisal Performance 6.1.1 At 31st May 2020, 85.7% of doctors were in date with their appraisals. This

breaks down to • Consultants : of 157 doctors 137 are in date = 85.7% • SAS grades : of 45 doctors 36 are in date = 80.0% • LAS doctor : one doctor was overdue

6.1.2 COVID-19 and Appraisal – appraisals between 1st April 2020 and 30th September 2020 were suspended due to COVID, therefore the above figures were impacted by the number of cancellations that were booked but cancelled. Guidance was circulated to doctors affected by cancellation informing them that their activities during the 12 months preceding the cancelled appraisal must be recorded for review at the 2021 appraisal. When the number of cancellations (26) are take into account, and

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assuming these would have been completed – 227 of 233 doctors would be in date, performance would therefore be 97.4%.

6.1.3 COVID-19 and Revalidation - In March 2020 the General Medical Council (GMC) issued guidance that all Revalidations due from 17th March 2020 until the end of September 2020 would be deferred by one year with and revalidation would recommence in October 2020. On 8th June 2020 the GMC further extended the one-year delay to appraisal period to cover the next six months of revalidations. However, the language has changed to one of flexibility and all new dates are “prospective”. The Trust is currently reviewing this change and will issue guidance shortly.

Governance: progress on appraisal and revalidation is reported through Q&G to Trust Board on an annual basis. BHNFT consistently achieves over 95% appraisal performance. There are no concerns about the process or performance given this achievement. The Trust would have maintained this performance if COVID-19 had not been a factor.

6.2 Responsible Officers Awareness Group (ROAG)

6.2.1 In line with national best practice and guidance from the GMC, the Medical Director chairs a group that considers and investigates HR issues related to, or complaints made against Doctors. The group meets monthly and membership includes HRD, the Deputy Medical Director and admin support. The group monitors any individual where a concern has been raised and works through actions to respond to any concerns. The response to any issue is discussed and agreed with the group

6.2.2 The output of this group forms of the basis of discussions at the quarterly meeting with the Trusts GMC liaison officer.

6.2.3 The group has continued to meet throughout the Covid Pandemic

7 MEDICAL DIRECTORATE PROJECTS / TASK AND FINISH GROUP INVOLVEMENT 7.1 The Medical Directorate both sponsor and run a number of Projects / Task and

Finish Groups, including: • ICE filing implementation – the project was impacted by COVID the completion

date described in the last report was March 2020, this has now been revised to Autumn 2020. Work to embed these changes and monitor progress will then move to CBU’s to monitor going forward.

• D1 Task and Finish Group – we are reviewing how to deliver D1’s going forward. The task and finish group will be re-constituted following COVID. There were issues with the eForm platform, and we have reverted back to the original delivery method through the ICE system. This is still sub-optimal, so we need a better delivery system going forward.

• Clinical Guidelines and Policies – as reported in the last report the infrastructure to deliver the system is complete. The system has gone live and is working extremely well compared to the old Policy Warehouse. There is still work to do to improve the system and migrate the remaining documents in to the system.

Governance: progress against all projects sponsored by the Medical Directorate is reported through to the identified and appropriate governance committee.

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8 CONCLUSION Since March 2020, the Directorate has focussed its attention away its core work in each of the departments, to support the Trust’s COVID response while maintaining progress in the majority of areas. The new ways of working and innovations that have been required as a result of the pandemic will be assessed and, if they are shown to be better, taken forward to improve the way in which we work. The Directorate is now supporting the Trust to get back on track with recovery from Covid and supporting its core business. If there should be a second wave, and taking into account the effect winter may/will have, we are now better equipped to deal with this as a result of the learning COVID has given us.

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SUBJECT: PUBLIC BOARD WORK PLAN AUGUST 2020 – MARCH 2021 DATE: 6 AUGUST 2020

PURPOSE:



PREPARED BY: Margaret Saunders, Director of Corporate Governance SPONSORED BY: Richard Jenkins, CEO PRESENTED BY: Margaret Saunders, Director of Corporate Governance STRATEGIC CONTEXT This report is presented to the Board of Directors to support the 2020 - 2021 Trust Objectives, Aim 4, Performance: We will achieve our goals sustainability by the key action of implementing new and improved governance arrangements. EXECUTIVE SUMMARY In 2019 – 2020 360 Assurance, the internal auditors, undertook an audit of the governance and risk management of the Trust. An agreed action was scrutiny and formal approval of the Board’s Annual Work Plans, public, private and Strategic Focus Group Workshop meetings cross referenced to the Trust Strategic Aims:

Strategic Aim 1 – Patients: will experience outstanding care

Strategic Aim 2 – Partners: we will work with partners to deliver better, more integrated care

Strategic Aim 3 – People: will be proud to work for us

Strategic Aim 4 – Performance: we will achieve our goals sustainably.

The Executive Team (ET) has now completed this action and the attached Public Work Plan is for the period to 1 August 2020 - March 2021. The 2021-22 Public Board Annual Public Work Plan will be presented to Board for approval in February 2021.

RECOMMENDATIONS

The Board is requested to approve the Public Board Work Plan for the period 1 August 2020 – 31 March 2021.

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DRAFT Public Work Plan

1 August 2020 – 31 March 2021

Strategic

Aims Standing Agenda Items Director R/O* Aug

6/8 Oct 1/10

Dec 3/12

Feb 21 4/2

3 Annual Freedom to Speak up Guardian Report 2020/21


R √

2 CEO – ICS report Dr R Jenkins Chief Executive

O √ √ √ √

1, 2, 3, 4 CEO report Dr R Jenkins Chief Executive

O √ √ √ √

1, 2 ,3 4, Chairs log from ET (verbal) Dr R Jenkins Chief Executive

O √ √ √ √

1, 3 Annual Health and Safety Report Mr B Kirton

Chief Delivery Officer R √

1, 2, 3, 4 Annual NHSE Emergency Prep Core Standards Mr B Kirton Chief Delivery Officer

R √

4 Integrated Performance Report (IPR) Mr B Kirton Chief Delivery Officer

O √ √ √ √

1, 2, 3 ,4 Quarterly report of Trust Objectives 2020/21 Mr B Kirton Chief Delivery Officer

O √ √ √

1, 3 Annual Drs appraisal and revalidation report Dr S Enright Medical Director

R √

2, 3 Health Education Self-assessment return Dr S Enright Medical Director

R √

1, 2, 3, 4 MD Quarterly Report (exec mortality and medical staffing)


O √ √ Pack Page 267

1 Mortality Report Dr S Enright

Medical Director R √

1, 2, 3 Annual safe guarding children and adults report

2020/21 Mrs J Murphy

Director of Nursing & Quality

R

√

1, 3 Quarterly Patient Experience Report incorporating Annual In-patient Survey Results and action plan

Mrs J Murphy Director of Nursing &

Quality

O √ √ √

1, 3 Patient/Staff Story Mrs J Murphy Director of Nursing &

Quality

O

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1 Chairs log for Q & G(Quality & Governance) Mrs J Murphy Director Nursing & Quality


Ms R Moore Chair of Q & G

O

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3, 4 Chairs log for People, Finance & Performance (P, F&P)

Mr C Thickett Director of Finance

Mrs K Firth Chair of P, F & P

O

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4 Annual review of the Standing Orders (SOs), Standing Financial Instructions (SFIs) and Scheme of Delegation

Mr C Thickett Director of Finance

R √

4 Chairs log of Audit Committee Mr C Thickett Director of Finance

Mr N Mapstone Chair of Audit

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4 Annual Audit Committee Report Mr C Thickett Director of Finance

Mr N Mapstone

R √

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Chair of Audit

4 Board Annual Work Plans √ 4 Bi annual approval the use of the Trust Seal Ms M Saunders

Director of Corporate Governance

R

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4 Annual submission of the Board of Directors Register of Interests (as at 31 March 2020)

Ms M Saunders Director of Corporate

Governance

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4 Quartley review of BAF Ms M Saunders Director of Corporate

Governance

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4 Quartley review of Corporate Risk Register (CRR) Ms M Saunders Director of Corporate

Governance

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4 Received and amend the Trusts Constitution Ms M Saunders Director of Corporate

Governance

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3 Annual fit and proper person test 2020/21 Mr S Ned

Director of Workforce/ Ms M Saunders

Director of Corporate Governance

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3 Annual Report of Workforce, Race and Equality Standard

Mr S Ned Director of Workforce

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3 Annual Workforce Disability Equality Standard Mr S Ned Director of Workforce

R √

1, 3 Celebrating our people Ms E Parkes Director of Comms

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1, 2, 3, 4 Intelligence report Ms E Parkes Director of Coms

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1, 2, 3, 4 Quartley comms update Ms E Parkes Director of Comms

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4 Cyber security Report Mr T Davidson Director of ICT

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1, 2, 3, 4 Chairman report (Verbal) Mr T Lake

Chairman

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2 Barnsley Integrated Care Partnership Group (verbal) Mr T Lake Chairman

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1, 2, 3, 4 Questions from public/observers Mr T Lake Chairman

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*R/O – Required/Optional Strategic Aims: Strategic Aim 1 – Patients: will experience outstanding care Strategic Aim 2 – Partners: We will work with partners to deliver better, more integrated care Strategic Aim 3 – People: will be proud to work for us Strategic Aim 4 – Performance: we will achieve our goals sustainably.

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EXECUTIVE SUMMARY

RECOMMENDATIONS

STRATEGIC CONTEXT


SUBJECT: CHIEF EXECUTIVE’S REPORT DATE: 6 AUGUST 2020

PURPOSE:

Tick as applicable

Tick as applicable

For decision/approval

Assurance


PREPARED BY: Emma Parkes, Director of Marketing & Communications SPONSORED BY: Dr Richard Jenkins, Chief Executive PRESENTED BY: Dr Richard Jenkins, Chief Executive

To report particular events, meetings publications and decisions that the Chief Executive would like to bring to the Board’s attention.

This report is intended to give a brief outline of some of the key activities undertaken as Chief Executive since the last meeting and highlight a number of items of interest. The items are not reported in any order of priority.

The Board of Directors is asked to receive and note this report.

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Subject: CHIEF EXECUTIVE’S REPORT Ref: BoD: 20/08/06/20 1 BARNSLEY HOSPITAL

1.1 CORONAVIRUS (COVID-19) UPDATE

Barnsley Hospital continues to work in alignment with national, regional and local preparations to support staff and patients during the Covid-19 global pandemic.

A two tier command and communication structure remains in place to manage activity relation to Covid-19 and the development of comprehensive plans to safely increase activity at Barnsley Hospital.

Now in the recovery phase, the management approach has an increased focus on the safe reintroduction of a wider range of services and activities.

1.1.1 Covid-19 Stabilisation

The Trust continues to work towards increasing activity and safe operating. This includes:

Staff: • The introduction of surgical masks for all staff across the site • Individual risk assessments for staff working on the site and at home • Safety and social distance practises in the workplace. • Continued encouragement of staff at higher risk, including BAME colleagues,

to access a risk assessment.

Visitors: • The introduction of face coverings for visitors to the site • Social distancing measures for patients and visitors within the hospital site • Utilising new technologies for patients and colleagues, according to their

needs • Continuing to safely increase patient and visitor numbers at an individual

service level • The reopening of Colliers restaurant, in line with Government guidelines on

social distancing and face coverings.

Activity levels from COVID-19 continue to decline – at the time of writing there are two positive inpatients which is the lowest number since the peak of wave one. The hospital pathways separating COVID-19 and non-COVID-19 patients continue at present however this will be reviewed as we continue to see case numbers decline. Non-COVID-19 activity continues to increase. Visitors to the Emergency Department are in general alignment with the expected projections. Out-patient activity continues, with the services continuing to utilise non-face-to-face using telephone and video alternatives where possible.

Work has recommenced on the new Paediatric Emergency Department and Children’s Assessment Unit during the period.

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1.2 COMMUNICATION AND INFORMATION 1.2.1 Public Information

Public information continues to be published on a regular basis through the Trust’s communication methods and in local and regional media. Intensive communications and public information has been undertaken to support the introduction of face coverings within the hospital site. This work has been supported by our hospital volunteers who I would like to thank for their invaluable contribution.

1.2.2 Information for Colleagues

Regular briefings covering all aspects of COVID-19 remain in place for colleagues. Email updates are sent frequently and weekly meetings with Staff Side representatives ensure any issues are addressed.

1.3 Health and Wellbeing

The health and wellbeing of colleagues remains a priority. To support this, the Trust’s annual health and wellbeing event has been re-designed so colleagues can get involved and still socially distance. The month has been broken down into themed weeks where we have shared, information, self-help resources, activities, videos, webinars and competitions all accessible to support colleagues health and wellbeing. The themed weeks have been:

• Week 1 - Physical activity • Week 2 - Healthy Eating • Week 3 – Quitting smoking and alcohol awareness • Week 4 – Mental health

The event and support has longevity beyond this month, so colleagues will be able to access this support at their convenience on the Hospital Hub intranet site. Related to this, the ICS has just agreed to restart the QUIT smoking cessation work programme which had been suspended due to the pandemic. This will go forward at half capacity once staff have been recruited.

2 MEDWAY GO LIVE

On 11 July the Trust successfully transitioned to Medway, a new patient information system. Work continues to support following the ‘go live’ period to support staff in using the new system effectively. Implementing the change of the Trust’s major IT system during the pandemic brought some unique challenges which our team and the System C supplier overcame through a range of innovative approaches. So far, there have been no major unexpected issues from the change which is very positive for such a significant piece of work. I would like to record my thanks to the members of the Trust’s ICT team who worked extremely hard to ensure a smooth transition to the new system.

3 PARTNERSHIP WORKING

The Trust continues to work with partners locally, regionally and at a national level to deliver a co-ordinated and consistent approach to the effective management of COVID-19.

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During the month, Barnsley, health and social care organisations have worked together to ensure a cohesive approach to the use of face coverings within health and social care settings in addition to the provision of information about case numbers within the borough.

Dr Richard Jenkins Chief Executive

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Enclosure C

CHIEF EXECUTIVE REPORT

July 2020

Author(s) Andrew Cash, Chief Executive Officer

Sponsor Andrew Cash, Chief Executive Officer

Is your report for Approval / Consideration / Noting

For noting and discussion

Links to the STP (please tick)

Reduce

inequalitiesJoin up health

and care

Invest and grow

primary and

community care

Treat the whole

person, mental

and physical

Standardise

acute hospital

care

Simplify urgent

and emergency

care

Develop our

workforce

Use the best

technology

Create financial

sustainability

Work with

patients and the

public to do

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

N/A

Summary of key issues

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

Recommendations

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

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South Yorkshire and Bassetlaw Integrated Care System

CHIEF EXECUTIVE REPORT

July 2020 1. Purpose

This paper from the South Yorkshire and Bassetlaw Integrated Care System System Lead provides an update on the work of the South Yorkshire and Bassetlaw Integrated Care System for the month of June 2020. 2. Summary update for activity during June 2020 2.1 Coronavirus (Covid-19): The South Yorkshire and Bassetlaw position There continues to be an ongoing decline in new cases, including the number of Covid-19 cases in South Yorkshire and Bassetlaw. This sustained reduction in new cases allows the system to firmly look ahead towards Phase Three from August 2020 to April 2021 - resetting the NHS. There are a number of key concerns for health leaders as the NHS recovery process looks to restore services. Issues raised include restoring the NHS amidst workforce challenges, potential lengthening of waiting lists, and strict infection control measures – all of which will significantly impede capacity. Supplies of Personal Protective Equipment (PPE) have improved significantly, particularly sterile gowns and sterile gloves and alternative suppliers through the support of Heads of Procurement have been sourced. General PPE continues to improve though there remain some concerns about the supply of PPE in Primary Care, and this remains a high priority. PCR testing (testing of swabs to see if people have the virus) continues to be in a strong position. SYB labs have capacity to undertake testing of NHS and social care patients and staff. In addition, members of the public with symptoms have access to swabbing via the regional testing sites at Doncaster Airport and Meadowhall as well as via the mobile testing units (MTUs) that are sited most days at Barnsley County Way, Rotherham AESSEAL stadium and Dearne Valley Leisure Centre. The MTU at Meadowhall continues to be one of the five busiest in England, typically undertaking more than 400 swabs per day. For antibody testing, approximately 50% of all NHS staff in SYB have now been tested (up to 22nd June) although this varies between each of SYB's five Places; Doncaster and Bassetlaw were first to have the analytical capacity in the lab and most staff there have been tested. With regards to the NHS reset, there is now a very strong case being considered for returning to fewer hospital Covid treatment sites in SYB. This would see the scale-down of the Covid surge capacity response, mirroring the original scaling up in March. At the same time, partners are now resuming some services, focusing on clinical priorities for those who most urgently require treatment. Cancer care continues to be one of the main priorities in SYB’s system recovery plans and partners are working to review and reprioritise patients. The System also has a role in supporting reset in the community. Working with partners in primary care and the community there is a need to ensure that population health and the needs of our communities post-Covid are understood and supported. This includes the plans that are underway for how to manage the follow-up and rehabilitation needs of patients who have had Covid. Each of SYB’s Local Authorities has a robust Local Outbreak Plan which is supported by a regular flow of data and led by Directors of Public Health. With the recent further easing of lockdown

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measures at the beginning of July, partners’ Plans took into account the potential for increase in demand, particularly in relation to urgent and emergency services. 2.2 National update On June 9th, there was a joint session between ICS and STP Independent Chairs and Executive leaders with senior colleagues at NHSE where the future of system working was discussed. The event was one of a broader conversation on the future of systems, alongside further opportunities to be involved in the coming months. 2.3 Regional Update

The North East and Humber Regional ICS Leaders continue to meet weekly with the NHS England and Improvement Regional Director to discuss where support during Covid-19 should be focused. Discussions during June focused on improving BAME inclusion, outbreak management arrangements, support for care homes, supporting urgent and emergency care as public confidence returns and planning for Phase Three. 2.4 Planning for Phase 3 and Phase 4

Further NHS planning guidance and a financial framework are expected in mid-July. A first draft SYB System Plan, which is an amalgamation of all five Place Plans, is currently in development. It takes into account constraints such as workforce, estates management, infection control and PPE while also incorporating examples of best practice in SYB and nationally. There will be a final submission at the end of July. To support the planning process, a workshop to stress test the restoration of broader health and sustainment of care services in a COVID environment with partners took place on June 1st. This valuable exercise explored four possible scenarios across Places, offering opportunities for colleagues across health and care to analyse local plans in order to make improvements. Feedback from the session was very positive, with the learning now being built into local plans. 2.5 Identifying and embedding transformational change across SYB and capturing

learning from the Covid-19 crisis The ICS Programme Management Office is working with the Yorkshire and Humber Academic Health Science Network to capture views of senior leaders and colleagues from across SYB's health and social care organisations to feed into the joint project: ‘Identifying and embedding transformational change across SYB and capturing learning from the Covid-19 crisis’. To accurately capture and understand the innovation that is emerging, views are being gathered from those directly involved in the implementation of the rapid changes through an extensive consultation exercise. 2.6 Cancer update Cancer care continues to be one of the main priorities in SYB’s system recovery plans. Partners are working to review and reprioritise patients who have previously been on waiting lists. Those patients who have waited for a long time already and are a priority clinically are very much at the forefront of efforts to receive fast-track diagnostic and treatment services. The results of the recently published NHS England and Improvement commissioned National Cancer Patient Experience Survey saw SYB 2% above the national average in the areas of patients thinking they were seen ‘as soon as necessary’ (86%) and the length of time ‘waiting for tests to be done being about right’ (90%). The survey monitors national progress on the patient’s experience of cancer care and acts as a driver to improve quality at local level. This is strong evidence of the excellent work taking place across SYB.

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2.7 Planning for Flu Modelling for influenza infections in the UK is now starting to take place as preparations for winter get underway, with a recognition that this could occur alongside a further Covid-19 peak. This is firmly on the radar of SYB’s testing cell which has started to devise a winter testing strategy to support the system level planning. Supporting this work will be a system level flu strategy, which will be made up of five Place plans and a SYB Flu Board. 2.8 Accelerating NHS progress on health inequalities during the next stage of COVID

recovery The disproportionate impact on people from Black, Asian and minority ethnic communities, people living in areas of high deprivation and inclusion health groups shows starkly the health inequalities which persist in England today. The NHS Long-Term Plan commits the NHS to addressing health inequalities and much excellent work is underway already, particularly focused on medium and long-term action. But progress needs to be accelerated; responding to and recovering from COVID calls for more focused, additional and immediate actions. To address this, NHS England and Improvement have established a Task and Finish Group, composed of a range of system leaders and voluntary sector partners, to focus on what specific, measurable actions should be taken by the NHS in the next few months. The Group will take account of feedback and ideas already received from BAME organisations, the VCSE sector, local systems and others. This work is distinct from but complementary to the dedicated work on the NHS as an employer being led by the Chief People Officer on supporting our BAME NHS staff and implementing the NHS Workforce Race Equality Standard. In SYB, the response to health inequalities is being taken forward by Workforce Leads, Kevan Taylor and Dean Royles. 2.9 Support for the Centre for Child Health Technology (CCHT) The Sheffield MPs wrote to the Government to outline their support for a new world class research and innovation facility in Sheffield. The Sheffield Children’s Hospital sponsored Centre for Child Health Technology (CCHT) at the Sheffield Olympic Legacy Park would be a multi-million transformational project supported by regional partners and international businesses including IBM Watson Health, Cannon Medical, Phillips and the South Yorkshire and Bassetlaw Integrated Care System. The site would span over 51,000 square metres, delivering world-class clinical and technical innovations to support children’s health and wellbeing in SYB and beyond. 2.10 Sheffield City Region devolution deal agreed South Yorkshire’s devolution deal has finally been agreed and brought to the House of Commons. This is a significant step forward for South Yorkshire’s economy and our congratulations go to Dan Jarvis, Mayor of the Sheffield City Region, and his team on this fantastic achievement. Once passed into law, an additional £30million pounds will be allocated to Sheffield City Region for regeneration projects supporting local growth and transformation. This is a great example of partnership working and its long-term impact is likely to shape the lives of the population for years to come. 2.11 Volunteers and Carers Partners recognised the thousands of carers in SYB during Carers Week (8-14 June). Many of the patients who visit GP surgeries or go into hospital are cared for by a relative or have caring responsibilities themselves. Carers Week was a timely opportunity to thank them for all they do and particularly for their vital role in helping vulnerable people manage their health and care needs during the coronavirus outbreak.

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It was also National Volunteers Week 1-7 June. Likewise, volunteers bring significant added value to health and care organisations with their experience and talent and the week was a great opportunity to thank the many thousands of volunteers in South Yorkshire and Bassetlaw for all they do. 3. Finance update A new national financial framework is being developed to cover the period from August 2020 to March 2021 which is built upon the financial framework adopted for the period from April 2020 to July 2020. This will form part of the planning guidance is due to be released shortly. The system has submitted capital plans to the region which total £47.1m which cover both the ‘base case’ and ‘stepped up case’ planning assumptions provided for this exercise. Further work is being undertaken to prioritise these schemes if the system is provided with a cash limited financial envelope to cover such expenditure. From March to July 2020, commissioners and providers have been funded at actual cost to enable a break even position each month. From August 2020 to March 2021 this will be replaced with a cash limited sum which will replace the retrospective top-ups to commissioners and providers to allow them to break even and to reimburse costs associated with COVID 19. The intention is to provide systems rather than organisations with a financial envelope. Andrew Cash System Lead, South Yorkshire and Bassetlaw Integrated Care System Date: 6 July 2020

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